The URL can be used to link to this page

173 Covington Drive Lot 55Davie County, NC Tax Parcel Report Tuesday, November 29, 2016 WARNING: THIN 15 NOTA SURVEY Parcel Information Parcel Number: H8060A0055 Township: Shady Grove NCPIN Number: 5789239917 Municipality: Account Number: 8301191 Census Tract: 37059-804 Listed Owner 1: LAMPKY JOHN R Voting Precinct: EAST SHADY GROVE Mailing Address 1: 173 COVINGTON DRIVE Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27006 Voluntary Ag. District: No Legal Description: LOT 55 COVINGTON CREEK PHASE ONE Fire Response District: ADVANCE Assessed Acreage: 0.70 Elementary School Zone: SHADY GROVE Deed Date: 7/2012 Middle School Zone: WILLIAM ELLIS Deed Book I Page: 008950353 Soil Types: PcB2 Plat Book: 0007 Flood Zone: Plat Page: 057 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding 8t Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 101 All data Is provided as Is without warranty or guarantee of any Idnd either eased or Implied Including but not limited to the Davie County, Implied wamantles of merchantability or fitness for a particular use. Ali users of Davie County's GIS website shall hold harmless tfie County of Davie, North Carolina, its agents,consultants, contractors or employees from any and ail claims or causes of action due to NC or arising out of the use or Inability to use the GIS data provided by this website. Permittee's f DAVIE COUNTY HEALTH DEPARTMENT Name: Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: Ll f l U Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 &tlr lir .�'.� �r H Section: Lot: AUTHORIZATION FOR � -7 r�Z,WASTEWATER Tax Office PIN:# J7fJ ` SYSTEM CONSTRUCTION + ..7' Cv�� fc►� Or AUTHORIZATION NO: 002986 l A Road Name: y Zip: 0c) **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. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED S F 4y RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No gcre!5 LOT SIZE 0' TYPE WATER SUPPLY CO DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE t� GAL?PUMP TANK GAL. TRENCH WIDTH ROCK DEPTHLINEAR FT.� VO 0 f- az P, -du cY r cvt REQUIRED SITE MODIFICATIONS/CONDITIONS: y -e ju 0-7 f ' f e, /10 0.4 %C 4 N 7 .o 7-0 u., IMPROVEMENT PERMIT LAYOUT pr;oe�Qy o < 3 r C tl 5 1t If 1 `I 11; 6' I .P C-611 if 5 v r4w / 'f'_a r� e -e s u-(( C) - , a00 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. gkitk l.i h:9k cap "cc* r Chem J, -e- 4--,5;-MAe , OPERATION PERMITQ M SYSTEM INSTALLED BY: U r 1 a Vl 1 , `= V1 lKC-0. v s 'S- f� Hit w�'*c� btw. 5 i S as � A e a c l `i a o Ne w SyS �c AUTHORIZATION NO. 00 q`'6 OPERATION PERMIT BY: �%%✓� DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) ' ' '.. 'tea\ .. ,: :1f-rl't \+ {..! . h..-. ii�_ir ., S,ti ^-\ •"`•tl �)}erm#ttee' 's ' •: :UVIE COUNTY HEALTH DEPARTMENT 'Name;'' I1► ��1 a X11 i't \.i i' Environmental Health Section PROPERTY,, INFORMATION P.O. Box 848 t . Directions to property:_ _ Mocksville, NC 27028 Subdivision -Name: lj Jlr! �r� Lt %rPhone #: 336-751-8760 1 �1 f�', :�l.s �(• Lpr ; ' 4. V1 Section: I Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# ��-_ - SYSTEM CONSTRUCTION j' CZ.: UI e• r lc;) I Gl' or AUTHORIZATION NO: {� Q 2 9B �! 1`1 Road Name: � Zip: **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. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) t ,'� , / � r,�/. ,✓ _ /,j_` �j ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,;, /, !, % •`�=�'* f1 J IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATEISISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE F# BEDROOMS f �% I� # BATHS # OCCUPANTS l GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 0' o3TYPE WATER SUPPLY �d DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE �G i SYSTEMSPECIFICATIONS: TANK SIZE GAL PUMP TANK_4GAL. TRENCH WIDTH ROCK DEPTH � LINEAR FT. I' �D of �� id 11, d C_% L 1 r GYl OTHER SQUIRED SITE MODIFICATIONS/CONDITIONS: Ir" U Le /� 11 � �f L/ L, a of Celt &i r0 Y ! e) C_/ &(14 4 6 .ri V ,v .mac' IMPROVEMENT PERMIT LAYOUT r LV 07 (i W U `/ •- 7. 110 0 DovF;> 3 0 4St 4"f(tc — -- _. - -,t pie,,/ FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT (� l4 . c . L4 h • `j t % ' r t-, e , e I,-, - S •"r. i SYSTEM INSTALLED BY: 1 [l V1 W= QqV) 12 Z to i1ii)c"c*id` -i �' •� •iQ �ft 4... i �, tla Y:.f 4.� f ..e ...« -4,AL �• ; '^ •.» t�,'.d� .... i � Cw Z,'Si' -T F'f 'j7�.�tl�..sy114df' (. rvir .» ;�• �` ii> -=ilii � �� n ,� y ,5 � �"` ��i- � `,%°%,l i ��. C\ t 1. Oi: r � "1 L. c%� �j at .S� • i K 1 i\\ 4 • _ .`f..._. t Y � t11V ,_C c r1 b -t .moi �8b �� DATE: AUTHORIZATION NOrIJy OC OPERATION PERMIT BY: �_ �z "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE,•, WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 01102 (Revised) I PermittV,s I AVIE COUNTY HEALTH DEPARTMENT ` Name:�-�� - LR Ai ' nvironmental Health Section PROPERT,�INFORMATION� }} P.O. Box 848 1 L' r/ Directions to property: l! l l.3`f" Mocksville, NC 27028 Subdivision Name: `< -tet. r'V,N stt N ` Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR AUTHORIZATION NO: '002667 A WASTEWATERTax Office PIN:# J P,� i - > � -1117 SYSTEM CONSTRUCTION " (;l Road Name: t�`-°"i7c Z�p A 6„ **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 fm- Building Permits. (In compliance with Article 1l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) r'***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 6; .` _,, f IS VALID FOR A PERIOD OF FIVE YEARS. 'AL"146ALTH VE ALIST DATIL ISPED RESIDENTIAL SPECIFICATION: BUILDING TYPE BEDROOMS L1 # BATHS L4 # OCCUPANTS A_GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No �v�rry LOT SIZE'_`_"_ TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE d � SYSTEM SPECIFICATIONS: TANK SIZE I0WGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH a A LINEAR FT. OTHER Okt�ET� REQUIRED SITE MODIFICATIONS/CONDITIONS: KL-- -P I'd OFF- Fr -op. IMPROVEMENT PERMIT LAYOUT 1 ~%-;;1 , .:... -- G ,,T (Co. I� 'svtl►� ae I,�.9'spuP FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: °"}^-� 1� l � �'L uag� 0016 1/ s� e q5t)> AUTHORIZATION NO. 7�i�� A OPERATION PERMIT BY:DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM CRIBED ABOV S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) ..+'--, Avtm AVIE C UNTY HEALTH DEPARTMENT ei x I-�( '� f Pit.f_¢(r tjvironmental Health Section PROPERTY INFORMATION .� „ 1'~ ` t P.O. Box 848 - --� Directions to -property: %t f � I ¢ Mocksville, NC 27028 Subdivision Name -- 1✓� 'j e t ' - �,�, ' Phone #: 336-751-8760 F r «,a.. V I�! -¢ ," �'` �. Section: Lot: —T AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION . AUTHORIZATION NO: -.002667, A Road Name: f � � �`c Zip: --L **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 Fon VAuthorization Number should be presented to the Davie County Building Inspections Office when applying forBui4ling Permits. (In compliance with Articled I of G.S. Chanter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION . j i' ; `✓ " i! _ f j.1 =... IS VALID FOR A PERIOD OF FIVE YEARS. h ENVIRYa�t649ENT—AL hiEALTHSPECILALIST DAT ISS ED RESIDENTIAL SPECIFICATION: BUILDING TYPE fILIrIL#BEDROOMS _q__ # BATHS L4 # OCCUPANTS A_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE` t -TYPE WATER SUPPLY + DESIGN WASTEWATER FLOW (GPD) .r1.L_ NEW SITE REPAIR SITE ✓ r! Jj SYSTEM SPECIFICATIONS: TANK SIZE J�GAL. PUMP TANK GAL. TRENCH WIDTH + ROCK DEPTH N ` LINEAR FT. OTHERnl �i �F:1�Y�� TI��1�f REQUIRED SITE MODIFICATIONS/CONDITIONS: .L=1 6f -C h. j= -,7_j letz9 ' 1 [-i LIE I.-• I -J IMPROVEMENT PERMIT LAYOUT r i4^`}1cl iGU FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT t ��; - (1 SYSTEM INSTALLED BY: L L-" 4 .. -' X tS7100 ti 11 114 JL, ++FF f �1) ` ,�[1 �,`("1 �{�{/�'y[—,'//1 fnf'^u.. .r.,. .t .w,a�Lw,.. n• .i+., �.`. .. '� YL«iw'++"+� T."- . AUTHORIZATION NO. tr �0� 4, OPERATION PERMIT BY: r **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE 4YSTE _ E_SCRIBED ABOV WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02102 (Revised) DATE: !-v EN INSTALLED IN COMPLIANCE SHALL IN NO WAY BE TAKEN ASA • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: Billed To: Reference Name: Proposed Facility: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: Date Evaluated: On -Site Well .11 Auger Boring Community Pit Public / Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: C l-�— t�%Vo*),p OTHER(S) PRESENT: `J0. 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 Mois 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 Note 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-term acceptance rate - gal/day/ft2 DCHD 05/99 'Revised' Landscapeposition —©00---- , , - . X11►��'��e�� HORIZON I DEPTH Texture group Consistence Mineralogy HORIZON 11 DEPTH. WHOM Texture group Consistence RM Mineralogy NEVORNME02"N' OWN, HORIZON III DEPTH_ WAMJM MOM WMEJ Texture group Consistence Mineralogy—HORIZON IV DEPTH_ Texture group_ Consistence Structure Mineralogy SOIL WETNESS SAPROLITE CLASSIFICATION OEM SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: C l-�— t�%Vo*),p OTHER(S) PRESENT: `J0. 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 Mois 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 Note 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-term acceptance rate - gal/day/ft2 DCHD 05/99 'Revised' ■■■ ■■■■■■ ■■■■■■ 1■■■■■■■■■■■■ ■ ■ ■ ■ May 26 06 11:11a davie county envhealth 336 751 0786 p.2 TION FOR SITE Davie County Health Department ENT PERMIT &ATC tment��•�� , Environmental Heahh Section P.O. Box 848/210 HospitsI Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786r �N1RpNV1E tion tte Evaluationlimprovement Permit ❑ Authoriza lon To Construct(AI'C) ❑ Both *'*IMPORTANT"'* THIS APPLI(:A TION CANNOT BE PROCESSED U ?LESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed—S tact Person t • — Billing Address I _ZV--7 U S, (�� t.J Hi me Phone C ity/S ta te IMP s'✓) yz It�t-J . Business Phone Name on Pcm-dt/ATC if Different than Above Mailing Address City/Ste te/Zip PKUPI;KTY MOKMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site pIan, no expiration wt complete plat.) Street Address_ j_ 3 _ C� _ (City a ^ < < Tax PIN# .S -7 V` -Z3 ' 2 91 Subdivision Name .. ,, ` _ .. _ e. ,a C Section/I ot#Lot Size X -� �-. • Directions To*S`e o S a Lam= C tC- - Date HousoTacility Corners Flagged ti I n b r If the answer to any of the following questions is "yes", supporting docu'meen_ntion must be attached. Are there any existing wastewater systems on the site? ffYes ❑No Does the site contain jurisdictional wetlands? 0 Yes Are there any easements or rigbt-of-ways on the site? OYes DRO --- Is the site subject to approval by another public agency? QYes B o Will wastewater other thandorrestic sewage b�eneria OYes t. IF RESIDENCE FILL OUT THE BOX BELOW_ ' # People _ # Bedrooms # Bathrooms _� Garden Tub/Whirlpool LW6 ONo Basement: OYes 0No Basement Plumbing: OYes DNo IF NON -RESIDENCE FILL O11T THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes _ # Showers _ # Urinals _ Estimated Water Usage (gallons per Jay) (Attach docur ientation of similar facility water consumption) FOODSERVICE ONLY: #Scats Type system requested: onvcntional OAcccpted ❑Innovative flAltemitive ❑Other Water Supply Type: a unty/City Wawr ❑ New Well nExist ng Well 0 Community Well Do you anticipate additions or expansion of the facility this system is intended to serve? ❑ Yes If yes, what type? This is to certify that the information pro.ided on this application is trate and c xrect to the best of my knowledge. I understand that any permit(s) or Algs) issued hereafter are subject to suspension or revocatic-n if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed l understand that lam responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Represertative of the Davie County Health Department to conduct necessary inspections to detenr¢ -e compli with described laws a:rd rules on the above desced property located in Davie County and owned by �'1- 1-v 1-11 9 rop 7 /wlne�'s rr owner's legal representative signature __ / Date Sign given fiYes ❑No Revised 2106 Site Revisit Charge Date(s):, Client Notification Date: EHS: Account # 90003 lnvoice # 1, GRADY L. TU77EROW , CERTIFY THAT UNDER MY DIRECTION ION AND SUPERVISION . THIS MAP VIAS DRPU'N FROM AN ACTUAL FIELD SURVEY tzADE DY TUTTEROW SURVEYING COMPANY. RCFC5510NAL LAND SURVEYOR —E'--2527 ............. 'A' YSURVEY U' � d L6,- �IL c ��Lq' K LL -z, -§TN-, cS YKME-,52 DRAWN 4 APPROVED By, i SCALE: Rhi:i I GLT REVISED: AUG -19-199 9 DATE: DRIVE 57 656) (ADDED CEMENT DR.) SUBDIVIc L AND SCREEN PORCH) 13EING LO 1 55 OF THE COVING ON CREEKCAR DAVIE COUNT Y NORTH IOLINA LYING IN TI -W !�,HADY GROVE TOWNSHIP. TuTTEROW SUR VEylyj comPANY 7QRAWhNG- -NU'V[3CR C 127LiBERTYHURCHROAD MOCKS VILLE, /V C. 27028 (336) 492 - 5616 �FF"+.�•.'Y':"'1 �y4. . :5,��:�a^rr*•�"r't fr'�n°'1'r',f�L'!�;-:�`�,..+ua{.�:ittu�r-..r...�lt,{�+r.;iyrY:�.t"r`�.. Y'. �,y .,., .x.: y�,..p„..,y,t,.� ;�„».. c,.4f ,..,,_��. 1. -; ..r ,..W.�j .. ..;. , ,a rTxc? TION NO: 3 DAVIE C LINTY HEALTH DEPARTMENT A Environmental Health Section PROPERTY INFORMATION Permittees 1 -�”' P.O. Box 848 Name: ' 4 � 1V ,A' Mocksville, NC 27028 Subdivision Name: f Al elzhft31� � Phone # 336-751-8760 Directions to property:L//,�l Section: f Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:45;w- - ~ SYSTEM CONSTRUCTION / ' 'J 8 V�' ''�• Road Name l�%rZip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance'of any BuildingPern its.. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. .(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ` f ✓, ', t,�`% ,!� ' �%l / . %:/ IS VALID FOR PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SP CIALIST DATE ISSUED � y",.,.A _ T7w 18,34bDAVIE LINTY HEALTH DEPARTMENT.,' IMPRO EMENT. AND OPERATION PERNUTS 0';F TY INFORMATION Subdivision Name: " ��f Section: Lot: ~ Directions to property: / . _ IMPPERMIT NT PERMIT Tax Office PIN:45 Road Nam �!? .� �� Zip: NOTE This Improvement Permit DOES NOT authoiae the constru ** ** p ��" ction or installation of aseptic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM,OONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** TILS PERMIT IS SUBJECT -TO REVOCATION IF, SITE ✓', PLANS OR THIS INTENDED USE CHANGE. YOUR WASTEWATER , ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE _ INSTALLING THE SYSTEM. RESIDE .. c_. NT[AL SPECIFICATION: BUILDING TYPE #BEDROOMS # BATHS OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) !3G� NEW SITE 1-- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE��DII ` GAL. PUMP TANK GAL. TRENCH WIDTH i 6r ROCK DEPTH, LINEAR FT�= OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: DCHD 051% (Revised) • e , APPLICATION FOR SITE EVAWA-HON/IMPROVEMENT PERMIT & AT Q v Davie County Health Department .7 Environmental Health Section DEC 1 019% P.O. Bon 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH n.vr nni wry ***ZWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. flame to be Billed I "axis/ �r�! ewe, contact Person Nailing Address 12-rN L/- // yj"r Home Phone City/State/ZIP -I ClIL6e XAle, Business Phone f �• S(.�Zi� 2. Name on Permit/ATC if Different than Above Nailing Address, City/State/Zip 3. Application For: &YSite Evaluation �( Improvement Permit/ATC 0 Both 4. System to Service: U House ❑ Mobile Home 0 Business 0 Industry 0 Other s. If Residence: # People # Bedrooms 5 # Bathrooms 0 Dishwasher O Garbage Disposal 0 Washing Machine 0 Basement/Plumbing U Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # Sinks # Co®odea # Showers # Urinals # Water Coolers IF FOODSERVICE: i1 Seats Estimated lister Usage (gallons per day) 7. Tgpe of water supply: 9 County/City 0 Well ❑ Community S. Do y:rj anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Yes 0 No ***IMFDRTANT*** CLIENTS JIIUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Esther a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 1 o6 X 3o z X 3a 2- !C 1 ob (WRITE DIItECTIONS (from MockrAlle) to PROPERTY: Tax Office PIN: # S —1 k 7 - Z 3 - `7 i 1-% Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: ��4 "y e: -e`% - Section: Block: Lot: Date Property Flagged: 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 lam reaponsiblefor aft charges incurred fmm 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 to conduct all testing procedures as necessary to determine the site suitability. DATE I A" / 0 " q g SIGNA THIS AREA MAY BE USED FOR DRAWING YOUR SITE'TP(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and sept.. ocations). Revised DCHD (07/98) Account No. Invoice No. / IVRE PHASE 2 5O SIDEWALK EASEMENT: 8' WIDE AND CENTERED ON SIDEWALK S , 63• O DRAINAGE EASEMENT: 25' WIDE AND I S i _ a� �'� • f. CENTERED ON CULVERTS AND DITCHES CONTROL 2r 7O DRAINAGE EASEMENT ALONG CREEK CORNER I '� 8� TYP. BUILDING SETBACK \ 83.21' 44.79' 128.00' S 87 55' 27^ \ TTENNIS COURT COMMON AREA 3 r - I S' \ FUTURE e, TENNIS cl) I COURTS \ \ I 8 cFQ�� `------- - - - - —- 5 45 0 K -- 4 5 / \\\ \ �' 4 /` G� \ \ G .20' — 300.40' _ _ 168.79' J � �� PUQLIC RD. TAI 4 9.19 N 731 31 ,cf, G' V GQ / \ \ _._. \ C: R G.v 21.19'10-0- \C, �� / C, 100. 100.00' 100. q0' ` ►�% J0v �> r---- 6 —98.00' 50.00' \ G :H Gp COQ ` I I I I I i -___, r----� r---- � ti Q0"s��\ 3�\ 52 I Lu La N, i Iw I I J 1" \ rn (N IN tin I Iw I �w i Iw I I \ \\ L\ \ I in �il I N I I `° Ln M `�S \ N, R8.) \ I t�l4 4 i' ` ds'� 51 ` °S\ I *I �z I I I 1`~ I I� I la t I 59 \ \ \ z I I z I 6 I I 57) \•. \\\ �`\� C61 IIz � \` \\ '9I to o I O I / \ !y\ 310.00' in 120- 00'- 100.00' 100.00' 100.00' t OQ.O ' 1 0.p0, 1. 0 AL 1918.48 M ' 31 31 W 38' LOT 36.01, MAP H-8 W.J. ELLIS & - r WIFE HAZEL L. ELLIS D8 49, PG 425 DEVELOPER R.C. SHORT CUSTOM HOMES (336)998-4772 NATE: APPLICAVON FOR SITE EVALUATION/IMPROV.r+-�1V jl2N,T'?E.IZV..IT Davie County Ilealth'Departme.nt Environmental Health Seetior. P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ""IMPORTANT"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL _► -`ZCTHE RE(,1UIRED INFORMATION IS PROVIDED. . �� <<r 1. Name to be Billed n • r,� mContact Person Mailing Address A P6 t) X 3 d Home Phone City/State/Zip ! t Ue1pu Ce N� - %OCA Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip i 3. Application For: ' ite Evaluation [ ] Improvement Permit b. ATC [ ] Both 4. System to Serve: [) House [ •] Mobile Home [ ] Business [ ] Industry [ ] Other % y+ �;' riot► d i.S /O•iJ 5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commoees # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 1 ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes H'No If yes, what type? 1 1!111 I; '.. I'!_ l l (,I: 1 PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'A FLAT OF TIS PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: _fir+ 04 66 &C, AACLe 'WRITE DIRECTIONS (from Mocksville) TO PROPERTYr Tax Office PIN: # 7`'l - - y_3 ut/ �5� n-} Adv4A;e�e Property Address: Road Dame 9101 �'v$�° � —• �ss�(Q n_ City/Zipy• Z?yo [ 'c'l�.cr.� s-�rn t�G �'_�� sE=_�< If in Subdivision provide information, as follows: Name: bt)�n re e. ��rt,�ocz ; SS Section: � Lot #: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter a; - subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified o changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authoriz Represenbtive of the Davie County Health Department to enter upon above described property located in Davie County and owne by Eonduct all testing^proce res as ne essary to determine the site suitability. DATE _ % • .�"SIGNATURE Revised DCHD (06-96) 7111, ,11,'-.1 ,1111 tir tl rU 1.011 I)IMIVIN6 J01IR SI U MAN: • „ ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION__,_�- LOTS Soil/Site Evaluation APPLICANT'S NAME _ DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION r �ne C - ROAD NAME Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit_T Cut FACTORS.. 1 2 3 4 5 6 7 Landscape position li, Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON 11 DEPTH Texture groupC_ Consistence r Structure Mineralogy` HORIZON III DEPTH Texture group Consistence Structure _ Mineralogy HORIZON IV j-'EPTH Texture group Consis`euce Struc. ure Minerplogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE - CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: 40i DCYD (01.90) EVALUATION BY: OTHER(S) PRESENT: 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 T?xture 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 M-01:51 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 S? - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crur,,b 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 Classificrtion - S(suitable), PS(pro 1:sionally suitab':e), U(unsuitable) LTAR - Long-term accencance .-ate - gal/day/ft2 IRE PHASE 2 6 1 � \ \\ Ir \\ F\ Cl U SIDEWALK EASEMENT: 8' WIDE AND 2$p�. CENTERED ON SIDEWALK . r O DRAINAGE EASEMENT' 25 WIDE AND o �\ CENTERED ON CULVERTS AND DITCHES CONTROL CORNER I O7 DRAINAGE EASEMENT ALONG CREEK O8 TYP. BUILDING SETBACK 83.21' 44.79"' ' 128.00• _587.55. 27" \ TENNIS COURT COMMON AREA 5\ 'J iv I FUTURE I TENNIS Q 1 COURTS 8 per\ \ ---C� _ _ _300.40' 4 5 4 \ \ i (,4) /� r tK :Q 20. ___. _ _ _ 168.79' �L�L \ \ /G �� PU$LIC RD. TAL 4 9.19 N 7.31 31 " 21.19' 1000— . ' / \G 100:00' 1— :N J0� I r- ~ - - - - - 6 oo.go' ! 98.00' GO Q ice. I i I r----_� r---- 50.00' v 1" G •��/� \\ gyp\ 52 I L''I v \ \\ `�B9\• \\ II .ar 1I jN II 1III I1 w • 1 1 I I WOt NIN I� III 1 1N 3II IN I ItG i I�p I IM I n 6\ \\ e.>p\ 1 54 IN I cJcJ I:V I IN I IN I 1 II tv 4 \ S\ \ \ I I ry 51 Iz �o CiD I 1� l L �� tiA•\ \ `' \ ' �I 1$ 1 io I I lx I t v l Cil o :1 o 50 `\ 9•\ \ �► ,� to i IN y \ Yj� \ `\ I I i IM I$ I cliI INo1 1000 o �----- --din L 310.00 In,L_ L__-_ JI -� I I 120.00' L --_--i 100. oo' 100.00' loo. 0. 1oq.o .Y 0 AL 1918.48 N '31 31 w 8 0 1 4 LOT 36.01, MAP H-8 W.J. ELLIS & WIFE HAZEL L. ELLIS DB 49, PG 425 DEVELOPER R.C. SHORT CUSTOM HOME (336)998-4772 _....�. i +7 I \ -., -+- I � � r-I I I i I - ! I � r � ' '� I- � • -.'_ - i -»- -i- i -•- _�--'-I--' ._--..-F_-_._-i-_.�-_ j I \ I I I - 1� I. 13oa'77 I 1 1 1 f ,�—. - 77 - i� o I LJ I o� anus P-; -� '-I I -" .��(1 -' -\ ---r--- � i— — �c `moi I —--I—ChI.,'►•►a1� ..�.� . ✓ :•' ; _� �. � j� j— j I ! .. 1,7 • ! vi --� �'ti_o 77 I -� ! ,-- � �- � --; I '-�-^--�-� � '- .--pox--a' -'-r--*-� -.---k ' '-T I I ; �-1-�-•- i-� -0- J _� II � TF I � i i - I i -� V I - -- 1.-- - - ! -}-�-- --�-- � I -� --�- _-;-,- -� '�° �-: --�• I I � b`� d � ga � ! i --I--; _ i-1-; �� _\ I i� �� I� i I� I i• �r�� j� l �I�r i! i �o I$jw.i�c�t�i► tl�;�•ve C I �� _j- -! � I I i� 1 I I J 71I I-1-t--� � • � I I - � --�-I - I---}---+-r-- L- I � -t'I-->_- �-,-� ,�-j-I � �r I J-. -I� �-' I-•-T-� -'- - -�—�I�—�--- ! I-t-�--*-'--i �---r-- __.=I- ! I--- Ir- i NAME _ M DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) N@2 9;1&L11?A1n' aw4s 110. —PHONE NUMBER WY' 3 VV ,(/6 ZZo0k _SUBDIVISION NAME �- LOT # DATE SYSTEM INSTALLED & NAME SYSTEMINSTALLED UNDER =Ste AI 6omik TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY // SPECIFY PROBLEM OCCURRING 4PA1111 LL, AfIh" NjjA s b gAA-11- A DATE REQUESTED NFORMATION TAKEN BY 11% /-Y/A.. - - This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am iesponsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 NIon December 10, 2009 Mr. Robert Nations, REHS Environmental Health Specialist Davie County Health Department Environmental Health Section PO Box 848 Mocksville, NC 27028 DECR GO. 14 2009 I DAVIEC6UNiV({EALTHDEPqRmgfNJ Re: Site Evaluation/Lot 55 Covington Creek Sub. 173 Covington Drive. Keith and Mary Kushner Dear Mr. Nations, Per your recent letter dated December 4h, 2009, in reference to your denial of the improvement permit submitted by our contractor (Con Shelton of Shelton Construction Services), I am hereby requesting an informal review by the NC Dept. of Environment and Natural Resources regional soil scientist. I can be contacted at 704-905-0196 to arrange for this informal review. Regards, Keith Kushner cc: Mr. Con Shelton DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 61 P.O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone#: (336) 751-8760 Fax#: (336) 751-8786 December 4, 2009 Shelton Construction Services 1257 US Highway 64 West Mocksville, NC 27028 Re: Site Evaluation/Lot 55 Covington Creek Sub. 173 Covington Drive. Keith and Mary Kushner Tax PIN: 5789-23-9917 Dear Mr. Shelton: As requested, Robert Nations, REHS; Environmental Health Specialist with this office on November 16, 2009, evaluated the above -referenced property at the site designated on the plat/site plan that accompanied your improvement permit application. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: Rule. 15A NCAC 18A .1941 Unsuitable Soil Characteristic Rule. 15A NCAC 18A. 1943 Soil Depth Rule. 15A NCAC 18A . 1945 Available Space These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, this office has determined that none of the above options will overcome the severe conditions on this site that would prevent the site from being expanded from a four bedroom septic system to a five. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVIONALLY SUITABLE if s written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor with this office. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, Environmental Health Section. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or from the OAH web site at www.ncoah.com/forms.shtml. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150-B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is December 4, 2009. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 15013-23) to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, NCDENR. Please call or write this office if you have any questions or need any additional assistance, as follows: Telephone number: (336) 751-8760 Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 Sincerely, Robert Nations, REHS Environmental Health Specialist /df Enclosure(s): Soil -Site Report Rule .1948 Invoice LAWS AND RULES FOR SEWAGE TREATMENT AND DISPOSAL SYSTEMS 15A NCAC 18A.1900 Rule .1948 .1948 SITE CLASSIFICATION (a) Sites classified as SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules. A suitable classification generally indicates soil and site conditions favorable for the operation of a ground absorption sewage treatment and disposal system or have slight limitations that are readily overcome by proper design and installation. (b) Sites classified as PROVISIONALLY SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules but have moderate limitations. Sites classified Provisionally Suitable require some modifications and careful planning, design, and installation in order for a ground absorption sewage treatment and disposal system to function satisfactorily. (c) Sites classified UNSUITABLE have severe limitations for the installation and use of a properly functioning ground absorption sewage treatment and disposal system. An improvement permit shall not be issued for a site which is classified as UNSUITABLE. However, where a site is UNSUITABLE, it may be reclassified PROVISIONALLY SUITABLE if a special investigation indicates that a modified or alternative system can be installed in accordance with Rules .1956 or .1957 or this Section. (d) A site classified as UNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956 or .1957 of this Section or a system approved under Rule .1969 if written documentation, including engineering, hydrogeologic, geologic or soil studies, indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SUITABLE if the local health department determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent will be non-pathogenic, non-infectious, non-toxic, and non -hazardous; (2) the effluent will not contaminate groundwater or surface water; and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people, animals, or vectors. The State shall review the substantiating data if requested by the local health department. History Note: Authority G.S. 130A -335(e); Eff. July 1 1982 Amended Eff. April 1, 1993; January 1, 1990. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION K',e*,4aeYK %,L!5 (l i4ee,- Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit PROPERTY INFORMATION 73 Co a.e 91., A- �, rz o a Le Ldp5h Ca'j""SJc"Cr, Public _� Cut FACTORS 5 6 7 Landscape position ` L•. L Sloe % 'Z 14 HORIZON I DEPTH — —r Texture groupG Consistence Structure�q 0} Ykb� MineralogyS HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure -P MineralogyJ HORIZON IV DEPTH Texture group Consistence I Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: S EVALUATION BY: PC, P'� LONG-TERM ACCEPTANCE RATE: 1 O l OTHER(S) PRESENT: REMARKS: l �N\©O Ci ,`'e U tin V�Owcae Landscape Position LEGEND R - Ridge S - Shoulder L - Linear slope FS - Foot slope N Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flodd 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 3Yt 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 LlQtes 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-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■1il17111■■■■■■■■■■■n■■■■■e■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■11■■■■■■fii ■IIIA!ii■�■■■■■ICIII■■■■■11■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■i■V��iV■■■■■■I►7■1111'■■■■■11■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■!■■■■11■■■■■�■■■■e■■■■■�►1■1111 ■■■■■II■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■e■■■■Ri■■■■It■■■■■ ■■■■■■■■■ilii■■111■■■■■I■■■■■■■■■■■■ ■■■■■■■■■■■■■■,■■■■■Jt■■■■■■It■■■■■■■■■■e■■■■■■i■■1111 ■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■le■■■■Lei■■■■■I■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■ MEMO ■mom MEN ■■11■■■■■■■■■■■■■■■w7R,\i1■■■■■■■■■■■■ Elm, II■■■■Him ■■ MEN ■■mom ■■■■■■■■■■■■■11■■■■ONE NONE ■■■■Illfitill■■■■■■■■■■■■■I■ NINE ■■If■■■■■■■■■■■■ ■■■■■■■■■■■■■11■■■■■■■■■■■■■■■1111011■■■■■■■■■■■■■I■11■■■■II■■■■■■■■■■■■ ■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■r■■■■■■■■■■■■II/ill■■■■I■■■■■■■■■■■■■ UiiiiiiieiiiiiiiMNON MENNEN iiiiVmiiOiiilr iiiiiiMENNEN ■■■■■■■■■■■■■11■■■■■■■■■e■■■■■■■■■■1��1■■■■■■■■ell■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■11■■■■■■■■■■■■■111■■■■■■■■/I■r\■■■■I■■■■■■■■I■■■■■■■■■■■e■ ■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■■ ■■11■■■■elf■■■■■■■■■11■■■■■■■■■■■■■ ■■■■■■■■■■■■■II■■■■■■■■■■■■■■■■■■■■'■■11■■■\■11■/I■■■■■■■1,1■■■■■■■■■■■■■ ■■■■■e■■■■■■■11■■■■■■■■■■■■■■■■■■ I■■'■t\Ili!■11■fl■■■■■■■11■■■■■■■■■■■■■ ■■■■■■■■■■■■■11■■■■■■■■■■e■■■■■■■■■■■■Iiia■■■■I■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■Ike■■■■■■■■■■■■■■■■■■■■■■■■■■■■!!�•��7■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■'■■■■■■■■■■■■■■■■■■■■\114WXWemom ■■I■61■■I11■■■I■■mom ■■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■O■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ A' � 1'PL;ICATI6 R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 r`r: ❑ Site Evalujtion/lmprovement Permit ❑ Aut�pbansion/ZCoddification nstruct (ATC) ❑ Both Application: ❑New System ❑Repair to Existing System of Existing System or Facility ***IMPORTANT"`** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. A DDT T(` A ATT TATUnD A A A TTn'KT Name to be Billed .ms s - �_ . _ A_!-, A: -- -Contact Person— Billfng Address Z -5 -7 L/ y t, %, , }- Home Phone City/State/ZIP /t21 j,, , J(, 11 < ,✓ . Z -7o -Z Business Phone 7 S / - Z Name on Permit/ATC if Different than Above e J. -. g Mailing Address 11.S e, �,- J _ _ I f-> _ 0 ...e —City/State/Zip:/� : ✓ a - t ,�/. C. Z� 0 0 rKUYEK l T 11NV UK1VIA l WIN TDate House/t acuity Comers Flaaaed NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) _ Owner's Name Ka `. } L-. C', ,1, , Phone Number. I 1 S�' Owner's Address 17'3 Cit /State/Zi 4/.. -�.) Y p �-�� . C -7 C .> Property Address S r _ City Lot Size , < , Tax PIN# Z3 Subdivision Name(if applicable) Section/Lot# S Directions To Site: �-O 7 '� > f . J If the answer to any of the following questions is "Yes",supportin cumentation must be attached: Are there any existing wastewater systems on the site? _ es No Does the site contain jurisdictional wetlands? _Yes 4-N6— Are there any easements or right-of-ways on the site? _Yes _ o Is the site subject to approval by another public agency? _Yes ZNO-- Will wastewater other than domestic sewage be generated? Yes 4AIo- fT nT[�TTTAT!'IT TTT T lITTT TTTT Tl��T T it R SIMENCE PILL UU 1 1HK BOX BELOW # People 41 # Bedrooms # Bathrooms Garden Tub/Whirlpool es ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating a d gging or staking the house/facili location, proposed well location nd the location of any other amenities. r _ 'er%' '''L a /,/- :-1 c. Site Revisit Charge Prop owne s or owner's legal representative signature Date(s): It 3 v % Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account # kq900093 Invoice # Permits s A I COUNTY HEALTH DEPARTMENT (��fo Lqnvironmental Health Section PROPERTY INFORMATION„ P.O. Box 848 Directions to property:'t-1"' Mocksville,NC27028 Subdivision Name. �1Vi1�i'��hJ -^'�\�4, Ut, vt•,J Phone #: 336-751-8760 } Section: 1 Lot: AUTHORIZATION FOR —7 WASTEWATER Tax Office PIN:# - ,_ - 15j 1 SYSTEM CONSTRUCTION 0426-33 AUTHORIZATION NO: 1� Road Name:ti~��"` l 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. (In compliance with Article I I of G.S.Mprer l30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ✓ �C , ,% ��'�,. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION o(, IS VALID FOR A PERIOD OF FIVE YEARS. �_--ENVIRON 'Njk At-Tli SPECIALIST DAT ISS ED RESIDENTIAL SPECIFICATION: BUILDING TYPE _J # BEDROOMS 14 # BATHS 4 # OCCUPANTS —4— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE t � # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE' SPE WATER SUPPLY bESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE y SYSTEM SPECIFICATIONS: TANK SIZE GOAL. PUMP TANK GAL. TRENCH WIDTH ' `"�' ROCK DEPTH LINEAR FT. OTHER �(�! ��O�rt..�t�rl=cam REQUIRED SITE MODIFICATIONS/CONDITIONS: KFS'. �l-! �'�1'� "hJ�'• L-1 1� IMPROVEMENT PERMIT LAYOUT w S UA bal a a FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. p OPERATION PERMITG 10 SYSTEM INSTALLED BY: to AUTHORIZATION NO.i'�'�\ OPERATION PERMIT rVk1S--11rq- t_1A= **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIC TE THAT THE LCR E HI WITH ARTICLE I I OF G.S. CHAPTER 130A, SECTION .1900 "SE NT A AL YSTEMS ' GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIO F TIME. DCHD oaro2 (Revised) fJ<�f J ? i6Ud ? j- 40;0c-0 5 701 DATE: EN INSTALLED IN COMPLIANCE SHALL IN NO WAY BE TAKEN AS A - s 1 _ l.h NTY HEALTH DEPARTMENT ((v(� t T DAVE CTvironmental Game:,: '' 't �" rs lam' ^1t Health Section PROPERTY INFORMATION:., • r Directions to -property: �.- �-' P.O. Box 848 Mocksville, NC ?7028 1 x ° �` Subdivision Name � :��' �'s:,l'� 4.. < � ,�,..:..: •• Phone #: 336-751-8760 1 Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# 5- A` 1,.1? 1- AUTHORIZATION NO: 002693 A Road Name 3'"5fiP **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 For n/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen -nits. (It1 compliance with Article 1 I of G.SX ter,130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVII20N(v11NNT L tEALTH SPECIALIST DAT ISS ED r tLl RESIDENTIAL SPECIFICATION: BUILDING TYPE _4jat -�1:?~ - # BEDROOMS i"'I #BATHS #OCCUPANTS i GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE F "--� A('4'21L WATER SUPPLY ` '1'L✓i"�I� DESIGN WASTEWATER FLOW (GPD) 1 E �. NEW SITE REPAIR SITE e SYSTEM SPECIFICATIONS: TANK SIZE GAL. ^-P.,UMP TANK GAL. TRENCH WIDTH �' ROCK DEPTH ?"'? LINEAR FT. OTHER P _f i ( 's I a,.l 'k) �I; .6.1 1�-. I a ~ ✓(i K`: t .�tic� tk ;;:, -I„I.� REQUIRED SITE MODIFICATIONS/CONDITIONS: .1 1 �t 1 T IMPROVEMENT PERMIT LAYOUT f�M. r tl - ------------- "I -._ _ - _..._........ FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT 1 v \ SYSTEM INSTALLED BY: M R ^ r - � i � or, Pat�1S L_.l AUTHORIZATION NO.i—t. 5/-\ OPERATION PERMIT 107.1 409 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIC TE THAT THE I2 ESCR WE HAAEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SE NT A AL SYSTEMS", SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY� GIV/EpN PERIO F TIME. DCHD 07102 (Revised) 'p. e., O t i iJ V DAVIE CQUNTY HEALTH DEPARTMENT .r�Environmental Health Section PROPERTY INFORMATION, P.O. Box 848 i Dlfections to -property: (' '' 1 `' Mocksville, NC 27028 Subdivision Name: V1 KY -I 1,, Phone #: 336-751-8760 Section: Lot: i AUTHORIZATION FOR i . WASTEWATER' w SYSTEM CONSTRUCTION Tax Office PIN:#, AUTHORIZATION NO: 002693 A Road Name:1 1 " !M 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. (In compliance with Article 11 of G.S.' Hli pter,I30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YE,�RS. ._ ENVIRON NTAL HEALTH SPECIALIST DAT ISSUED ti RESIDENTIAL SPECIFICATION: BUILDING TYPE ±LJ;�I~.# BEDROOMS I # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No � l LOT SIZE" 4YPE WATER SUPPLY `—' �''YESIGN WASTEWATER FLOW (GPD) �" � NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. +- OTHER J!n t..- .�1 �t r� ,' . �% \t -t. V� 1 t.►+� �Y TLL REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 0 a �--� .--�` rte' ► tvd ._. ,_ '! y , .I LtA vit;r,► r % , {, �� :, it rMt�I�t S ! 1 vr.t-1 i Ott Is',t: ior't`rlwl` 1 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) f51-8760:- OPERATION {51-8760-OPERATION PERMIT��' SYSTEM INSTALLED BY: tis AUTHORIZATION NO, LOPERATION PERMIT "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA] WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEV\h GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT( DCHDovoz(Revisea) 000q TEHTTHE SJf+5ItIPHqT ESCR ,10FAL SYSTEMS" [LYFORANY GIVEN PERIOD -0F TIME. ai' ��UVUr(t- X701 0 ,u ..DATE:4 '/ i / EN INSTALLED IN COMPLLQIriCE .> SHALL IN NO WAY BE TAKIN-AS A N ' .. DAVIE COUNTY HEALTH DEPARTMENT •°- - �'1 i 1�t - nvironmental Health Section PROPERTY INFORMATION tions to P i f-:' P.O. Box 848 Subdivision Name: dir) property: -( Mocksville, NC 27028 w (' 6 ,�-' j ! r j Phone #: 336-751-8760 t:-4 Section: Lot: + AUTHORIZATION FOR _7WASTEWATERfj Tax Office PIN:# d - --- - A SYSTEM CONSTRUCTION. 17 �'k'�1 "'^I� AUTHORIZATION NO: 002667 Road Name: Zip. **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. (In compliance with -Articlei'11 of G.S. Cha ter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION _r 1 IS VALID FOR A PERIOD OF FIVE YEARS. DATE ISS; ED RESIDENTIAL SPECIFICATION: BUILDING TYPEI } S,: BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE J 4). TYPE WATER SUPPLY 1 + DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE G� ,(y t SYSTEM SPECIFICATIONS: TANK SIZE I?GAL. PUMP TANK GAL. TRENCH WIDTH ti--fi �?+ ROCK DEPTH LINEAR FT. ---1-r_,' OTHER e d � r REQUIRED SITE MODIFICATIONS/CONDITIONS: +.. :-4•) (,> q..r� �l I% • 4 - IMPROVEMENT PERMIT LAYOUT IJl)Pr6"'1 k, "17, L 10 1 4 loe, 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: Ey, tST1L* z U�v -tA34D4TE- qr AUTHORIZATION NO. ZW ' A OPERATION PERM T BY: DATE: 10& - "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM ACRIBEDABtOV S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. _#__ATION NO: 1834 DAVIE COUNTY HEALTH DEPARTMENT A 1Z Environmental Health Section PROPERTY INFORMATION �ittee`s P.O. Box 848` j -, 4a " �� ' r _%. r Mocksville, NC 27028 Subdivision Name: �. y �; l Phone # 336-751-8760 Directions to property: � LJ%i / t Section: Lot: AUTHORIZATION FOR WASTEWATERf .,- SYSTEM CONSTRUCTION Tax Office PIN:# - Pl C!G• I,) 2. Road Name>.�� .°- �wl—zip: 4va06 **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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f�.*t, / d, � .4, DNMENTAL HEALTH SPI ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION • _� . i ij'r;, IS VALID FOR A PERIOD OF FIVE YEARS. ALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS V' # BATHS ?,f# OCCUPANTS GARBAGE DISPOSAL: Yes or No V COMMERCI'jAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE V/'// TYPE WATER SUPPLY { [.I DESIGN WASTEWATER FLOW (GPD) C5�0 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE.%��, GAL. PUMP TANK GAL. TRENCH WIDTH L: Pc � ROCK DEPTH., r,.! LINEAR FT: E�f OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1 , — "CONTACT A REPRESENTATIVE OF THE DAVIEOU HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:030 PHE Wq OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT �+( f2- SY M TALY: 0�6 r AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED W COMPLIANCE WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) APPUCATION FOR SITE EVALUAHON/IMPROVEMENT PERMIT & AT Davie County Health Department Environmental Health Seecbion DEC 10 1998 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH n ur nnn.ry ***IIWCRTANT*** THIS -APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED. INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed > ff / -dkyx so, - : , Wcll Contact Person Nailing Address _ I 7 My (w we4r Boma Phone 44 V-- 7,012 'V"' city/state/ZIP , Business Phone 1_15/. S (vu� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: &YS1te Evaluation V Improvement Permit/ATC 0 Both 4. System to service: V House ❑ Mobile Home 0 Business ❑ Industry 0 Other 5. If Residence: # People # Bedrooms 5 # Bathrooms D Dishwasher O Garbage Disposal 0 hashing Machine 0 Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/other: Specify type # Commodes # Showers # Urinals # People # Sinks # hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 0 well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No If yes, what type? ***IMPDRTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: _l L)6 X 3v z)( %) 2 -)Oyy WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # S -1 k'7 - 2 3 " `1 I "7 ��!!!5"e-- Property Address: Road Name / City/Zip rl If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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. 1, 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 to conduct all testing procedures as necessary to determine the site suitability. DATE I A -/D- 9y S1GNA THIS AREA MAY BE USED FOR DRAWING YOUR SITE' P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and sept locations). Revised DCHD (07/98) Account No. q 3 Invoice No. 3 1 Permitteee's �- DA I C s LINTY HEALTH DEPARTMENT �t.-•environmental �,_,� Health Section PROPERTY INFORMATION., 'P.O. Directions to property: L^'7 t Box 848 Mocksville, NC 27028 ^^)) tt Subdivision Name. Phone #: 336-751-8760 Section: I Lot: - -= AUTHORIZATION FOR WASTEWATER _ Tax Office PIN:#.° �`r"'� - P - 's SYSTEM CONSTRUCTION AUTHORIZATION NO: 002693 A Road Name: '.,L ;f�� i�Lt`Ztip.t,.�..,(,, **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. (In compliance with Article I I of G.S. CT a-ptte ,,l 30A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE r i # BEDROOMS Ll # BATHS �'y # OCCUPANTS 1 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE {,,� # PEOPLE # PEOPLE/SHIFT 1# SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE`6 _€ YPE WATER SUPPLY —U'L)t'31 bESIGN WASTEWATER FLOW (GPD) 7' /NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GOAL. PUMP TANK ^ GAL. _ TRENCH WIDTH ` ' ROCK DEPTH !�L LINEAR FT. OTHER (�? " 3 "+ r=j=-�'r� \!-'l d. 1 e=ra; ��`� ak' �a~" REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT A,. , T'� x 's { t. -,.:-t'' Y `1",12 <t xr I� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT L�A� SYSTEM INSTALLED BY: fAtw AUTHORIZATION NO.) -L 54\ OPERATION PERMIT **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIC TE THAT THE ESCR ABGVI WITH ARTICLE 11, OF G.S. CHAPTER 130A-, SECTION .1900 "SE NT A AL YSTED GUARANTEE THAT THE SYSTEM WILL FUNCTIO/N� SATISFACTORILY FOR ANY GIVEN PERIOO F TTI�ME. rrwn mm� ra..,i..ni �f: i r..`=� lr r. r` , ; DATE: q8 AEEN INSTALLED IN COMPLIANCE (er SHALL IN NO WAY BE TAKEN AS A *.*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 forBuilding Permits. (In compliance with Aiticle tl l of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ell-{ r' { ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - t IS VALID FOR A PERIOD OF FIVE YEARS. lNMENTAL HEAT TH SPEOALIST DATI ISSbED RESIDEI I4TIAL SPECIFICATION: BUILDING TYPE 'fg % # BEDROOMS I # BATHS 14 # OCCUPANTS t GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE r�� S`�;=-TYPE WATER SUPPLY DESIGN WASTEWATER FLOW GPD +�.�-NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 10JGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH � LINEAR FT.'•--�•-� - OTHER "tilpP.i=rt-I��•_.ic«.i--11 fr f 4ft'.6 if REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ti, p ;fi'^• � ,a..t.iB:i f�-,C, ��,�.:� V�a11_id"` 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED, BY: t X / J 2qNJL i jATC 4�� AUTHORIZATION NO. Z60A A OPERATION PERMIT BY: DATE: CI Gt/ 10(0 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM CRIBED ABOV S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I i OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. _Permittees _ 9 DAVIE CUNTY HEALTH DEPARTMENT 1, Name: i -4,r a nvironmental Health Section PROPERTY INFORMATION Directions to property: � P.O. Box 848 hocksville, NC 27028 Subdivision Name: ` �.. �- ~.�1' *w- ..^+V r ,:t :t^, �: ; -o Phone #: 336-751-8760 Section: Lot: T AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - AUTHORIZATION NO: 002667 - Road Name: Zip: *.*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 forBuilding Permits. (In compliance with Aiticle tl l of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ell-{ r' { ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - t IS VALID FOR A PERIOD OF FIVE YEARS. lNMENTAL HEAT TH SPEOALIST DATI ISSbED RESIDEI I4TIAL SPECIFICATION: BUILDING TYPE 'fg % # BEDROOMS I # BATHS 14 # OCCUPANTS t GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE r�� S`�;=-TYPE WATER SUPPLY DESIGN WASTEWATER FLOW GPD +�.�-NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 10JGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH � LINEAR FT.'•--�•-� - OTHER "tilpP.i=rt-I��•_.ic«.i--11 fr f 4ft'.6 if REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ti, p ;fi'^• � ,a..t.iB:i f�-,C, ��,�.:� V�a11_id"` 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED, BY: t X / J 2qNJL i jATC 4�� AUTHORIZATION NO. Z60A A OPERATION PERMIT BY: DATE: CI Gt/ 10(0 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM CRIBED ABOV S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I i OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. May 26 06 11:11a Ju` 1 2 2O '0V davie county envhealth 336 751 6796 P.2 Ind ASTI=JZ17T7�-C= TION FOR SITE EVALUATION/IM'PROVEMENT PERMIT & ATC ,y � Davie County Health Department Environmental Heahh Section P.O. Box 848/210 Hospita I Street Mocksville, NC 27018 (336)751-8760/ Fax (336)731-8786 Alt on F • ice Evaluation/hnprovement Permit ❑ Authoriza Jon To Construct(AT'C) D Both *"'IMPORTANT*'* THIS APPLICATION CANNOTBE PROCESSED U BLESS ALL OF THE REQUIRED Q% INFORMATION 1S PROVIDED. Refer to the INFORMA'T'ION BULLET IN for instructions. 1101RIM410VAkLOM Name to be Billed �/-_ , 4 . ,t -koi tact Person (f� Billing Address -1 Z zs--7y S I -l-, (, �l LJ IFomc Phone City/State/ZIP pl-7. ` l _ j, t . BusinessPhone -I?- S ^Zoo Name on Permit/ATC if Different than Above Mailing Address r;tv/Str 1s /7;,, NOTE: iKYY LNIIUKMA'IIUN _ A surveyplat or site plan must accompany this application, (Permit is valid for 60 months with site plan, no expiration % Street Address 1 "' z 1 10,- lf^: Subdivision Name - Direction 9 ameDirections To �� Site: , Q. coq)lete plat.) Tax P N#. 5 Lot Size- . 25 & ,fir- -- L_• I—Ir a 7►, 1 t J Date House/Facility Comets Flagged D o b If the answer to any of the following questions is "yes", supporting dtion must be attached. ocument Are there any existing wastewater systems on the site? DNo Does the site contain jurisdictional wetlands? Dyes C! i—1 Are there any easements or right-ofways on the site? Oyes Is the site subject to approval b another public agency? ayes Will wastewater other than durrestic sewage be generated? Dyes;3 . IF RESIDENCE FILL OUT THE BOX BELOW_ _ # People _ # BedraoMS �Z # Bathrooms _ _ Garden Tub/Whirlpool es ONo Basement: Oyes CINo Basement Plumbing: DYes DNo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footal;e of Building # People # Sinks # Commodes _ # Showers _ # Urinals _ Estimated Water Usage (gallons pLT -:lay) (Attach docur ientation of similar facility water consumption) FOODSERVICE ONLY: # Scats Type system requested onvcndonal OAcceptcd Dlnnovative flAltem Itive ❑Other Water Supply Type: oonty/City Wavir D Now Well DExist ng Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes If yes, what type? This is to certify that the information pra.ided on this application is true and c.orrect to the best of my knowledge. I understand that any permits) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Represertative of the Davie County Health Department to conduct necessary inspections to etenni:- t:omph with applicable laws aad Hiles on the above described property located in Davie County and owned by e I � L ry S L. -e-- r rop wner's r owner's legal representative signature —7 41 d Date Sigagiven DYes ONo Revised 2106 Site Revisit Charge Date(s):_ Client Notification Date: EHS: r�f Account # %) % Ly� V' 1+ V Invoice # AUTHORr7—,ATION NO: 1834 DAVIE COUNTY HEALTH DEPARTMENT A 2�z r `Environmental Health Section PROPERTY INFORMATION Permittee's , / P.O. Box 848 �� '*kir Name: n'a •JnI� �,? ,. Mocksville, NC 27028 Subdivision Name: � �/`/A4?7M/L ,A y� /f Phone # 336-751-8760 Directions to property: c'1 [ i/, "/ E'� Section: Lot: 11 AUTHORIZATION FOR WASTEWATER Tax Office PIN: �s;� SYSTEM CONSTRUCTION 4 ! 3 C a v ,'J±' Ck . R• Road Name zip: A. **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building-Peimits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office whegapplying for Building Permits. (In compliance•with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ✓. , F y' �: 'r' IS VALID FOR A PERIOD OF FIVE YEARS. 'AL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE — # BEDROOMS S0 # BATHS, Sr# OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE! i TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE,�),P,% GAL. PUMP TANK GAL. TRENCH WIDTH "ROCK DEPTH,6LL LINEAR FT: ?r?' OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "CONTACT A REPRESENTATIVE OF THE DAVIE BETWEEN 8:30 - 9:30 A.M. OR I:0%X30 P. OPERATION PERMIT JAL SOD HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM EpIJ OF INSTALLATION. TELEPHONE # IS (336)751-8760. I � L ALP Y: n a AUTHORIZATION NO.jV�/ OPERATION PERMIT BY: � DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) • Permittee's r y,a 1 DAVIE, COUNTY HEALTH DEPARTMENT ;?ame: ''t a $, ' i k.\ ' a in0 Environmental Health Section PROPERTY INFORMATION Directions to .1 taP P.O. Box 848 t property: --•. Mocksville, NC 27028 Subdivision Name Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#f> E �i� AUTHORIZATION Mp awe n'P NO: G 2 9 6 6 A Road Name: Zip. **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. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE Y # BEDROOMS # BATHS # OCCUPANTS e/ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ,.° • NEW SITE REPAIR SITE" ~ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK a°�,/t� GAL. TRENCH WIDTH r ~�� ROCK DEPTH,c �7�={ LINEAR FF.� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS:.,f6' "S 14, P`-e'� e: >" r; r' ,( �' .. i ?•° L% i P ;t +•s i' r; .',"art rr / .A, (Z ! .r? 9'� P''� ...,. . 4 F'! a r"3� 'S •e^ .�! !F , /" i e . I'r L-. �r•e IMPROVEMENT PERMIT -LAYOUT / r g f ILI r ! ......,....,w w,F Y "j�/ s�Yt; . 1 t ""'r '_ F�•,� 7 "'t ! a ! 1'r 5= � �= r"� ^ d t" r' f v � r� r. � 1 � R l r- t ' FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 1 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. nrun mm iu.,.;—, Edo RIA -11L, ?14#1pm DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION 0, 'R IV 4 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME-Nav k4,5hWz_ PHONE NUMBER ADDRESS Adva Ivee- SUBDIVISION NAME �- LOT # DIRECTIONS TO SITE (�`7 �• �e� W Y nig C�//I fJ�®%X 'Y 1�9��PS DATE SYSTEM INSTALLENAME SYSTEMINSTALLED UNDER/,Pi�f /U lX//y?rf'• TYPE FACILITY , NUMBER BEDROOMS NUMBER PEOPLE SERVED— TYPE ERVEDTYPE WATER SUPPLY _SPECIFY PROBLEM OCCURRING At B14 6wlw%Z- lValas whir DATE REQUESTED- d ZQ 9 INFORMATION TAKEN BY AANC& This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Fley. 1/93 n balrm&! iAler&SPl J, •�yrrrif 1'.•• "'APPLICATION ` R SITE EVALUATION/IMPROVEMENT PERMIT &ATC ✓.1 Y-- �9u=For: ❑ Site Evaluation/Improvement Permit ❑ Authorizaftan'`Io Construct (ATC) ❑ Both Application: ❑New System ❑Repair to Existing System PL�ansion/Modification of Existing System or Facility "Appli Davie County Environmental Health � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 ***IMPORTANP** THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED j &ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. l AFFLILAN 1 Name to be Billed Contact Personr Bil ig Address �2 -7 1� ; a- ` �/ �� •: > i."' Home Phone City/Statg/ZIP 4�''7 1� .: )► �•' 2- -? Z S Business Phone Name on Permit/ATC if Different than Abover_� Mailing Address l J 5 T . . �. City/State/Zip r} _•T J --y. C. FKUFLK 1 Y 1NfUKMA I1UN *"Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pen -nit is'. valid for 60 months with site plan, no expiration with complete plat.) Owner's Name jf ti '.�� ._ >, _ .. - Phone Number Owner's .Address i 7 'S L -• . -_. 1 . - L .- . �.. City/State/Zip �% Property Address �� . _. City Lot Size - Tax PIN# '� $ `7 - t. 3 71/'-7 Subdivision Name(if applicable) C' ., '. ; . _ C"+. . , P" Section/Lot# ' Directions To Site: ✓ t'' „, _/, r` ( -7 ' ( { 1 If the answer to any of the following questions is "Yes",supportin cumentation must be. attached: Are there any existing wastewater systems on the site? _ es No Does the site contain jurisdictional wetlands? _Yes i..N _ Are there any easements or right-of-ways on the site? _Yes :_N6 Is the site subject to approval by another public agency? _Yes =old' Will wastewater other than domestic sewage be generated? Yes ,,No r It KL' Jllli'.1V1 r. TILL UU l Mr, 15UA 151;LU W # People # Bedrooms S # Bathrooms ' Garden Tub/Whirlpool es =No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: _ onventional ❑Accepted ❑innovative ❑Alternative ❑Other Water Supply Type: R-County/City Water ❑ New Well' ❑Existing Well n Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? f_l Yes L1•-NIo' If yes, what type? This is to'certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pennit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating apd,f�agging or staking the house/facilitylocation, proposed well locationrDate(s): n of any other amenities: - Site Revisit Charge Prop'o'wne ski' or owner's legal representative signature 1�� / / A / C, ; cation Date: Date Sign given []Yes t_ -!No Account # C Cl J a I goV Revised 11/06 invoice # DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil / Site Evaluation APPLICANT INFORMATION Water Supply: Evaluation By: PROPERTY INFORMATION -73 9 -1G _A' 91-d C/ Le MUre•' . IOU � .,,t ..,ter ,� I s; -uctuier 1neral6 ALWETNESS. ?STRICTIVE'HORIZON CC Concave slopehouldCV > Cozwex� s'lopelope T Tena eoot sIFP Flo d pJ. N n e sloH Head slope d ^ Texture ' S = ,Sand LS ` Loamy sand # x SL Sandy loam L ' LoamSilt ` SICL Silty clay loam , SIL •Silty�lgam l tCLr"Ctay�loam �SCL `Sandy ciayloam SiSandvi.�clav SIC � Siltv:`clav C F"C'lavI I lug e �► dJ i I, BMW ,II t r MUre•' . IOU � .,,t ..,ter ,� I s; -uctuier 1neral6 ALWETNESS. ?STRICTIVE'HORIZON CC Concave slopehouldCV > Cozwex� s'lopelope T Tena eoot sIFP Flo d pJ. N n e sloH Head slope d ^ Texture ' S = ,Sand LS ` Loamy sand # x SL Sandy loam L ' LoamSilt ` SICL Silty clay loam , SIL •Silty�lgam l tCLr"Ctay�loam �SCL `Sandy ciayloam SiSandvi.�clav SIC � Siltv:`clav C F"C'lavI I "A ITHOW,ATION NO: 1 8,34 DAVIE COUNTY HEALTH DEPARTMENT A ?~' _ Environmental Health Section PROPERTY INFORMATION Permittee's Z. £F* �,'M' P.O. Box 848 �� ! f� Name:�a� Mocksville, NC 27028 Subdivision Name: F*? .a�" ; ; Phone # 336-751-8760 Directions to property: <'.� C. �a r'Y! t' Section: Lot: AUTHORIZATION FOR. WASTEWATER Tax Office PIN: SYSTEM CONSTRUCTION - 3 8 V �' ,' �t. 2• Road Name ANA, .Zip: a **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. (In compliance -with Article I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE .t # BEDROOMS S".S' # BATHS,;V, Ste# OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE`1" r; ,' TYPE WATER SUPPLY �� ' DESIGN WASTEWATER FLOW (GPD) t NEW SITE 1--F REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE.%1.7 'U GAL. PUMP TANK GAL. TRENCH WIDTH w%f ROCK DEPTH.-� LINEAR FT: „fr,-,;'" REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "CONTACT A REPRESENTATIVE OF THE DAVIE BETWEEN 8:30 - 9:30 A.M. OR 1:0630 P. OPERATION PERMIT jp HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM E, PAJ OF INSTALLATION. TELEPHONE # IS (336)751-8760. ;tr � AUTHORIZATION NO. OPERATION PERMIT BY: ,� �� DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05196 (Revised) APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT h °1 tt ' Davie County Health Department Environmenfa/Nealth Seg Hw DEC 10 10 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVI DAV EENTAL HEALTH LTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Biiled (Xjj �p.1G &-'rd: Contact Person !failing Address /ice% wil (i . we' -Sr Home Phone ?Q VL� City/State/ZIP S t//lily , Al -el Business Phone 7�/• 7 �Z� 2. Name on Permit/ASC if Diffexent than Above Mailing Address 3. Application For: &VSite Evaluation City/State/zip T Improvement Permit/ATC ❑ Both 4. system `to service: W House ❑ Mobile Home ❑ Business ❑ Industry ' ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Mater Usage (gallons per day) 7. Type of water supply: 9 County/City ❑ well ❑ Community a. Do yoj anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type' ***IMPORTANT*** CLIENTS 11IUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. F.yther a PLAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: lob X 3vz X 3vz- X l vz WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: t# 5 —7 2 -S 1 1 % • DOT) fns —wti Property Address: Road Name 061 5 . `0 cw City/Zip !A L 6 If in a Subdivision provide information, as follows: Name: 00V,,L�Z'nV-' et -eek Section: Block: Lot: •5y Date Property Flagged: 16^ —p 0 This is to certify that the -information provided is correct to the best of my knowledge. I understand that any permits) 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 1 am responsiblefor all charges incurred frons 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 to conduct all testing procedures as necessary to determine the site suitability. DATE j c" j a" 0J g SIGNA' AP THIS AREA MAY BE USED FOR DRAWING YOUR SITETIInclude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and sept)Z vocations). Revised DCHD (07/98) Account No. Invoice No. 316 ,e F F Revised DCHD (07/98) Account No. Invoice No. 316 NHAJk L JIVCYYAU\ tAJkMt.N I: t1 WIUt AND �$�•\ T CENTERED ON SIDEWALK 0 w \ O DRAINAGE EASEMENT: 25' WIDE. AND 7 �\ �\ CENTERED ON CULVERTS AND DITCHES CONTROL"' r \, CORNER 1 7D DRAINAGE EASEMENT ALONG CREEK ' 83.21' +14.79' \ O TYP. BUILDING SETBACK 1x8Z7" \ .00' S 87' S5' • r �'• ` ` � 90 TENNIS COURT COMMON AREA � r — -1:!-- ??'•06• `P \ ` ` ` • 1, � k`L ` \ 44, � 1 4 \4 5 N I TENNIS g \ & \\ F\ \ I COURTS 8 8 \ i •� o l 45 // / h� �, \ c.3 _ _ 3oo.ao'_ 4 5 _ _ 168.79' i o \ \ / /fes G� %� Q ?O PUBLIC RD. ' TAL 4 9.19 N \ GG . — I C: S 6 21.19' 1000;•— 100.00' 100.00' 98.00' 50.00' X 1 1 I 11 i WI Iw 52 ;t ink I� i� I jW rt NI IN ( IN I IN 1 1 ,' 1 CO a G� t `� G`\ I N 10 i Iry 1 I~, I lay 1 C•� A N4 53 54 I I I 55 IcV N I ►N I 1w I 1� 1 to I 1. ,1 59 .�' *i Z 4 �/ \\ �s��\ 5j `\ OSo•\ I I 1z I tz I�_'' I I5% ► I 58 Ian 1 0 8 ` �` ►. I I. I I. 1 Iz I Iz ► I� 1 O o I 1 I oil IN 1 iso I IQ 1 I� '91'o I I0 i I 0 1 1 l0 1 0 I \ 4-\ -J C -----J L 310.00' 120.00' t 00.00' 100.00' 100.00' 100.0 108.00, 0 AL 1918.48 N 7'31'31 W -� 38' LOT 36.01, MAP H-8 W.J. ELLIS & WIFE HAZEL L. ELLIS DB 49, PG 426 .DEVELOPER R.C. SHORT CUSTOM HOMES (336)998-4772 APPLICATION FOR SITE EVALUATION/IMPROVEMENT 3ETZArIT Davie County Health Department D f Environmental Health Section P.J. Box 848 Mocksville, NC 27028 (704) 634-8760 ""IMPORTANT"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. el e� 11 1. Name to be Billed - l�'�D +•+4 E S Contact Person rir' Mailing Address ?1)/1 jpi (1 ?( oZ►�� C� t� / Home Phone t City/State/Zip di'/1 Udij La_�70 k3 Business Phone / �k-Y7%1 A3-��%/P 2, Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 015ilte Evaluation [ ] Improvement Permit & ATC,� [ 1 Both , 4. System to Serve: [ ] House [ •] Mobile Home [ ] Business [ ] Industry [ ] Other 10+ tiitr l di S ioyJ 5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [, ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commoees # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes H'No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: A>7 C4 60 a4,PCC-e- WRITE DIRECTIONS (from Mocksville) TO PROPE] Tax Office PIN: # 's -!)-4 - _—V3 % c�126 1 ni 1\ ind V mit; Property Address: Road lameDVro� J( / m ) — jG Z p� j G City/Zip r�. m ij If in Subdivision provide information, as follows:' Name: btl�n-,46Aj Oreek / /agQaSed Section: I Lot #: A- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued here.41 subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsil changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Auth, ve of the Davie County Health Department to enter upon above described property located in Davie. County and c �r v -1.1 IM=. � • Revised DCHD (06-96) all testing proce,Oui�es as necessary to determine the site suitability. Ml;; ,tl;r.t A11111LiF 11,5T.0 )-Oft I)IMIVIN6 5111 PIAN: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION r e _ Water Supply: Evaluation By: On -Site Well Auger Boring Community, Pit SECTION LOT DATE EVALUATED ! PROPERTY SIZE�� ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landsca fe position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON lI DEPTH Texture group C— Consistence ? Structure ,{' Mineralogyj HORIZON III DEPTH Texture group_ Consistence Structure Mineralogy HORIZON IV DEPTH Texture,lroup Consistence Strut. ,ure Minera.logy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION / LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE. RA REMARKS: DC' .4 (01-90) Landscaae Position EVALUATION BY: OTHER(S) PRESENT: 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 oist 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 • :,R - 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(suitabie), PS(pro-risionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 U SIDEWALK EASEMENT: 8' WIDE AND 2QO. enc r n�J� CENTERED ON SIDEWALK (` S DRAINAGE EASEMENT: 25' WIDE AND cp •� 7 �� \ CENTERED ON CULVERTS AND DITCHES CONTROL 2 �• 1. 3" t~ � � � CORNER � DRAINAGE EASEMENT ALONG CREEK ' `C TYP. BUILDING SETBACK 83.21' X14.79' \ g 3 6 \ 1 sem\ \ 1 ag.00 X87' 55' 27" ?c J TENNIS COURT COMMON AREA 3 r — — - -- — — -- -- os. s ti i S` 4 ' 4 5 �, 1 FUTURE TENNIS COURTS L------------ — 5 4 `O / / h� Ca — — 300.40' _ 4 5 16879- s �_ _i � � / / � � C,• — TAL 469.19 N 7' 31 31 -- G O 6 21.19' 100�0� inn nn, — 100.QO98.00' 50.00' ' / 1 ' 6 J' � `��\,5 �^\ \\\ I w1 I``' I Iw I I I I 1 I• I 8 I' I Q� .3 S2 I I • Iw Iw 1 r.1 l /� \\ ��Icv I Icw In I I I Im C•( G� \ \\ '1'g\ I r, �I N I1N � �N I I� I� i . 54 IN I 55 IN i 1�I io i �N < / \ s\ ` �S\ I zl Iz Iz I I I 57 I I �8 4 I i �. 51 \\ •o.\\ I I ►. I Iz I ►$• 1 0 Iz I I� I A \ V a i O�IINO I to r o 50 \\ �j�\ \\ ► I I I I I I i� I I0 I +o --------------------J' L 310.00' 120.00' 100.00' 1 100.00' 100.00' 10Q.0 1 8. 0' t 0.00' 0 AL 1918.48 N 7' 31 31 w 38 LOT 36.01, MAP H-8 • W.J. ELLIS & WIFE HAZEL L. ELLIS D8 49, PG 425 QEVELOPER R.C. SHORT CUSTOM HOME .(336)998-4772 //.Cu Permt�tec's n ' y DAVIE CUNTY HEALTH DEPARTMENT Dame: 3 `>�'1{ i''' i . At nvironmental Health Section PROPERTY INFORMATION . P.O. Box 848 1 l y..r. -. t F Directions to property: * .� t- Mocksville. NC 27028 Subdivision Name: A' ? '• Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION t AUTHORIZATION NO: 0 0 2'S 6`7 A Road Name " Ztp r : **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. (In compliance with-Aiticle A I of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIROi4MEv NTAL HEALTH "SPEdALISi' DATE ISSUED RESIDE14TIAL SPECIFICATION: BUILDING TYPE�(. %s#BEDROOMS L! #BATHS L4 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No % KI' - r 3� � �' " ~ LOT SIZE' .TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) :'r NEW SITE REPAIR SITE hY �y SYSTEM SPECIFICATIONS: TANK SIZE AL. PUMP TANK GAL. TRENCH WIDTH ^ ROCK DEPTH j'`Aa LINEAR FT. •': r p [ 't 3iQ h.._-7 -•• d`^ 8 p R...; r � a. T OTHER } {'.% t• ..lnJ _ r REQUIRED SITE MODIFICATIONS/CONDITIONS:'"� A * y 1 , • I° a.:'a s f• I IMPROVEMENT PERMIT LAYOUT iI 1 t }i" r kb..r. �• { FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT I� ►7 SYSTEM INSTALLED,BY: 2,q 1�7 z AUTHORIZATION NO. OPERATION PERMIT BY: DATE: ta "THE ISSUANCE OF THIS OPERATION PERMIT. SHALL INDICATE THAT THE SYSTEM));rCRIBED ABOV S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. n14n mm,) (R—i.ml DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION �i PROPERTY INFORMATION Account #: Tax PIN/EH #: Billed To: Subdivision Info: Reference Name: Location/Address: Proposed Facility: Property Size: Date Evaluated: _% 17kCl Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4, 5 6 7 Landscape position Slope % HORIZON I DEPTH O _. Texture group Consistence 5 Structure CK I -Q Mineralo S - HORIZON II DEPTH - i - 2 Texture group Consistence 511r $ Structure Mineralogy HORIZON III DEPTH �- _ -. 3 G,• Texture group SO_+n Com` t� } _ , Consistence 0i"; 'D • Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: EVALUATION BY: 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-term acceptance rate - gal/day/ft2 May 26 06 11:11a JUS 1 2 '�06 ppV1E- devie county envhealth 336 751 0786 p.2 TION FOR SITE EVALUATIONAMPROI Eh vAENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)731-8786 " Permit O Authorization To Construct(ATC) O Both ***IMPORTANT*** THIS APPLICATION C4AWOTBEPROCESSED UZESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 4a�P,6 1 &VCTC-)yJA- Name to be Billed 1"1- . �- 1r-- , �4 �Qot tact Person C� � � � � ` t�• Billing Address L?S'"7U _Ili Pme Phone City/State/ZIP , H�1. Ks _I1 1�i L : ^ $us iness Phone _3 S = Z u Name on Pennit/ATC if Different than Above Mailing Address _ City/St. le/Zip YK0FhKfY INr"UKMA'f1UN -7671 W1 :s3 NOTE: A surveyplat or site plan must accompany flus application. (Permit is valid for 60 months with site plan, no expiration witbi complete plat.) Street Address 3 C.-,-l(City 14a - < < Tax PIN# - -7 k�7 -2,3 Subdivision Name_ C.. ,,' _ ,,-.a e.. Section/Lot#Size 25 Directions To} Site: C tC- -� J-7'5 Date House/Facility Comers Flagged 'I I I Doto If the answer to any of the following questions is "yes", suppo�mrt g documents. tion inust be attached. Are there'any existing wastewater systems on the site? C�'t"es ONo Does the site containjurisdictional wetlands? ❑Yes C1tdi Are there any easements or rigbi-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? O Yes 19� Will wastewater other than domestic sewage be generated? ❑Yes 0 0 IF RESIDENCE FILL OUT THE BOX BELOW # People —# Bedrooms fy # Bathrooms _ Garden Tub/Whirlpool es ONo Basement: DYes CINo Basement Plumbing: DYes DNo IF NON -RESIDENCE FILL OI)T THE BOX BELOW Type of Facility/Business Total Square Footaltc of Building # People # Sinks # Commodes _ # Showers _ # Urinals _ Estimated Water Usage (gallons pLK Jay) (Attach docur-ientation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested onvendonal l:lAccepted oinnovative nAltemitive DOther Water Supply Type: aunty/City Water D New Well ❑Exist ng Well 0 Cottununity Well Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes �-fPtf If yes, what type? This is to certify that the information pro.ided on this application is true and c xrect to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafier are subject to suspension or revocatit in if the site is altered, the intended use changes, or if the infomntion submitted in this application is falsified or changed. I underst: rad that 1 am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Represertative of the Davie County Health Department to conduct necessary inspections toetenni"�e compIi with applicable laws avid rules on the above described property located in Davie County and owned by e . t_ y L e-- `r rope ;wnees rr owner's legal representative signature f 0 Date Sign given nycs ONo Revised 2106 Site Revisit Charge Date(s):_ Client Notification Date: EHS: /t Account# `"%�t+'v Invoice # PermattaP's^DL0�AVIE COUNTY HEALTH DEPARTMENT INVO �, me: �_ ° `-' �• .Environmental Health Section PROPERTY INFORMATION P.O. Box 848 sr Directions to property: ° ' ' {-' Mocksville, NC 27028 Subdivision Name: J Phone #: 336-751-8760 Section: Lot: AUTHORIZATION NO: . 00261113 A AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#--.." Road Name **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 Fonn/Authorization Number should be presented to the Davie County Building Inspections I Office when applying for Building Permits. (111 compliance with Article I I of G.S. RTppter I30A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. TAL JEALTH SPECIALIST DATt ISS IED RESIDE15TIAL SPECIFICATION: BUILDING TYPE l_. L�"'F-# BEDROOMS t # BATHS : # OCCUPANTS ! GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE r t a TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)., •' NEW SITE REPAIR SITE a` SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ': ROCK DEPTH "-' i '" LINEAR FT. GAL. TRENCH WIDTH—' '` � r' M OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: 1, ti �'"<) Yf•,.-? q ,' ° t„..4 : > >—)„:.., IMPROVEMENT PERMIT LAYOUT q ...�..v. , II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. fl OPERATION PERMIT' 1 p `"=-R, SYSTEM INSTALLED,BY: i0 AUTHORIZATION NO.2-LA'3�A OPERATION PERMIT _ekis;I—I A ca _ Ic _ Z DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICkTE THAT THE�CR WE HAgEEN INSTALLED IN COMPLIANCE WITH ARTICLE i I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE-MlEA £K2 NT A AL SYSTEMS", SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIO F TIME. rv-u M° A,-,11, �.. ..a :., !irk ti .,1 ^ /I -j _4 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) F, NAME' �`'"`� PHONE NUMBER ��2CCa ADDRESS 1� OS H 113q Vj 13 SUBDIVISION NAME LOT # DIRECTIONS TO SITE i -73 C-i�y i�Q DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER 61-V0,1 -`rV-3 Cz-)5 7 -- TYPE .TYPE FACILITY �L' NUMBER BEDROOMS _NUMBER PEOPLE SERVED TYPE WATER SUPPLY C SPECIFY PROBLEM OCCURRING 00VO10 `,VSTI?�%, 'To WSOW'aD'!�'w Pooh DATE REQUESTED t © 211) INFORMATION TAKEN BY This is to certify tFiat the Information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges Incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev, 1/93 e DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION K, A -� k � Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit _,� PROPERTY INFORMATION 1-73 Co 51G -Pr AVj AA- Ce� Re 1:11-70a L� L d_t 5 C 1'j.""5 j r"' C d, Public Cut FACTORS 1 �r('2 5 6 7 Landscape position L Slope % HORIZON I DEPTH — rj — Texture group G G Consistence Structure SAk 15K -444V V Ir Mineralogy3 HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure .P MineralogyJ HORIZON IV DEPTH Texture group Consistence r` Structure Mineralogy SOIL WETNESS Lift RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE , " SITE CLASSIFICATION: EVALUATION BY: ¢ ✓ RQapl.5 LONG-TERM ACCEPTANCE RATE: O ( OTHER(S) PRESENT: REMARKS: l � 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 lu rim VFR - Very friable FR - Friable FI - Firm VFI Very firm EFI - Extremely firm 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 Nato 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 chrome 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) _LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) Map Frame Davie County, NC - GIS/Mapping System .-b 4M71 I n F.- " - Oick Here To Start Over Quick Search:(County ID orOwner -N� 0 Active layer: F,"YE -,,,tap rips fr Ma L7 0 e E PARCELS (Map Tips Available) Addre Aw" X DR lie Page I of I http://maps.co.davie.ne.us/GoMaps/map/mapframe.cfm?CFID=17813 &CFTOKEN=49736... 2/12/2009 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 989900093 Billed To: Shelton Construction Services Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5789-23-9917 Subdivision Info: Covington Creek Lot # 55 Location/Address: 173 Covington Creek Drive -270063 0.8 Acres Date Evaluated: Community Pit Public FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: 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 1► � VFR -Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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) TTAR - T.nno_tr.rm arrentanra ratr - oal/riau/ft7 rnTir ncInc m__.:__�� ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ EMOMMEN MENNEN MEMNON MMEMME MMEMME ■moss■■■■■■■■ ■■moms■■/■■■■ ■■■m■■■mmm■■■ ■■mm■m■m■■mm■ ■■■m/mmmm■m■■ ■m■■■mm■■mmm■ ■■■mm■mmt■mm■ ■■■■■■■m■■■■■ ■■m■■mms■■m■■ ■■■mmo■■■■■■■ ■■■■■■■■■■m■■ ■■■m■■m■m■■■■ ■■■■■■■■s■■■■ ■■mm■■■■■■■■■ ■■■mm■■m■■■m■ ■■■s■■■■o■■■■ ■■■mos■■m■■■■ ■■■m■■mom■■m■ ■■m■m■■m■mmm■ ■mm■■■mm■m■■■ ■■mm■mmmm■om■ ■smms■■m■m■■■ ■■■o■■■mm■■o■ ■■■Moos■m■■m■ ■■■■■■//■m/■■ ■m■mmmmmmm■m■ ■■■■■■■■■■■m■ ■■m■■■■m■s■■■ ■m■■■■■m■m■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Water Supply: Evaluation By: /�. _146 __61f On -Site Well Community Auger Boring Pit— PROPERTY INFORMATION 1-73 Co I),eT0VLf Lal 5_6_ Ccl-' "rs 1 cH C✓, Public Cut FACTORS 5 6 7 Landscape position 77 Slope % 13– HORIZON I DEPTH — — Texture group G Consistence P -f Structure <51 k 5 9,kq f} y"r MineralogyS HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure _Pb Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS " RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE , P 7 V SITE CLASSIFICATION: S EVALUATION BY: Q5 7-10 LONG-TERM ACCEPTANCE RATE: 4 O57 OTHER(S) PRESENT: REMARKS: Landscape Position LEGEND K, C�i Vk l/, L-5 h o P_ P„ 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 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-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)