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345 Hobson Drive Lot 6FsL ORIZAhJON NO: 0772 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee s ti c : P.O. Box 848 Name: : -� —'��- Mocksville, NC 27028 Subdivision Name: � �` _ Directions to property: ` �''� Phone #: 704-634-8760. Section: Lot: AUTHORIZATION FOR 2?a I t�s—vzc, s"* r . `��., ;�•r-- WASTEWATER Tax Office PIN SYSTEM CONSTRUCTION �a �. :>- 1�" `1.Yt` �v y°`' ROa Name` ...1'_titi a tiL Zl ^t7()�li 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. 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 DAVI'E COUP1i1TRY HsEA�LTHDEPAR�THM�ENT ' r r, 11141 UVEMENT AND' OPERATION PERMITS PROPERTY INFORMATION ♦.,T . .H.... w pe T Name_ v_ t� w"-~ Subdivision Name: Directions to property: Section: Lot: 4 Il"ROQMMENT ,_; h mac•" �,, w PERMTI Tax Office PIN:# 4S7 _ , "21 -W fi} �. ..: Road Name ae���..��•o. 4n+•a.�.�ww+.`,Y`d,.�. w . **NOTE** Thi I�iprouement Pemufk FS NOIT authonae-0tHe construc�tloricoremstllk ion of a sept c tank sy�stemEor y wastewater system. An A " : OO + TT©N F©RWzAeSTsEWTER SI'�STEM C®NSTRUpCTION+must�be`obtauled3from:tlusDepartrnent pnor to the . �.� .4 s cons>n�ctio talladon�ofQasystemorthe issuanceofa l;uildtngl t a -tiTW:s y (In compliance wlthtArUcle"" 11�`of G S Chapter 130A, Wastewater SystemsSechon 1900 Sewage Treatment and,Dispo��Systems) I ti IA c NOTICE THIS PERMIT IS SUBJECT TOO REYOO CATION IF UP- S eS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH -SPECIAL IST DATE^ISSUED. SYSTEM CONTRACTOR MUST SEETHES PERMIT BEFOG REf. INSaTAI.I ING THE SYSo + M Ii RESIDENTIAL•SPECIFICATION: BUILDING TYPEW M';#BEDROOMS # BATHS # OCCUPANTS GARBAGE%DISPOSAL: Yes o> COMMERCIAL"- SPECIFICATION: FACILELY TYPE' # PEOPLE #'P,E©PL•'E/SHIFT #.,SEATS' INDUSTRIAL WfASTE: Yes or No I � . L®TSIZ� T,YPEMWATER SUPPLY DESIGN WASTEWATER FLOW (GPD) . �04 NEW SITE- '" REPAIR S n « SYSTEMSPECIFICATIONS: TANK SIZALP GAL. PUMP TANK GAL. TRENCH'.:WIOTH , ROCK>DEPTH' gII �:LINEAR'FT. OTHER a REQUIRED, SITE MODIFICATIONS/CONDITIONS: PEWol _u F. . •. ;. IMPROVEN4ENTjPERMIT*L 'YOUT /001 Al T Y • I **CONTACT;A REPRESENTATIYE4®FTHE DA�VIE C®UNI Y HEALTH0EPAMMENT FOR;FINAL IN SPECTI®NOF§THIS SYS I BEsT,WEEN 8'53"0 =A:30 A M OR+1 00 - d'30 P Iv1:;0,4„THE"DAY OF'INSTUALLATI®N. TELEPHONE # IS'(704)s63�4� z h �� •• G �flh.uv�rk a 5'S .� k! A OPERATION PERMIT -° s F a SYSTEM INSTALLED BY.; � ` �; a�./�c�� Y 1 1W �d-s a o AUTHORIZATION NO.O1 OP,ERATION;-PERMFT- BYi It DATE: **THE ISSUANCE OF THIS"OPERATION�PERMIT SHA,LL�INDICA+TE THAT THE SYSTEM�DESCRIBED ABOVE HAS BEEN•INSTALLED INsCOMPL"IANCE LIQ•$ YF•a<2':3NdCtrJ.b', 'ha:. 1 -S 'Lr .. y»; :".G ,,:. :--t "WITH AR+TICLE 11;®F G S 'CHAPTER 130A SECm+TION1.900,k?Q AGEMmEATMEN'TrANpsDISPQSAL SYSrTEMS' ;'BUT SHALL IN.`M& AS A• a a f'J...,, x(.Ydnti J T,h - GUARANTEE aTHAT THE SaYSTEMW,aILL FUNCTIONSATISFAC�T©Y FOR ANY GIVENPERI®D OF TIME.' DCHD 05/961(Redised) ;i — .�:..o..,�,u�...�..__�"' . ,...:-.._ __ ._a b;: , .,t:�,�:�r:��'. �e.':L:y�-.._ ,,. . _ ..,. ,.,.sir,.b,,..:.w.:.•.�isa;�.uta...e _,,...,_, • . APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC' ' - Davie County Health Department Environmental Health Section P. O. Box 848 I MAR 2 61997 I Mocksville, NC 27028 U (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS -`— --1 I- ALL THE REQUIRED INFORMATION IS PROVIDED. ��Rb1. Name to be Billed p be -f-4 �_ .>r)', ry-\n q Contact PersonnC7l(Y�.i'�� ��� J I ��NO Mailing Address a 0'n �Et 0 'L Home Phone City/State/Zip(x���U'� ►I�,��C 1oag Business Phone 2. Name on Permit/ATC if Different than Above�� Mailing Address -44,00 to City/State/Zip 3. Application For: -ite Evaluation ❑ Improvement Permit & ATC /Both 4. System to Serve: ❑ House O Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People S� # Bedrooms # Bathrooms ❑ Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type Ul [ le # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons p r day) Type of water supply: ❑ Count County/City 6 Well ❑ Community 7• 'h'PY Y 1 Y 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes vt No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: i� U 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # Property Address: Road Name ci rdc 1 bso cl l City/Zip C' 17 OQ�� 1 1 If in Subdivision provide information, as follows: 1 , Name: /^ 1 Section: Lot #: 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by I�Of"t-� �'U'1 n �, , (Man to conduct all testing procedures as necessary to determine the site suitability. DATE C4,fl I`7 SIGNATURE , Revised DCHD (06-96) • .r .h / I 1; J T' •E9 d 117/904(y, ; k • r o� • N Y � \ k t T� a r Prncv.�s. co =M Twx "a awry C., ( C, fp- ... ; ? °` CA VA( a � %� ' i .fir M ♦ �J ® .ceRltp i++at-.soh r�.s� • me) (deed de3criptios • ,ure 3% ealeulatedrt� . ' • r ti 4.t)0w11 is broken lines ook ...._..... P -- .; . . ,dance with G. S. 4730 S _at this J..s_day of pcAM•rc N u • h \ y M k 31 • Tire O ` 4o k t T� a r Prncv.�s. co I C., fp- ... ; ? °` CA � %� ' K .fir M ♦ �J ® a • (�� n o�tRNR �.J 1 Llb ® e ,circ O f � r _ J 4♦ 4 , Is F II S f Vp "% Ol7 pcAM•rc N u • h \ y M !D ♦ 31 P,,bm t j ® �o f CA ® 1 Llb ® e ,circ O t r _ J , Is F II S • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT L Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED — +� PROPOSED FACILITY \' x ' 6p PROPERTY SIZE SUBDIVISION Sc b\ \'6 V'z^� ROAD NAME Water Supply: Evaluation By0,�, On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position S Slope % o -6 HORIZON I DEPTH Texture group Consistence Structure Mineralogy' ! 1 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 ,S - LONG -TERM ACCEPTANCE RATE SITE CLASSIFICATION: R •� LONG-TERM ACCEPTANCE RATE: REMARKS:S� DCHD (01-90) Landscape Position EVALUATION BY: OTHER(S) PRESENT: � 0 "A-9 END 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 ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ENO ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■!/■■■■■■/■!/■/!■■■■/■■■\� `���1�■■/■■■■■■►!►_-%!!�■\\■■CEJ■■■■ ■■■■■■ ■■■■■■ ■■■■■L., 1■■R1■■■ 1lI\■■i'C' awl".:■Ii1■ ■■'■■■■ ON ■■■■■■■■■■■■■■■■■■■■■SCJ■■'�■■■■■■■■■■■■■■■■■■■■■//■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■1/■■\�■■■■■■■111► \�■1�■■■■■■■/■■■\1■■��■ ■■■/■■/■■■/■■/■■■■■■■■l\■■■■■ti.!\■\■.fir■■��■■■■■■■■■■■■■■IIID ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ENO