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180 Calvin Lane Section C Lot 15Y, ., t2:�a.f,.rr.., ,.,a%'�, +..^.,. .. 4..i..t :., c,.. e.. ,. ., s6: ,, .... �-+. •'+: C-. ,. ._ -i 7c ' i ;_ ..:,.. ... i., UT O?Z]ZATION NO: H 17 7 � DAVIE COUNTY HEALTH DEPARTMENT ', � i Environmental Health Section PROPERTY INFORMATION Permittee'~ r',P.O. Box 848 J_ I �� Name:tr' ) U V%O%N Mocksville, NC 27028 Subdivision Name: Directions to property: (��. 15 ?o �� ,� Phone # 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER / Tax Office PIN:# ' i �`��+ SYSTEM CONSTRUCTION L Fy: rc � -r 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) l" ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � - J 1 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONIN ALTH.SPECI ESL T DATE ISSUED 17 4 4. DAVIE OUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Petee's Name; - a 2 :_ ! t L yi, r. Subdivision Name: j [ /i Directions-to property: '! t c� r ` ` Section: Lot: IMPROVEMENT t r PERMIT Tax Office PIN:#.. Road Name: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) �' i' ...... ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECI(1LIST l DA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS _ # OCCUPANTS —4f GARBAGE DISPOSAL: Yes or COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No 1�C I LOT SIZE IQQY 3' YPE WATER SUPPLY 7y DESIGN WASTEWATER FLOW (GPD) NEW SITE --- ZREPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE Cool -AL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12- LINEAR FT. OTHER f�IST�ZtOJI�/��1��Yw REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 ICJTL�� IMPROVEMENT PERMIT LAYOUT 5� x' N "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 SYSTEM INSTALLED BY: /'`�.,1el- 114974 d/'1L \ AUTHORIZATION NO. � � OPERATION PERMIT BY: DATE: — **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE"SYST44SCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) APPUCAIION FOR SITE ENAUTAHON/IMPROVEMENT PERMIT do ATCKEjIvIROWIDITAL Q �V1 [`5 Davie County Health Department Envlronmenfal Hea/Hr Section P.O. Box 8#8/210 Hospital street T 1 3 1998Mockaville, NC 27028 1336)751-8760 HEALTHtivtErc�urmr ***ZHP0itTA1M*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructiona- l. Name to be Billed S /r P Contact person Mailing Address 1161,6/ Bame Phone city/state/ZIP ,I Q Business Phone Z. Dame on Permit/ATC if Different than Above Hailing Address 3. Application For: U Site Evaluation 4. system to service: 0 House Home s. If Residence: # People_ City/state/Zip 0 Improvement Permit/ATC 411 oth 0 Business 0 Industry ❑ Other # Bedrooms # Bathrooms 0 Dishwasher 0 Garbage Disposal 0'Ilishing Machine O Basement/Plumbing 0 Basement/No Plumbing 6. If Business/industry/Other: specify type # People # Sinha # Commodes # showers # urinals # Rater Coolers IP i'OODSERVICS: 11 Seats �Estimated dates Usage (gallons per day) 7. Type of water supply: lfi C/ounty/City 0 Well 0 Co=m2nity s. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 0 No If yes, what type' ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # EMP107MI-// Pm. perty Address: Road Name 131_ wi.ty/Zip (1 C 4 ki Ve- " l6;. )f to c Subdivision pro de informs ion, as follows: Name: " Section: C, lock: Lot: / DIRECTIONS (fromHoc le) to PROPERTY: o/ I Date Property Flagged:. / / J 131 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 on r tsponsible for all charges incurred from this appUcation. I, hereby, give consent to the Authorized Representative of the Da Cod ty Health Depa(meat to enter upon above described property located in Davie County and owned b?" i to conduct all testing procedures as necessary to determine the site suitability". DATE lo— /3 1 r SIGNATURE &Crrz THIS AREA MAY BE USED FOR DRAWERG YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07198) Account No. off Invoice No. • &4 71 WOAPO i� W•W Date Property Flagged:. / / J 131 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 on r tsponsible for all charges incurred from this appUcation. I, hereby, give consent to the Authorized Representative of the Da Cod ty Health Depa(meat to enter upon above described property located in Davie County and owned b?" i to conduct all testing procedures as necessary to determine the site suitability". DATE lo— /3 1 r SIGNATURE &Crrz THIS AREA MAY BE USED FOR DRAWERG YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07198) Account No. off Invoice No. • &4 71 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT I� Soil/Site Evaluation APPLICANT'S NAME �I 9 1U.JkQ� DATE EVALUATED I L4 ID PROPOSED FACILITY PROPERTY SIZE IOD 3 ' SUBDIVISION )AD1L1 r) A CA6 ROAD NAME Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public I --- Cut FACTORS 1 2 3 1 4 5 6 7 Landscape position L Slope % 1170 HORIZON I DEPTH - 0-10 Texture group Consistence Structure Mineralogy HORIZON II DEPTH p Texture group r/ Consistence - (� Structure A.5 iL- Mineralogy(: (: HORIZON III DEPTH - q o Texture group Consistence Gr 5S 91 F Structure Mineralogy HORIZON IV DEPTH Texture group % q Consistence ipr SS 51P Y Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: r✓ LONG-TERM ACCEPTANCE RATE: 0' q REMARKS: LEGEND DCHD (01-90) Landscape 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 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 No on ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ WOMEN ■■N■■ ■ENE■ WOMEN ■■NE■ MESON ■■NE■ WOMEN ■■M■■ ■■■■■ ■■■■■ ■■N■■ ■SONO ■■■N■ ■■ME■ SEMEN ■■ENE SOMME ■■■■■ ■■■■■ memo■ ■■■■■■■■■■■■■■■■/.i■■■■■■■■■■■MIS■ ■■MM■■ENN■■M■MEEMME■ ■E■E■■M■■IO■ ■■■■■■■■■■11■mMEEE■■■■■■■■MMS■■■It■ ■■■■■■NMN■11■■■■■■■■■■■■■■■■■■■SIl■ ■■■■■■■■■■1t■mNE■E■■■ ■■■■■■■■■171■ ■■■■■II■■■■■■■mm"M ■■■■■It■■■■■■■■■■■■ ■■■■■11■■■■■■■■■■■■ ■■■■■IIM■■■■■■■N■■■ ■EEM0IIM■■M■■■MEME11 ■■■■■11■■■■■■■■■EIV ■EME■ITEM■E■■■M■RNM ■m■mmllm■■m■■■■■ ■ ■Mmm■lIM■■■■■■EM��■ ■E■NNIIE■■E■E■M■NE■ ■E■■■11■■MEMEMM■■MP ■■■■■II■■■■■■M■■NEM ■■■■■11■■■■■■■■■■■■ ■■■EE11■■■■■■■■E■■p ■■■■■11■■■E■■■■■E■■ ■■EEE11■milmo■mom ■ ■■MM■I1■M1t■Mrn■nl _P.w ■■M■■M■M■ ■■■m■mm■■ ■■■OMON■■ ■■■EM■M■■ ■E■■M■M■■ ■E■EM■M■■ ■M■■■■■■■ ■■■NEEM■■ ■■■■■ENE■ ■■■■■ME■■ ■M■■■E■■■ ■M■■■M■■■ ■■NN■■■■■ ■M■■■■■■■ ■■■■■EEE■ ■M■■■■■■■ ■■■E■■■E■ ■■■MNEME■ ■■■■■■■■■ ■■■■■■■■■ ■■■■ENE■■ ■■■Mee■■■ ■■■ENE■■■ ■■■■■■■■■ ■■■M■■■■■ ■■■ME■■■■ ■E■■■■■■■ ■■■■■■M■■ ■■■■NONE■ ■M■M■■■■■ ■■EEM■■■■ ■■■■■■■■■■ ■■EEE■■■■■ ■■■■■■NEEM ■■■M■■■■■■ ■■■■■■■■■■ ■■■■■■■■N■ ■■M■■■■■■■ ■■E■■■■■■■ ■■■■■■■■M■ ■NEEM■■■M■ ■■■■■■■■■■ ■EN■■■■ME■ ■■■■■■■■■■ ■E■■EMEM■■ ■■■■■■EM■■ MEMMEMMENE ■■■■■MMON■ ■ ■