140 Cooks Trail Lot 3AAUTHORI 6TION No: _ 16 2 5 DAVIEOUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's • �%�;, /�/ P.O. Box 848
Name: /� Mocksville, NC 27028 Subdivision Name:
c,<r Phone# 336-751-8760
%.
Directions to property: ��/l^ Section: Lot: �w�
.., AUTHORIZATION FOR:
WASTEWATER " Tax Office PIN.#
SYSTEM CONSTRUCTION ..
Road Name:P:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building -Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. -
4n comp Article 11 of G.S. Chapter 130A', Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-I
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
j'Y%•J �/ `� �7d"
ISVALID FOR PERIOD OF FIVE YEARS.
:,;:,,ENVIRONMENTAL HEALTH SPECIALIST. DATEISSUED
1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &[ENVIRO:NMENTAL
U R
1; Davie County Health Department LS
C ,ail � Environmental Health Section
P. vi Box 848 1998
C� Mocksville, NC 27028
(704) 634-8760 HEALTH
\ NTY
d ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
/ / ', ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed eV'�' U tb0b ^t Contact Person
Mailing Address P�j�y
OyNY &2 / Home Phone
City/State0p "'moo"`eme6 a70� L� " Business Phone �° Q
41. 255/
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
M' Dishwasher
❑ Site Evaluation
❑ House ❑ Mobile Home
# People
❑ Garbage Disposal
6. If Business/Other:
# Commodes
If Foodservice:
7. Type of water supply:
Specify type
# Showers
City/State/Zip
❑ Improvement Permit & ATC tT 11 Both
❑ Business ❑ Industry
# Bedrooms 13
❑ Other
# Bathrooms Z
LY Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# Urinals
# People # Sinks
# Seats Estimated Water Usage (gallonsperday)
❑ County/City & Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
INFORMATION
t� X
❑ Community
❑ Yes W"Ro
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: a L
I WRITE DIRECTIONS (from
5��i
D�1
Q
Mocksville) TO PROPERTY:
TaxOfficePIN: # -
-z,1vnn
I
Property Address: Road Name
cZ702Q
city/Zip
If in Subdivision provide information, as follows:
Name:
1
Section:
Lot #:
1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by
as necessary to determine the site suitability.
DATE —7-
2o—q6 SIGNATURE
conduct all testing procedures
Revised DCHD (06-96)
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1/2" EIR
159.42'
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n/f William L. Link
and W'fe
Marie Smith Link
DB 61 O PG 38
N 02"43'20"E 942.6•
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of Parcel 1 Zoned RIA '_ $
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IRS 221.50'
P
428.52'
Part of Tax Lot 16
Parcel 1
Total Area: 5.001 Acres +/-
Note: 3.5 Acres of Parcel 1 Zoned Industr
B13.83' Total S 02"43'20"W
592.33'
•— L-7
Centerline Proposed 60' Access Easement S
IRS N
Part of Tax Lot 16
Parcel 2
Total Area: 5.098 Acres
N 02°43'20"£ 337.38' IRS
IRS O
i
Part of Tax Lot 16.
Parcel 3 h p .� Tax Lot
Total Area: 5.027 Acres +/- 5 �1 �p lb l Tax Map c
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Part of Tax Lot 16
?orcel 4
/
foal Area: 5.022 Acres +/- IRS IRS
125.00'
S 83°46'55"N
N 03°44'15"E 669.40'
7259.51' \ /�. y IRS S
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409.89'
Tax Lot 16
Tnr Alnn A4-5
DAVIE COUNTY HEALTH DEPARTMENT
< Environmental Health Section SECTION LOTZA
Soil/Site Evaluation
APPLICANT'S NAME L u`7 i� DATE EVALUATED
PROPOSED FACILITY %�Z�� PROPERTY SIZE
SUBDIVISION ROAD NAME ///�J XPi
Water Supply: " On -Site Well Community Public
Evaluation By: Auger Boring it ✓ Cut
FACTORS 1 2 3 4 5 6 7
Landsca e nosition L Z
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON H DEPTH 1
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy -
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R Ridge S -Shoulder L -Linear slope ; FS - Foot slope N - Nose slope
CC.- Concave slope CV -Convex slope T- Terrace FP - Flood plain H - Head slope'
Texture
S -Sand LS - Loamy sand SL - Sandy loam L - Loam , SI - Silt
SICL - Silty clay loam ' SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI -Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS -Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long -tern acceptance rate - gal/day/ft2
DCHD (01-90)
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