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171 Oak Tree Drive Lot 140mp•�� .,, i �4�i',r'-0...:..."r2.1'.-V4... .. ..'��,.;,,,, ..::_o, - r. . .. �. -� .•o Permittee s ff-� c ,DAVIE COUNTY HEALTH DEPARTMENT 2� 407 Name: IrLt l " Environmental Health Section PROPERTY INFORMATION . .tom P.O. Box 848 ihredWdn7 to property: Mocksville, NC 27028 Subdivision Name: � .��- ►# -1 � ( ,,� ( Phone #: 336-751-8760 f Section: Lot: 1 AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION .Y AUTHORIZATION NO: 002734 A Road Name: 14 (2, V-7 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 Pen -nits. (1q,compliance wi idle l of G.S*CNter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) TH TE ISSUED ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. RESIDENTIAL SPECIFICATION: BUILDING TYPE �A # BEDROOMS # BATHS Z # OCCUPANTS-4—GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE4(�YPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)' NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR Ff. OTHER Mr,d PI-Q)Z W REQUIRED SITE MODIFICATIONS/CONDITIONS: I0STt\U_.. 0o los F✓< b� c GI S tic S IMPROVEMENT PERMIT LAYOUT ,t!$Tl 11�" , :-- t-�c�N1 AST LCASi ;_'S I Q e 1 a m t � _ 1 \4 P 716" P 41�D sii t , N�1 4e q "Ta Ft�77 TlrL^X . i.i,S 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. II OPERATION PERMIT •��b , A r, i �� SYSTEM INSTALLED BY: up g, ISL Zr AUTHORIZATION NOZI OPERATION PERMIT'BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSftM DESCRMED ABOVE HA'T&EEN 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: Dcxnmroz(RehKa) 12e��.L /0or i;►►�n:no - AV -2-2 (. - y.I -- r 41 L/Iw% ' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION . j AUTHORIZATION NO: 002734 A Road Name: = ! (f � 1p:l - • " �''' j **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 l;l of G.S`CFtill tter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ?� ,. r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1i - "� ; { 01? IS VALID FOR A PERIOD OF FIVE YEARS. ,TH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE U t # BEDROOMS - ' # BATHS '2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE M Ar -TYPE WATER SUPPLY ������ DESIGN WASTEWATER FLOW (GPD) ✓ NEW SITE REPAIR SITE ('or SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH r J ROCK DEPTH l4 LINEAR FT. l L� OTHER I(n- ( =J 1 I ' L� c� 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: I o S L\\_1...-- r o ('&-) -r0JZ . h a ► IV C -c - 1r 1',-t �-j rjo- IMPROVEMENT PERMIT LAYOUT 1)Y f , �•..� �I�D .� i is 1'Fnh�;..l i f, C: `"'< io ���.::i? �l�.d-,r � r► -+tel. t�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 YPqE-a 1) P 1 Pr. I-1— -4"do lX (? j d 2/CJct i a) SYSTEM INSTALLED BY: I AUTHORIZATION NO.L?=��gk f --U A4 OPERATION PERMIT BY:a4L DATE: C **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS M DESCR ED ABOVE HA EEN 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. Dctlnovoz(Rev;see)lieel_1-�Ub���` `�O>� DAVIE COUNTY HEALTH DEPARTMENT pj.� 1,003 Permittee's,,,' , Name: Environmental Health Section PROPERTY INFORMATION * Directions to property: P.O. Box 848_ Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: ' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION . j AUTHORIZATION NO: 002734 A Road Name: = ! (f � 1p:l - • " �''' j **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 l;l of G.S`CFtill tter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ?� ,. r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1i - "� ; { 01? IS VALID FOR A PERIOD OF FIVE YEARS. ,TH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE U t # BEDROOMS - ' # BATHS '2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE M Ar -TYPE WATER SUPPLY ������ DESIGN WASTEWATER FLOW (GPD) ✓ NEW SITE REPAIR SITE ('or SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH r J ROCK DEPTH l4 LINEAR FT. l L� OTHER I(n- ( =J 1 I ' L� c� 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: I o S L\\_1...-- r o ('&-) -r0JZ . h a ► IV C -c - 1r 1',-t �-j rjo- IMPROVEMENT PERMIT LAYOUT 1)Y f , �•..� �I�D .� i is 1'Fnh�;..l i f, C: `"'< io ���.::i? �l�.d-,r � r► -+tel. t�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 YPqE-a 1) P 1 Pr. I-1— -4"do lX (? j d 2/CJct i a) SYSTEM INSTALLED BY: I AUTHORIZATION NO.L?=��gk f --U A4 OPERATION PERMIT BY:a4L DATE: C **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS M DESCR ED ABOVE HA EEN 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. Dctlnovoz(Rev;see)lieel_1-�Ub���` `�O>� C .P 01 Mailing DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING Ch,ecj,. One REPLACEMENT REMODELING ❑ RECONNECTION ❑��� L'4154)r ► ! Q Phone Number: s Y� - 7 �Z- / d� d (Home) r cress: / 'I r V e (Work) AA fic r '' /_� I� rections To Site; %7ik faA, ,1 Dr, [/- _ TV �//%� f� '�/-c e ! J ✓1 I� �- Property Address , % / f�y� �� /) t/� C -Cif /YZ Please Fill In The Following I ormation About The Existing Dwelling: l T Of Dwelling:/J Name System Installed Under: 1'4t/1 6'S t._. , T ----Type 1 �/ Date System Installed(Month/Day/Year): ? -( -�- V Number Of Bedrooms: Number Of People:T_ Is The Dwelling Currently Vacant? Yes ❑ No/_G� If Yes, For How Long? Any Known Problems? Yes ❑ No'If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: Number Of Bedrooms: Number Of People: c Requested By: ALI 2�. �— /1V r • GJ� I CUh Date Requested: I 1 a " �7 b- M-11rPI For Environmental Health Office Use Only Approved ❑ Disapproved ❑ d Environmental Health -Me signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # - Amount: $ Date: Paid By: Received By: Account #: Invoice #: AU ;HORI'AATION NO: Z DAVIE � OUNTY HEALTH DEPARTMENT —;� Environmental Health Section PROPERTY INFORMATION Permittee's f P.O. Box 848 Name: �9A(��5lrCWO Mocksville, NC 27028 Subdivision Name: D'AIO&O A'e-1 { _ �_�� Phone # 336-751-8760 Directions to property: ilk �. qt�. Section: Lot: 1. - AUTHORIZATION FOR WASTEWATER .may i _ L- T (.'"a " ;,fit t!1 �1`.i Tax Office PIN:# 4 1 1 - qtp - 3651 SYSTEM CONSTRUCTION -`�Tu C Road Name: 6AWROMR-f Zip: Al **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 .1900Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. :NVIRC NT'AL"HEALTH SPtCIAL[ST) DATE I SUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS I # OCCUPANTS 'Z- GARBAGE DISPOSAL: Yes o&. - COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE C> x 24PE WAITER SUPPLYCDvniiY DESIGN WASTEWATER FLOW (GPD) ��1f✓ NEW SITE `"' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �l�'C- �? GAL. PUMP TANK GAL. TRENCH WIDTH --41" ROCK DEPTH I t, t LINEAR FT. ! J OTHER i t�'ITO 9 0 REQUIRED SITE MODIFICATIONS/CONDITIONS: ►KY, -i t�+11- O J i.b,'�J iU�.i I ( {(7� t?( -F J6 Q t�I,dr� 1�C �-� �� G + �' r IMPROVEMENT PERMIT LAYOUT FtA Bu-6AI!�" J tC - -T "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 (336)751-8760. OPERATION PERMIT S�' �31� � S t� S �' s� 14 SYSTEM INSTALLED BY: AUTHORIZATION NO. L45 i3> OPERATION PERMIT BY: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTEM DESCRIBED ABO HAS BEEN II WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) �KLLED IN COMPLIANCE N/N0 WAY BE TAKEN AS A DKO (D� - **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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION y, 1 4IS VALID FOR A PERIOD OF FIVE YEARS. `ENVIR(!N4,N, AT1-IEALTH SP CIALLfT,) DATE 1 SUED AUTHORIZATION NO: DAVIE OUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Perrhittee'ti �h ��5 P.O. Box 848 Subdivision Name: dA1te��t71� Name: Mocksville, NC 27028 Directions to property: [,'q,) —k` C (tE Phone # 336-751-8760 Section: Lot: ( AUTHORIZATION FOR WASTEWATER g - Tax Office PIN:#- s SYSTEM CONSTRUCTION rTCt- �c J 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 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION y, 1 4IS VALID FOR A PERIOD OF FIVE YEARS. `ENVIR(!N4,N, AT1-IEALTH SP CIALLfT,) DATE 1 SUED o. DAVIE 4UNTY HEALTH DEPARTMENT �, TMPROV MENT AND OPERATION PERMITS PROPERTY INFORMATION Peri�'fiitee'"s NJfne: ` � i A �.N S t' Subdivision Name: Q Ti1 C P+�f� %4 T5 ections to property: i 1 • ' �, .: l` r, l Section: Lot: T' - p; IMPROVEMENT � z , t ,1 t 3 t ',' R PERMIT Tax Office PIN:# 4''19 8 - 1 b - Bo5l Itrj Road Name:0AM.-EE &1 -- Zip: A `Q . **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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 ENVIRONM AL HEALTH SPECIALIST DATE S!! } PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE / INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE M li # BEDROOMS 7 # BATHS I # OCCUPANTS Z GARBAGE DISPOSAL: Yes o60D. COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT � / # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE`S _ x hi3� 2� WATER SUPPLYCQ(1p� DESIGN WASTEWATER FLOW (GPD) 'NQ NEW SITE REPAIR SITE 11 wl � SYSTEM SPECIFICATIONS: TANK SIZE ICtV GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. S OTHER 1 ISTQ t� O T1 a 1 7X­',-- REQUIRED X.-XREQUIRED SITE MODIFICATIONS/CONDITIONS: Ont C_01� 10' 10 i'OUC;� KL- a -P SOS [fir G4C3�4 IMPROVEMENT PERMIT LAYOUT 4 �o' -Tu FCoaT vE !A- l W A&r_ f>gSTi 7_ r✓W�T \ok- M.i, J I 'y,' P_k . -A hAOS-T i SgC"r, r41- V31 J GF Lo —I "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 (336)751-8760. OPERATION PERMIT W4/D(r f � q�e SYSTEM INSTALLED BY: r'"• ' ' / SS-- F Simi AUTHORIZATION NO. OPERATION PERMIT BY: DATE: Ly i "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE iYSTEM DESCRIBED ABO 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) (3pkl°►,c� �y �.. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC L4f Davie County Health Department Environmental Health Section P. O. Box 848 P D Mocksville, NC 27028 (336)751-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE UN E ALL THE REQUIRED INFORMATION IS PROV ED. EI Nav-le3 1. Name to be Billed I /OrContact Person AUG - 4 vl.e � r, e ,'Lfl— Mailing Address 173 WUi`ckla l C- Drl ✓y Home Phone 33 92 -72 U � City/State/Zip ill nek5 Vl /e- i IV d ?W Y Business Phone 709 (4 ??S 2. Name on Permit/ATC if Different than Above Mailing Address . 3. Application For: 4. System to Serve: 5. If Residence: ❑ Dishwasher 6. If Business/Other: # Commodes _ If Foodservice: ❑ Site Evaluation ❑ House 14 Mobile Home # People ❑ Garbage Disposal Specify type _ # Showers # Seats 7. Type of water supply: -. County/City City/State/Zip k Improvement Permit & ATC 0 Both ❑ Business ❑ Industry ❑ Other # Bedrooms 62, # Bathrooms 1 Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # People # Urinals Estimated Water Usage (gallons per day) _ ❑ Well # Sinks # Water Coolers ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'A No If yes, what type? t L 111t K A rLA 1 UR 6 L l L PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A Pk HE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. 1 Property Dimensions: V `7 3 X d SU X a l 0 1 WRITE DIRECTIONS (from 76- , Mocksville) TO PROPERTY: Tax Office PIN: # �-1 / / / 6 - - - 3 0 J 1 ! Property Address: Road Name 04/C I Y ee PO at J �f City/Zip /V l �C�S �1(l2 . /VC. 1Gylm� epw r' ~� /\ 1 �"� 0'-k -w- U 1 If in Subdivision provide information, as follows: ; 3 /W�� [ � /_ S/ srl Name: © 0 a,d ) / 1 �/ �%`Q I I O Section: Lot #: �y 1 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by Ck0A(7J--C- lot ncl Ek n(k -S . ?) L I C.q— to conduct all testing procedures as necessaryto determine the site suitability. DATE 0 - 3-W SIGNATURE Revised DCHD (06-96) JOU MANY USE THE BACK OF THIS FORM FOR PRAWING YOUR SITE PLAN. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE Davie County Health Department u u Environmental Health Section P. O. Box 848 1 7 1998 Mocksville, NC 27028 (336)751-8760 LN 4.20'11,;ENTAL H EALTH ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCE �" COUNTY n ALL THE REQUIRED INFORMATION IS PROVIDED.. I- 1. Name to be Billed l Ql`I ell 0 i� ',a(�` M Contact Person cAalj s Mailing Address 1-3 W at'y-) '' - Dr" • Home Phone 99f- it 0117— City/State/Zip am:l7— City/State/Zip Ad V am C 11, . �J • C' ;.7 Business Phone Irl -35 -fol 5 % c Jfn C44D 2. Name on Permit/ATC if Different than Above Mailing Address City/State/g 3. Application For: Er Site Evaluation Improvement Permit & ATC oth 4. System to Serve: ❑ House Er Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _.T-- # Bedrooms 3 # Bathrooms Z 5k'bishwasher ❑ Garbage Disposal firWashing 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: Nl County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 13" No If yes, what type? tL1111K A tLAL UK JLlt PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A K)"M THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: S'�C /�A70 WRITE DIRECTIONS (from -- _ 4ot /440 - 44-79%-96-3oS7 1 Mocksville) TO PROPERTY: Tax Office PIN: # (,, q 1 D "O � 11 _/ Property Address: Road Name 15 7 rem city/zip M0CKSu•l1L 2,10 2 V 1 � /h�c�scc�ron �u C If in Subdivision provide information, as follows: 1 f Wkyl I 70 nd Gild 3 n ��/ Name: ti u n� i i j'l �S r i �c k.1 Section: Lot #- �'{re zecl Nou sL This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by as necessary to determine the site suitability. DATE H" 17 - 9 T' SIGNATURE 6461U11-0 Revised DCHD (06-96) YOU MAI�J. USE THE $ACK OF THIS FORM FOR DRAWINC7 YOUR SITE PLAN. conduct all testing procedures �'JDB/LL - %2?dy/i—a e j�►s C/e ve/col �►/L In r,7d/5 _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �- 5 Vt L A(*', PROPOSED FACILITY �flyn t: SUBDIVISION KLA -9 Water Supply: On -Site Well Community Evaluation By: Auger Boring ✓ Pit DATE EVALUATED 151is b PROPERTY SIZE ROAD NAME DQt�'rD 7Q Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % 5 HORIZON I DEPTH i0 - Texture groupGL L Consistence S P Structure S gk k Mineralogy HORIZON II DEPTH Q0- 2 - Texture group G G Consistence < r Structure 4 k 14 Mineralogy1: t HORIZON III DEPTH -7-(P Texture group C f Consistence r SS Structure SB k 5 e- Mineralogy HORIZON IV DEPTH Texture group 5 $� Consistence SSS 5 14 Structure G� Mineralogy 1 SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE >' . 47 - SITE CLASSIFICATION es LONG-TERM ACCEPTANCE RATE: 0• EVALUATION BY: C . L �►�T OTHER(S) PRESENT: C�� rs1 Aj REMARKS: J5 - Cb Q Lj-L Y Ac_ LSS M i Q O LE cc --' S T2zn^'- R-) Al (o 441 LEGEND fOM101nl - P4of4&Y /MFEO3a Landscape Position �Zp��''3� o.J - �S'e R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope LCX4M4. 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 DCHD (0I-90) ■■ ■E iii iii iii iii ONE NEE Mils ■ i ■ MONS■■ ■■■■■■ ■■■■E■ ■ ■ MEMO ■■■■ ■EO■ ■■E■ ■M■■ ■ ■E■E■■ ■MMM■■ ■MMM■■ ■M■■M■ ■M■■E■ ■EMNO■ ■ME■■■ ■■MN■■ ■E■■M■ ■M■MM■ ■■■M■ ■■■■■ L £9 ss 91ro J l4t /0 Cb Lb 61 N � U V TFZ ONO, ��szj tiv LZ `'o'' s9, so, iZ 1 (ev) (9Z1 b0�o� (OZI) Sp 16v 1 Z3 G 'lop F9 \ CIC, \ � t 09 L� (9£1) 9 L� wti 4) ti 92 O O Davie County Health Department oNE 22� 99a andHome -Come .wealth Agency 0P _" Environmenta(Health Section ¢,fF�G�l3'� 151 P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 June 10, 1998 Charles P. Griffin 113 Alamosa Dr. Advance, KC 27006 Re: Site Evaluation Oakland Heights/Lot 140 Tax PIN: #4798-96-3057 Dear Client(s): As requested, a representative from this office visited the aforementioned site on May 18, 1998. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for installation of an on-site sewage disposal system, pumping probably required. Before a permit can be issued the appropriate application must be filled out and the house/mobile home locatior3 staked off. If you have any questions, please feel free to contact this office. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Specialist JB/wd Enclosure(s) -7 ( �� 11 APPLICANT INFORMATION "W. -I �U�'OC3 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit PROPERTY INFORMATION Public Cut / /,,5;' >l 07 I71 0j891U FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH —90-444 Texture group"G } 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 r CONSISTENCE waist 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) ■■M■■M■ ■EMMEE■ ■■■■■■■■■■■■iii■1\■■■■E■■■■E■■■■■■■■SIS■■E■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■►\■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■IEEE■■■ Gi■ ■■ ■/■■■■■■■■■■■■■■■■■■■/Eli■■■■■■■ ■■■■■■■■■/■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■" MEMO ■EM■ NONE ■O■■ SEEM ■■■E■HE■MEME■ ■■■■II■■■ME■■■ ■EMN%M■MMEM■■ ■■■UMMEM■■■■■ ■E■■■■■■■■■E■ ■■m■■■■■■■■■■ NNUMMEN■E■■■■ ■■■■■■/■■■■■■ ■■■■■■■■M■■■■ ■■■E■■■■■■■■■ ■■■■M■■■■■■■■ ■E■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■E■■■■■■■■■■■ ■■■■■■■■■■■■■ ■E■■EE■■E■■E■ ■■■■■■■■■■■■■ ■E■■E■EO■■■E■ ■■■■■■■■■■■■■ ■■■■■■E■■■■■■ ■■■■■■■E■■■■■ ■■■■■■■■■■■■■ ■■■E■■■■■■■■■ ■■E■■■■■■■■■■ ■SSS/E■E■■/■■ ■■■■■■■■■■■■■ ■ ■ ■■■EM■■ ■■E■E■■ ■MME■■■ SOMEONE ■■■■■■■ ■■■■■■■ ■■■ ■■■■■ SOMME ■E■■■ ■EEE■ ■nMN■ ■■■■■