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164 Calvin Lane Section C Lot 17AUTHORIZATION NO:1746 DAVIE COUNTY ' HEALTH DEPARTMENT /✓�� Environmental Health Section PROPERTY INFORMATION Perrmttee's` P.O. Box 848 j Name: LL' Mocksville, NC 27028 Subdivision Name: 7 �U L1 ( /! ..7r �Ci f }z'�� Phone # 336-751-8760 � 1-7 Directions to propeRy: —T Section: Lot: AUTHORIZATION FOR Tax Office PIN:#�� n Road Name: WASTEWATER SYSTEM CONSTRUCTION **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 C,>':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. :NVtRONM NT ALTH SPE CIA 4 `r DATE ISS ED _ 1746 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION -Perim'' " Name: -1 -; L(- Subdivision Name: t/ a Directions to property:. 'r' t''{ �" Section: - Lot: ) % IMPROVEMENT —j PERMIT Tax Office PIN:# Road Name: ,. ar ,."l Zip i **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 I l 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 ENVIRONMEN I`AL HEALTH SPECIALIST DATA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ,_J RESIDENTIAL SPECIFICATION: BUILDING TYPE hi # BEDROOMS # BATHS z # OCCUPANTS / GARBAGE DISPOSAL: Yes orc) COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE kaon TYPE WATER SUPPLY` -+^'DESIGN WASTEWATER FLOW (GPD) NEW SITE ✓ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE jQ00GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 17- LINEAR FT. 4)0 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: f /JST4 LL owl C04 10 0R, kz;. p 0 Orr 02t:p L v -J-90 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 (336)751-8760. T' AUTHORIZATION NO. 17-4(o OPERATION PERMIT BY: DATE: r/ 149 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT M 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 EVAWATION/IMPROVEMENT PERMIT do ATC r Davie County Health Department 4 Environmental Nea/th Suction C P.O. Box 848/210 Hospital Street OCT 13 1998 j Mocksville, NC 27028 4336)751-8760 EPIViRONh1EPJTAI HEALTH u i niry F***IIV0RTA1M*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL QVIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Hilted ! S i f Q' Contact Person Mailing Address Home Phone City/state/ZIP it '2 Q \ Business Phone 2. Name on Permit/ATC if Different than Above Mailing -Address City/state/Zip .. // 3. Application For: U Site Evaluation 0 Improvement Permit/ATC both 4. system to Service: 0 House wi;M ile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms R # Bathrooms 2� O Dishwasher 0 Garbage Disposal O Shing Machine 0 Basement/�P1umbing 0 Basement/No Plumbing 6. if Business/Industry/other: Specify type # People # Sinks # Commodes # Showers # urinals # water Coolers II' FOODSERVICE: 11 Seats / �' Estimated crater Usage (gallons per day) 7. Type of water supply: 1Z County/City ❑Well 0 Community e. Do you anticipate additions or expauslons of the facility this system is Intended to serve! 0 Yes 0 No If yes, what type! ***IMPVRTANT***CLIEMMUSTWA[PLETETHE REQUIRED PROPERTY INFORMATION REQUMED BELOW. Either a PLAT or SITE PLAN MUST BESURSHIl'ED by the client with TRIS APPLICATION. Property Dimensions: - A00 X 9610 7`o OWURITE DIRECTIONS (from Moc7,0' le) to PROPERTY: Tax Oftice PIN: # 0 1h7 Property Address: Road Name 13 OY2 City/Zip .m f' C ky"M, h W �X If in a Subdivision pnv de informs ion, as rollows: L 0 - Name: Name: AP e! Section: lock: 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 rrponsible for all charges Incurred front this appU action. I, hereby, give consent to the Authorized Representative of the Da C maty He lib Depa went to enter upon above described property located in Davie County and owned bF L;SLQ—,-—�.YI to conduct all testing procedures as necessary to determine the site suitability. DATE V t r� SIGNATURE rri THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCLD (07/98) XC 1'- 40 40 x� Account No. a4 Invoice No. 30 r.., DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION G LOT 1 Soil/Site Evaluation APPLICANT'S NAME wV-4-) DATE EVALUATED PROPOSED FACILITY. = PROPERTY SIZE %Df1 geo 't SUBDIVISION HorLI OlA 1,J AC� ROAD NAME 14&,,*X/1 Sir Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit .LI -11, Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L� Slope % -3707 R- HORIZON I DEPTH Texture group CL C- --Consistence 5 r SS Structure f2 - Mineralogy 1 1 ' HORIZON II DEPTH (4 -ILI Texture groupC Consistence Structure IsL� lc Mineralogyl HORIZON III DEPTH -4 Texture group { Consistence -r Structure 43 L /4.q - Mineralogy HORIZON IV DEPTH (4 -4 Texture group Consistence 0 Structure Mineralogy1� SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: V—s nn LONG :TERM ACCEPTANCE RATE:y' REMARKS: _ y C1-0 IA 0 of PL DCHD (01-90) Landscaoe Position EVALUATION BY: OTHER(S) PRESENT: 2,> o� 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 ■ i ■ ■ ■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■Ott■■■■■■ ■■■■■�iiiiiiil�iiii iil�iiiiiii MENNENmilmomil�i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■m■■■1■■■m■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■MME■■E■■■■■■■I■■■■NS■ ■■M■ MEMO ■■M■ MEMO SEEN ONE ■■■ son ■E■■N■E■■■■NEE■ ■Emm■■■■m■■E■■■ ■■■■m■■m■■m■■■■ ■■■EM■■E■ENE■M■ ■o■■■■momm■■■■■ ■EM■■■E■■E■ENE■ ■ENE■■E■E■■■E■■ ■■■m■■■■■■mm■■■ ■■■■m■o■■■m■oo■ ■o■■m■■m■■m■■m■ ■■■■ml ■■ omml ■■ ■/al mzmmm■■ UNM■■N■ ■■mm■■■ NEMESES NEMESES ■omw2m■ *:::::: 1■■E■ME■ 1■■E■EE■ 1■m■■m■■ 1■■■m■■■ 1■■■mm■■ 1m■■m■E■ 1■■m■■m■ MEMO ■E■■ NEON ONES ■■■N■■■■E■■■■ ■■m■■■■■■■■■■ ■■■■■■■E■■■E■ ■■■■■■EE■■■■■ ■M■■■■■■■■■■■ ■■■■■■■■■E■■■ ■■■■■■m■■■■■■ ■■■■■■■■■■■■■ ■■■■■E■■■■■■■ ■M■■■■M■■■■■■ ■■■■■■■EEE■■■ ■■■■■■■■■m■E■ ■■■EE■■■EE■■■ ■■NMN■■Emm■■■ ■■E■■■■EE■E■■ ■■E■■■EE■■S■■ ■■■■■■mE■■■■■ ■■■■■■■■■■■■■ SENSE moons SEEMS NEMS■ SENSE ■E■E■ ■E■■■ SENSE WOMEN ■■■■■ ■■■■■ ■■■■■ ■E■■■ ■E■■■ ■ENN■ ■■■■■■■■■■■■■■■■��IIm■■v�ti;��■■iiii�iiiiiiiiiiiiiiiiiiiiiiiii ■■■■■■■■■■■■■■■ilk■M■■N■■■N■■II■■■■■■■II■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ill■■■■■■■II■■■■■■■■■■■■■■■■■■■■■■