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250 Grannaman DrSYSTEMCONSTRUCTION Road Name: awayl Pip: 74,99 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section phor to issuanceof 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 AUTHORIZATION NO: 0672 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permitted's P.O. Box 848 Nan�e: �-7�;- ARd I I Mocksville, NC 27028, Subdivision Name: Phone #: 704-634-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:o 6661 SYSTEMCONSTRUCTION Road Name: awayl Pip: 74,99 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section phor to issuanceof 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 r. r'^"c,:,ytrn;A"'ti �..=•�,`et "t'�.:-,,, �P�,. .r 114j.4f �b DAVIE C6VNTY HEALTH DEPARTMENT AND OPERATION PERMITS PROPERTY INFORMATION IMPROt N Perrit�te x Name: -Subdivision Name: ' Directions to property: i°1id d I ,zW 6: � �� Section Lot: ENPROVEMENT PERMIT Tax Office PIN10 i q- - Road Name: t.`!"i A ))i j�7 Y11Lii' 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 penrut. ' (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section1, 900 Sewage Treatment and Disposal Systems) r , "**NOTICE*** THIS PERM[T IS SUBJECT TO REVOCATION IF SITE :-fit: ;� �1 :1/I�d ✓� ' �f f'' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE A # BEDROOMS -*4F # BATHS c� _ # OCCUPANTS S GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE, i.<//r TYPE WATER SUPPLY _h&JDESIGN WASTEWATER FLOW (GPD) NEW SITE t/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE :&-�-GAL. PUMP TANK GAL. TRENCH WIDTH rel ROCK DEPTH IZ / LINEAR FT., c Z0' OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: "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. OPERATION PERMIT SY TEM INSTALLED BY: DCHD 05/96 (Revised) NO. OPERATION PERMIT BY: ! /J,/AUTHORIZATION DATE: "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) C6Y v APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department ^ a Environmental Health Section ( @G WE P. O. Box 848 D Mocksville, NC 27028 (704) 634-8760 I FEB ! 01997 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE UNLESS ALL THE REQUIRED INFORMATION IS PROV ,, 90. ✓ 11 1. Name to be Billed Contact Person,),l� �CIUJyi�l�iii4J(J Ct Mailing Address �,�L41LL�ft�LilA`L� l��ll/�=_ Home Phone 7 7v� '" 7�t City/State/Ziply l () �C /1 --�= /�� ► %?� Business Phone k3ptU G 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: ADishwasher 6. If Business/Other: # Commodes If Foodservice: # People IT ❑ Garbage Disposal Specify type _ # Showers # Seats Both # Bedrooms —5 # Bathrooms 2 XWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 7. Type of water supply: ❑ County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes X No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Jai C 1 WRITE DIRECTIONS (from q 1 Mocksville) TO PROPERTY: Tax Office PIN: # 1 GD / .— K) /O 126111d Property Address: Road Name 1 /vR�u k F! 0i) TIAMr Cit /Zi 7D A.SS' 1 City/Zip SL L 6D %p 99MAIAM) AA) -Z>( If in Subdivision provide information, as follows: i I Name: %O r -1P,5 Lea T Section: Lot #: i fZ l 6l -i% 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 e --,/t9' ��7 SIGNATURE Revised DCHD (06-96) conduct all testing procedures 701.36 Ate) 14.52 Ac 3$ 5g 7.01 10 5.3J r3 2.53 ? - l52 2.2 A.c 5.01 9 92 Ac m y- 8.01 22 B I 250 48.14 Ac / `4 ao 0 P19,II _ - •-i 238.06 5 O;. 5v 41 �Ga _ 14. 11 A c. ) N� C 15 \PGT 6.62 u-) g N 56 4. 50 N 17 N 7J� nye k2�� U.A 16'74 r J A C . 539 50 368 3c- 368 E368 i 18 19 20 M 5 A- 5 A c ., 21 a 1o1.11A� J 0"-' 302 3 2 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY AL SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring 1-1— Pit DATE EVALUATED PROPERTY SIZES r? ROAD NAME �i",.� ¢ ./I�i-r�•� -•`�'� Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t c Texture group Consistence Structure 6 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:y i LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) EVALUATION BY: )4 OTHER(S) PRESENT: LEGEND 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 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 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENMENNENMENNENiiiiieiiiiiiiiiiiiMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■