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129 San Carlos Court Lot 74AL-Mir'RIZATION NO: 1572. DAVIE CpUNTY HEALTH DEPARTMENT r'Environmental Health Section PROPERTY INFORMATION ` Permittee's j� P.O. Box 848 Name:did/fj,' i►'eF� :+ Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 �t,=�(,, Directions to property: drr Section: Lot: AUTHORIZATION FOR WASTEWATER Tax O SYSTEM CONSTRUCTION Office PIN:- Road Name: r° i Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 IS VALID FOR A PERIOD OF FIVE YEARS. , ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 1572 DAVIEOUNTY HEALTH DEPARTMENT IMP OVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ,� Name: Subdivision Name r Directions to property:. Section: Lot: IMPROVEMENT PERMIT Tax Office PIN: r Road Name:—U& p **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE 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 # BEDROOMS ....P # BATHS �_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT -� # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE C P TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE_y/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE wGAL. PUMP TANK GAL. TRENCH WIDTH Y ROCK DEPTH AP LINEAR FT OD 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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. _ / OPERATION PERMIT BY: `�u�/l DATE: L **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) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848 NEW PHONE NUMGER: Mocksville, NC 27028 EFFECTIVE MARCH 22, 1998 (704) 634-8760 336 751-8760 ***IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed ag- EX77-77-6 L�7/1/0 Contact Person t - /moo Mailing Address Home Phone o Cj f City/State/Zip q l�y6y�� ItIZ , Business Phone(33(o) 99 o2/D� Name on Permit/ATC if Different than Above Mailing Address City/State/Zip Application For: [ 1 Site Evaluation Improvement Permit & ATC Both System to Serve: [ J House [ obile Home [ ] Business [ ] Industry [ ] Other If Residence: # People # Bedrooms 3 # Bathrooms o2 [' ] D shwasher [ J Garbage Disposal JG] Shing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing If Business/Other: Specify type # People #Sinks # Commodes — # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) Type of water supply: ounty/City [ ] Well [ ] Community Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes 1-1-141c, If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: .s -P2 hl 4 r� 'WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # - - Property Address: Road lame -S,,q N elgr•GDJ C9'. ; i City/zip qd L/,1,4/ LE 412 If in Subdivision provide information, as follows: Name: , Section: Lot #: his is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are bject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or anged. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized epresentative of the Davie County Health Department to enter upon above described property located in Davie County and owned vised DCHD (06-96) HIS ARE,1 hl.11l 13E 11SE.b FOR L)RM 1NC I10111? SITE PbIN: Ls necessary to determine the site suitability. �0-cf- a9 �V //g s R HAS i CaR"FY TNAT Tfila ;'t* r1Y sup4taYislon)(" Y SdPtR1/ISi0N)P"*4 (AA -LED OEsCRiPT10M "cO/R Of CLOSURE AS CALCULATE 9 IS 1s € SOUNDARitt INT EIL LINES PILOTTE R fR0V ,phaE—._,TNAT ORGANCE *ITN S:S. 4T.30 ANO SEAL THIS -`C SURVEYOR r 4-4rl Ir WE THIS- _ LAY OP If " COMMISSION EXPIRES _ I'ER SUPPLY ANO SEWAGE DISPOSAL ED FOR INSTALLATION, iN THE SUB- - 'T 3 OF THE NORTH CAROLINA STATE E REBY APFROVEC AS SHOWN. ,SEALTH OFFICER OR HIS ar PRESENTIVE f v� C-6, ` 2� W- PQI cgoo - N 9pl 10 9- � J to J `��, „? Ni • Q a• 4-S.3a' ' -03 1p ' � i ; : � max, �, `� ` \`?p • � _ Z O �I Jo r V 10 Orr �;� tib • +� a5 S,i o2"v 3 Z � � � 2 • � Q, �� • -f •d `,gyp � p`" '> ;�9 l� sa• ` o s � vi �^ 1 Z — ,`� may• ^? Ir f'—p L - S �3•�l2W ) ti3':15'4ajE -. 'G. v, � 3 � air s �r�Q r f f � ,•� _ It fV r+ v\cp 9� r -- 42.•5' ori -- 'SO.�' ---- —� _ D D �� 5 0 -- — '� 44. '1- *' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME 49A PROPOSED FACILITY '`v SUBDIVISION /14 (jv q �' Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit SECTION LOT DATE EVALUATEDy�� PROPERTY SIZE J.._ c G Or - ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy 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 LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: EVALUATION BY: 1 LONG-TERM ACCEPTANCE RATE: / OTHER(S) PRESENT: REMARKS: 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 DCHD (01-90) ■ ■ ■ ■ ■ENNE■ ■ENN■■ ■■MONS ■■M■■■ ■■N■E■ ■E■■M■ ■■MN■■ ■■MO■■ ■■M■M■ ■■N■E■ ■■■NE■ ■■MME■ ■■NN■■ ■■M■M■ ■■MO■■ ■■M■■■ ■■NNE■ ■■MNO■ mom mom ■■■M■M■M■ MEMMAIMMEM ■M■M■■M■■ ■■N■■ON■■ ■■MME■■E■ ■M■MMS■■■ ■MSM■■■M■ ■ME■■MM■■ ■S■■MO■■■ ■ ■ ■ ■ ■■■E■■■ ■■■■■■■ SOMEONE ■MMES■■ ■E■EEE■ ■ ■M■MME■M■ ■O■■■M■M■ ■■■ME■EM■ EMEMEMEME ■■MME■EM■ ■■M■MEMM■ ■EME■E■M■ ■O■■■E■M■ MEMMEMEME ■M■ME■E■■ ■■MEM■EM■ ■E■E■■■M■ ■E■■ME■■■S■E■ ■■■SMO■M■MMO■ ■■SMS■MSM■MM■ ■■■M■M■■M■■M■ ■■■SMS■M■E■E■ ■M■ME■■■■MM■■ ■MSM■MSM■MM■■ ■MSM■■M■M■MS■ ■■■ME■■M■■ME■ ■ENU■MMMMOU ■M■ ■MSM■■ ■MSM■■MSM■■M■ ■M■M■■M■M■MM■ ■■M■MM■M■■■ME ■■M■■■■M■■■■■ ■■MM■M■M■■■M■ ■■■MMM■■■■MM■ ■S■MSM■M■■■■■ ■■MM■■MM■MM■■ ■M■■■■■E■■■M■ ■■E■■E■■■M■E■ ■ G-8-