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131 Oakridge Lane Lot 78YAUTHORiZATION NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's7,44T14,10-1 �I,� `fes . / P.O. Box 848*' Name: �.`� a !�' ewr '! Mocksville, NC 27028 Subdivision Name: �' I t- - Phone #: 704-634-8760 Directions to property:i�I I Section: Lot: r' CL AUTHORIZATION FORWASTEWATER ry�JJQ Q�, SYSTEM CONSTRUCTION Tax Office PIN,::# / u // Road Name: U%� I � T� Z p: ci rQ **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) � ,J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION s° Zee a Y-4 YL IS VALID FOR A PERIOD OF FIVE YEARS. L 1VIRONMENTAL HEALTH SPECIALIST DATE ISSUED � .. { _.F .c� tom'... ;. -r. - i .!u✓' / DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name. r t� '; ; �, L� • f r f ?�,�f, . I ' Dlr_,ctions to property: Subdivision Name: {Section: of Lot:°% IMPROVEMENT PERMIT Tax Office PIN:# I :� I /leaf ' r Road Name: (/ �1 t� %A ;: >--Zip: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 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*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER b'NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS S # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE LOT SIZE TYPE WATER SUPPLY (,y # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No DESIGN WASTEWATER FLOW (GPD) �P�� NEW SITE -� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 19 LINEAR Fr. ,30 REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. I OPERATION PERMIT SYSTEM IN LED BY: r AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE: 7-2 "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 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC FT; Davie County Health DepartmentEnvironmental Health SectionP.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ��! ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCE THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Mailing Addressf City/State/Zip \ 421i/ 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [1?] ite Evaluation Contact Person)J Home Phone Business Phone City/State/Zip [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [1^ouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms # Bathrooms _ [ tj Dishwasher [ ] Garbage Disposal [+Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes - # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ['A"County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [t rNo If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �YXA106,XIVXX,/0 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # - r) (04 ct-� e Property Address: Road lame CQ , L- - "� City/Zip If in Subdivision provide information, as follows: Name: �f� 1Cd7t oC o if I 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 are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by LIPlr NA //M fe= Pt 1✓l c t5conducl all testin procedure/s� as necessary to determine the site suitability. DATE -"( 1Q - (� SIGNATUREj.�-,.. Revised DCHD (06-96) THIS AREA AtAy BE USED FOR DRAINING YOUR SITE PLAN: Pev- ,tel b+ -t� 9L ?S F� 7� 3 i � f r ) `� , U IV to E.Z. 0&,e ,___ V, N. 19 .0 of e s, urceS " oe -etion -72 o Sq 0 • ' ' DAVIE COUNTY HEALTH DEPARTMENT p� Environmental Health Section SECTION f LOT �J Soil/Site Evaluation APPLICANT'S NAME �i/l.?��'i DATE EVALUATED f / PROPOSED FACILITY PROPERTY SIZE %� SUBDIVISION ROAD NAME Oft� L& &L, Z, -4J Water Supply: On -Site Well Community Evaluation By: Auger Boring i Pit Public >% -o Cut FACTORS 1 2 3 4 5 6 7 Landscape position k Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence r 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 DCHD (01.90) Landscape Position EVALUATION BY: /l3✓�� 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 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 Mineralog 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 SEEM■■ ■■■MM■ ■■MME■ ■EMEO■ ■EME■■ ■■■■E■ ■E■EM■ ■E■■E■ ■■■EE■ ■ ■ ■ ■ ■ ■E■EM■ ■ ■EM■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■rid: ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO EMEMEMEEM ■E■■E■■E■ ■MO■■M■M■ MEMEMEMEM ■ ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■