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355 Bracken Rdf �avie Countv. NC Tax Parcel Renort Wednesdav, October 12, 201 E WARNING: THIS 1S NOT A SURVEY �..-.� _-. ry `° ParcelInformation � =a _,�_�.._..___�::,,_�_w___ . �_a�_.�s��.��_._�ws _ �ti_�..,F�_ � �_v�.�..�,� �.,,,s� ..,�. ,.;,, :. ,, �, �� P.��,r.___,.�. �e�:,_ �.� � � � Parcel Number: F300000071 Township: Clarksville NCPIN Number: 5820498815 Municipality: Account Number: 66511500 Census Tract: 37059-801 Listed Owner 1: SLATER TERRY GLENN Voting Precinct: CLARKSVILLE Mailing Address 1: 355 BRACKEN ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20 State: NC Zoning Overlay: Zip Code: 27028-5654 Voluntary Ag. District: No Legal Description: 10 AC BRACKEN RD Fire Response District: WILLIAM R. DAVIE Assessed Acreage: 10.94 Elementary School Zone: WILLIAM R DAVIE Deed Date: 5/1996 Middle School Zone: NORTH DAVIE Deed Book / Page: 001870524 Soil Types: MnC2,MnB2,MdD,ChA,WATER Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: 20100.00 Outbuilding 8� Extra 44970.00 Freatures Value: Land Value: 64360.00 Total Market Value: 129430.00 Total Assessed Value: 129430.00 9"N'�' Davie County, °�UN�'` NC �..:�,, ;',�� "'.;�;w,o,s,:�,�+ �1" ��„�: ' 'i� _ .� 44 . .. r. r.,� ���X�,� ���-=; ,�:�.-� ,� � - : /f c�a AUTH0�1L;1T�N N�: `� � Q,� DAVIE �OUNTY HEALTH DEPARTMENT ✓X8 ' � � r Environmental Health Section PROPERTY II�iFORMATION� Pecmittee's :, � � �'� � � P.O. Box 848 Name: ` �'`' Mocksville, NC 27028 Subdivision Name: - /`, � �' `lI ,`' . _ � J Phone # 336-751-8760 Directions to property: .�- l f� ��' Section: Lot: : AUTHORIZATION FOR ; r.: 1 WASTEWATER �°r", �y;,� ,� f' '�`�� fi -� �_. ��' SYSTEM CONSTRUCTION Tax Office PIN:#..-r «= x�� �' � _ c� ��• Road Name: �.��":��" =�`+ � Zip: , �n�� **NOTE** This Authonzation for Wastewater System Construction MUST BE ISSUED by thebavie County Environmental Health Section prior to issuance of any Building Pernuts. This Form/Authorization Number should be presented ro the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f �" �`� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,,T"'� -1 �/.;, ��"t=�'��', � % O�Y IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED : � T�:..�..�5 ` .. ' ' � w � �• . 1 ♦ . .. � .. ♦ . . . � a . . � _ . .. ..n .. . . .. . . . . . � ..-,./.. 1'�. 1�. r,�.�,.. �` � . , _ . , � i . . �:f f ! i !,4', ls R/ � �,' f -_ : f `r ; .e....,,sn,�►�...:' ... �.-•�. �.. ... . � y. . . . , � . . . • . . ' . -- �-'� " '� � � � �;y DAVIE OUNTY HEALTH DEPARTMENT f/ ��O rc:«:�-��,'� ,''�' ''� - . z.:._--. � ..=.,x IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's ,�` ' � Name: _ � '��a.� •-,.� ..�'"�r ` ' . ��'�� Subdivision Name: ' __ -_ � ..._ - �-� ,; ,r � I3irections to property: ,.�''. .'` �% Section: � Lot:: IlVIPROVEMENT �,..,, r. , ,j w� �a � „�.- .. � � PERMIT Tax Office PIN:#:� �,--1"�- �"f - ����"�—' � Road Name: !�� ''� ' ��''�Zip: � � r' �' C;* **NOTE** This Improvement Pernut DOES NOT authorize the constcuction or installation of a septic tanlc system or any wastewater system. An AU'I'HORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this Department prior to the conshuction/'mstallation of a system or the issuance of a building pernut (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section 1900 Sewage Treatment and Disposal Systems) � ;: ',, ***NOTTCE*** TI-IIS PERNIIT IS SUBJECT TO REVOCATTON IF STI'E �i t,� ; ", ' � � t : �`" ' . - � , PLANS OR TI-� INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISS ED SYSTEM CONTRACTOR MUST SEE THI� PERNIIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEDROOMS „� # BATHS �# OCCUPANTS _� GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILII'Y TYPE # PEOPLE # PEOPLF/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE D� TYPE WATER SUPPLY U�' DESIGN WASTEWATER FLOW (GPD) �G� NEW SITE�REPAIR SITE � , ,;, .,�d0 SYSTEM SPECIFICATIONS: TANK SIZE �, ve��GAL. PUMP TANK GAL. TRENCH WIDTH �._ ROCK DEPTH /;�=J LINEAR FT. ,-="�'� REQUIRED SITE MODIFICATIONS/CONDITIONS: 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. OPERATION PERMIT -/' SYSTEM IN ALL Y: ��/ n'i �119 /yt G�_ lcx�e��1. � AUTHORIZATION NO. ��� OPERATION PERMIT BY: DATE: � *•Tf� ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT Tf� SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPUSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WII,L FUNGfION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) f,�°.__D�� APPL1CA710N F Dav e C unty H alth Depardnent p�MIT �C ATC .� ��-�� � ���a�r� S� ; �� Envfronmenia/Nea/thSe+ci3on P.O. Box 8�B/210 Hospital 3treet � � r��B.►�ii@, Nc z�oze NOV I 7 1998 (336)751-8760 1. Z. 3. ***IMPORTANT*** THI3 APPLICATION ('.ANN01' 8E PROCESSED UNLE33 ALL INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN for 0 Name to be Silled �e i� ri/ �! i�Tio i` Contaat Peraon ( C i� r �� S�, �-Tr_ t'' Mailinq 8ddress C/� e 1 / �� 11 C°,� 1� � g0� �lOI1e `f ��` c 7 [X I��i City/8tate/ZIP �%�,(� �� S l� i' � � N �f� � � ot O Businesa Fhone G ( J � -" � � � � Name on IIesmit/l►1C i! Diflerent than Above_ Te {� (�� / S' �}-�� (� Mailing Address r�� � i l��`c� n ►C�C� City/8tate/Z1P ��,r y�SIJI'�' e .�1.� ���� Applicatioa For: ❑ Site Evaluation ❑ Improvement Permit/ATC �'Soth 4. systrm to "sesvlce: ❑ House �`d'Mobile Home 0 Business 0 Industry [] Other s. If Reaideace: � People _� # Hedrooms �_ • Bathrooms �_ 0 Diahwasher 0 Qarbaqe Diaposal F�aahing !lachine 0 Baaement/Plumbinq D Saaement/No Plumbinq 6. i! Buaineas/Industry/Other: Specity typa / Beapie # Co�uodea + 8hoxera � tlrinals i Sinis % iiater Coolera IP i'OOD3ERVICE: � 3eats Estimated iiater iJsage (Qaiions per day) 7. Tppe of Mater supply: ❑ Connty/City �ell ❑ Cma�mstiity e. Do you anticipate additiona or e:panaiona of the facility t6is ayatem is intended to serve! U yes, wbat type' 0 Yea �YNo "'*IMPIDRTANT'�'• CLIENTS �1lAST CO�IlPLETE THE REQUlRED PROPERTY INFORMATION REQUESTED � BELOW. Either a PL.AT or S1TE PI.AN �lUST BESUBMITTED by t6e client wit6 THiS APPLICATION. Property Dimenaiona: � � f-ri! (` e_ 5 � DIRECTIONS ([rom Mocksville) to PROPERTY: Ta: Oftice PIN: #�i � a 0- y°� S g l.�i �O d d� � I �t/, -i-� „� A-e,l�. e���i,. Prnperty Addrrsa: Road Name %�fl�p,lC e,r�, Q.cl. G c� �D �. Y1.c�. � G r�� � City/Zip II � n r�,,,�s �r; c�.��oa� �� fi, ��. �� r�-r� p roD.T c�. s�-,� . It in a Subdivisioo provide information, as 1'oilowa: Name: Section: Block: Lot: . ���� ���.� ��� �.��x�.� % Date Property Ftagged: �� i-% ;� e.f' �, This is to certify that the intormation prnvided is correct to the best of my knowledgG I understand that any permit(a) issued hereafter are subject to auspension or �vocation, if tbe aite plans or intended use change, or if t6e information submitted in thi� application is talsitied or chaoged I, also, ttnderstarrd that I anr responsiblejor o/l charges i�rcurred from this appl;c,utio,r. I, hereby, give coneeut to the Aat6oriud Reprr�essentative of t6e Davie County Health Department to eoter upon above described property locuted in Davie County and owned b�• ��� l� �%a-'�1— to conduct all te�ting procedurea s�a neceasary to determine the �ite auitabilih�. DATE II ` � � '9K� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: E�sting and proposed property lines and dimensiona, at�vctures, setbacks, and aeptic locationa). Reviaed DCHD (07/98) Accouot No. r��� Invoice No. ��� 4�ie f�' :f. -;;;;�;�._ 63 (815) r�=!''�:�;;��":'� � '�'J.,S.\�.;•`� �� t�j � l. � 1 \ � � � e� � �/ ��n � _1 �/�/� Y/ � � \� - X ON 5 820 h��w, _ _ � � � � A� ^ O ... 00 "� (�0.94A1 �' � V � �� O `� 8 815 This map is for PERC TEST � end BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office assumes no liability for any ^ � information contained on this map . M ,�,15T�� �g411 N � �N COUNTY-ID:F300000071 . , November 17,199810:31 AM � � � Parcel Identificetion Number �'` 5820-49-8615 ;; . : ` pAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME S� �2 DATE EVALUATED %%/�/9d" PROPOSED FACILITY _ �%! PROPERTY SIZE O SUBDIVISION ROAD NAME ���� Water Supply: On-Site Well � Community Evaluation By: Auger Boring !/ Pit IC�J 1 Kll, l 1 V� riVK1GVIV I,LHJJ1C1l..H 11V1V i hAT!_ TIIDI�d A!'!` SITE CLASSIFICATION: EVALUATION BY: Public Cut LONG-TERM ACCEPTANCE RATE: ��% OTHER(S) PRESENT: REMARKS: LEGEND � Landscape Position R- Ridge S- Shoulder L- Lineaz 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 day 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 piastic Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangulaz blocky PL - Platy PR - Prismatic Mineralo� 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 - gaUday/ft2 DCHD (01-90) �� ■����■■�■���■����■�■■�■■�■�■��■■�■■■ ■�■■■�■���■��■�■■■��■��■��■�■��■��■■ ■��■���■�����■��■�■�����■�■�■ ■■��■ ■��■��■■���■�■■�■■■��■��■���■ ■■■■■ ■��■���■�■�■■�■�■■■��■��■�■��■��■■■■ ■��■■��■■��■■������■����■■���■■�■■■■ ■■�������■■�■��■�■�■■�■��■■■��■��■■■ ■�■��■��■■■i���■■■��■�■��■■■��■■��■■ ■��■������■�������■�■��■��■�■��■��■■ ■■�■��■��■���■��■���■��■����■�■■���■ ■��■���■�■���■■�■����■�■■���■�■���■ ■■■■���■■��■■■��■■■��■��■���■ ■■��■ ■■��■■�■���■����■�■■�■�������■��■��■ ■�■��■�■■��■��■�■�■■�■■�■■■■�■■�■■■■ ■�■■�■■�����■��■�■��■�■��■■■��■r�■■■ ■■������■�■�■■�■■���■������■■��■��■■ ■��■��■■�■0■��■�■�■�■■�■■�■�■■�■■�■■ ■��■■�■■���■■■■�■�■��■����■��■�■■■�■ ■��■�����■�■■�����������■�■���■■■■■ ■��■■��■■��■■�■�■�■■�■■�■■�■■ ■■■■■ ■■■�■■��■�■�■��������■■��■�■��■��■�■ ■■■��■■�■■■�■��■�■�■���■■�■■■��■■�■■■ ■�■��■■��■■■�■�■��������■��■■■�■■���■ ■��■��■■���■�■�■■■��■ur�■��■■■�■■���■ ■��■■��■���■■■��■■■�����■����■��■■�■ ■■■��■■����■■���■■■■�■■��■�■�■■�■■�■ ■�■��■�■����■������■�■■����■���■■■■ ■�■■�■■�■■■�■��■����■�■■�■�■■ ■�■�■ ■��■��■���■��■�■■■■�■�����■■��■■���■ ■��■■��■���■�■��■�■�■��■■���■�■■��■■ ■■■�■��■■■�■■�■���■■��■�■���■■�■■��■ i�■���■�■■■■�■������■�■������■�����■■ i��������■■■■■��■�■����■�■■�■�■��■��■ i■��■��■■■■�■��■■■■�����■�■■■�■■��■■■ ■ ■■ ■■�■■■ ■��■■■ ■■�■■■ ■■■■�■ ■�■�■■ ■��■■■ ■����■ ■�■�■ ■ ■�■ ■■■■�■ ■■■■�■ ■�■■■■■ ■■■■��■ ■����■■ ■��■�■■ ■�����■ ■■��■�■ ■■■�■�■ ■■■�■�■ ■�■■■�■ ■����■■ ■��■�■■ ■■�■��■ ■■�■■�■ ■�■���■ ■�■�■■■ ■■■�■■■ ■�■���■ ■�■�■ ■�■�■ ■■�■■ ■■�■■ ■■�■■ ■■�■■ ■■��■ ■■ ■■���■ ■■���■ ■■�■�■ ■■■■�■ ■�■■■■ ■�■■■■ ■����■ ■■���■ ���==� ■��■�■ ■■�■�■ ■■�■■�� ■����■�� ■■���■r� ■■■■��■ ■■■���■ ■���■�■ ■�■■■■■ ■�A��■�■�■■ ■��■����■�■ ■■�■��■�■�■ ■■��■�■■��■ ■�■��■�■��■ ■�■�■��■■�■ ■■■����■■�■ ■�����■■■■■ ■■�■■�■■�■■ ■■����■■�■■ ■■���■■■■■■ ■■■�■�■■■�■ ■■��■�■�■■■ ■�■�■■��■�■ ■�■����■��■ ■���■■■�■�■■�■ ■�■■�e��■��■�■ ■�■�����■■�■■■ ■��■�■��■■��■■ ■�������■■�■�■ ■■��■�■■�■���■ ■■��■�■■�■■��■ ■■��■�■■��■�■■ ■�■����■■�■��■ ■�■��■�����■■■ ■�■■�■��■��■■■ ■■�■�■���■�■■■ ■����■■��■��■■ ■���■�■��■■�■■ ■�■�■��■��■■�■ ■���■�����■■t■ ■��■■■�■■�■■�■ ■���■������■■■ ■■����■■�■■��■ ■������■��■��■ �■����■■t■■��■ �■■�■��■�■■��■ ■�■�■�����■■�■ ■�■■�■�■■�■■�■ ■����■■�■■��■■ ■■��■■■�■■��■■ ���■■■■�■��■■ ii ■■�■■���■■����■��■��■■■ ■■���■■��■�■■�■■�■��■■■ �■■■■■■�■���■■■■�■��■■■ ■■���■�■■�■■�■■������■ ■■■������■■�■�����■���■ ■■■���■■�■��■����■■��■■ ■�■■■�■■����■��■��■■��■ ■�■��■�■�■■■■��■���■■■■ ■��■■■��������■�■��■■■■ ■��■■■��■��■�■■�■0�■■�■ �■������■�■��■■�■■�■■■■ ■��■■■�■■��■�■��■��■■■ ■■■���■■�■��■■�■�■■�■�■ ■■■■■�■!■■■■■■�■��■�■■■ ■�■�■�■■�■■■■��■��■�■�■ ■�■■��■■■�■■■■����■��■■ ■�■■■�■■�■��������■��■■ ■�■■�■����■�■���■�■■��■ ��■■�■�■�■����■���■■■■■ ■�■�■�■■��■����■��■��■ ■■�■�■��■��■��■���■■■�■ ■■■��■��■��■��■�■■■�■�■ ■■��■�■�������■��■����■ ■■■�■■■��■����■��■■�■�■ ■■■�■�■■�■��■��■�■■■■■■ ■■ ��� iii ■■■ ■�■■■�■�■ Z■■■■■■ ��■■■■' ■���■■■�■ ■���■�■�■ ■���■�■�s ■■■����■■ ■�■■����■ ■��■�■��■ ■���■■■�■ ■■���■��■ ■■■�■�■�■ ■�■■��■�■ ■�■■■�■■■ ■�■■ ■■�■ ._. . . , ., . , . . , , . ._ . , � . . '�o ' � . DRVIE COUNTY F�flLTH DEPRRTMENT " � IMPROVEI�(T PEAMIT and OPERATION PEAMIT Ib�ROVEI�NT PERMIT �+�t�TE�+� This i�prove�ent per�it DOES NOT authorize the construction or installation of a septic tank syste� or any NasteNater syste�. AN RUTHORIZATION FDR HASTEWRTER 5Y5TEM CDNSTRIICTI�I �ust be obtained fro� this Depart�ent prior to the construction/installation of a syste� or the issuance of a building per�it. iIn co�pliance Nith Article 11 of 6.5. Chapter 130A, NasteNater Syste�s, 5ection .1900 SeHage Treat�ent and Disposal Syste�s) NAME � r�� 1�,� PROPERTY ADDRE55 � ra C�E r� � ��O a Y DATE -�`�r LOL'ATION (��/'/i�'.c��r� ��IaC/ SUBDIVI5ION NflMIE LDT MA4BER 5EC. /BLOG{ MJMBER RESIDENTAI SPECIFICATION: BUILDIt� TYPE �� BEDRWMS �� BATHS � t O(�t1RAMT5 � 6AABA6E DISPDSAI.: Yes/No COMMERCIflL 5PECIFICRTIOM: FF�ILITY TYRE t PEORLE � PEDPLE/SHIfT # SERT5 INDU5TRI� NA5TE: YeslNo LOT SIZE _t��e TYPE NRTER SUPPLY _,��� DESI6`�1 WASTEWATER FLOW iGPU) s�� F�J SITE �''�REPAIR SITE 5Y5TEM SPECIFICATIONS: TANI( SIZE Y�i 6AL. W�IP TRFM 6RL. TRENCH WIDTH ...�� �� ROCK DEPTH /�„ LII�AA fT. ��v OTHER REQUIRED 5ITE MODIFICATIONS/COrIDITIDNS: *+�}THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TF� INTENDED U� CHANGE. YDUR ►,�ISTERWATER SYSTEM CONTRF�TOR h�JST SEE THI5 PERMIT BffORE INSTALLIN6 THE SYSTEM. n l�,,.��.,,�a+..�...w..�+....�..�.r�,.�..o.e �„'"' � . _ . . . . . . . . . . .. IMPRDVEMENT PERMIT BY ,%�-,�%� **CONTACT A REPAESENTATIVE � THE DAVIE C�11JTY HEALTH DEPARTMENT FOR FINAL INBPECTION � THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:�-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHOt� � I5 (7@41 E34-8760. �ERATION PERMIT SYSTEM INSTALLED BY s � �o � .�.�..` /Y� O �..� AUTHORIZATION N0. ��/ OPERATION PERMIT BY �� DATE l.� �� f�THE IS�INCE OF THI5 OPERATIOM PERMIT SHALL INDICpTE TF�T TFIE 5Y5TEM DESCAIBED ABDVE F�S BEEN INSTALLED IN tXIMIPLIANCE WITH I AATICIE 11 OF G.S. CHAPTER 130A� SECTIQN .1908 "�'iE TRFATl�NT AND DISPOSAL SYSTEMS°, BUT SHALL IN NO WAY BE TAKEN A5 A 6'UARANTEE TF�T TF� SYSTEM WILL FIArCTION SATISFACTORILY FOR ANY 6IVEN PERIOU � TIME. DCAD 10/95 � ,. .,. � _. _...�.�: �� .. . • :��','xtT ' <.'✓ � � ��- ... .�.�.: _ . . �� � Davie County Health Depart�ent ENVIRONMENTAL HEALTH SECTIDN f �' P.�. Aox 665 Mocksville, N.C. 27028 AUTFIORIZATION FOR {q5TE�qTER SYSTEN CONSTRUCTIaI lIssued in co�plianre Hith Article 11 of G.S. Chapter 130A, Wastewater Syste�s) '�G,_ +�+�+�This Ruthorization Far WasteNater Syste� Construction wst be issued by the Dav:e County Environiental Health Section prior� to is5uance of any Building Per�ita. This For�/fluthorization Nu�ber should be presented to the Davie County Building Inspe�tior�s Office when applying for Building Per�its.+�+� �/� , AUTF�RIZRTION t�JP�R NAME ���'./'�" r� �...1 /l'- �'' l'"-/'J ` DATE % /�, `�`� j s � '� f ; � "i NRME �N IIPRDVQENT PERMIT iIf different than above) 5ITE LOCATIaI �f�,/�;�%r"�'�✓ .��T COMI�NT5/I;O�mITI0N5 ON RUTHDRIZATIDN TO (;ONSTRIJCT WRSTEWATER SYSTE�I f+fNOTICE� THI5 RUTHORIZflTIDN FD flSTEWATER 5YSTEM CDNSTRIICTIDN IS VflLID fOR A PERIOD DF FIVE t5) YEAR5. �.�� .` '''� ` 'r ,y"� ,.i /� �`�,� r. ,c.i �k ENVIkOMEHTAL IfAL1'H'SPECIALIST DATE DCHD 10/95 , ' , • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC , Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT�*** THIS APPLICATION CANNOT BE PROCESSED'1 THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed I•P t' � �/ � ���� e r Contact Person � a✓t'► � Mailing Address �3 � S � t'� ck ��cU Home Phone 4�9 2- 5 2 I�, City/State/Zip � � C K S U i I(-2 /�% �- 2 7 C� �-g Business Phone 9� O�%� C3Z� 2. Name on PermidATC if Different than Above S� m e Mailing Address City/State/Zip 3. Application For: [] Site Evaluation [] Improvement Permit & ATC �Q Both � � 4. System to Serve: [] House '[� Mobile Home [] Business [] Industry [] Other 5. If Residence: # People� # Bedrooms 2 # Bathrooms� [] Dishwasher [] Garbage Disposal �Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [] County/City � Well [] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes [�No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A�LAT OF THE PROPERTY MUST BE SUBMITTED WITH TffiS APPLICATION. Property Dimensions: �� x� 7s � d 4crA � WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #.� � Z� -�_ -$� � J� ; � �' � d a � �. � U�'J Property Address: Road Name ���� c k�N �� � o � 1"�' o� City/Zip �V� oc �C ���� �� 2. ; ��s C. �4'� 0 1 If in Subdivision provide information, as follows: � Name: � � � Section: Lot #: ; 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 incuned 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 �T, e c c G S -2 c' to conduct all testing procedures a_-�� to determine the site suitability. DATE �I " � J I % SIGNATURE „� ! � Revised DCHD (06-96) �9/!� J " e �Gt � �% t.' ��� / j�� ✓.e a1 �� 5 CQK�'✓ � � y�` .5 n� Lc H lac. ,�ed�,� Sl) �c�c� �"�'//'' �! R % i— ,— .. . -__ .__ ...------. ..__._...____.._..--. _—. _---------^-----'---�-'_.----_--- --�---------�-------^-�-�--�._. ---------------------------------""------ S ��� � � j' /`�. "u I , , , . � q� q . • �� �'✓ � - � c_ �� • :\, K; � i � 5��� _ `" � I � �� .- - — �:�' �� -�'nSZI — — — �'� I t � if,. rr � _ - ��� C�L, � o 't � �. __ - � `� � I� � �. . y� �_ o) �� � u �, 2Po 8� �9�' V� � H � N � � i � � � ; y ` � �� � �J �, � s� . 11 K' `� , � ,y�, , _ � � �' � ! i � p�` ` � r-- £ �=_-- � � �i R, � _ _ __ = ti �,1,�. 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C7i � 'v � �t 3 � - ` �n �, � ' `" � , rn : q . .. . � � �� � '�._...�,---- - r _ _ . - -- -_ � _ r _ _ _ _ - __ -- _ , _--__ --__ __ � ______ _, - __. - - _ _ __ _- _ r� _ _�_� ____ , _ ____________ . � � , = � - � -. ____ ,� _ s- - - - _ _� __,_-� --- _ _ ____ , , .� � � q � � ! � ' ' � ' DAVIE COUNTY HEALTH DEPARTMENT � • Environmental Health Section . � Soil/Site Evaluation NAME ��/ .j!.ro DATE EVALUATED � lh �� ADDRESS PROPERTY SIZE ��/�i PROPOSED FACIILTY ,�� LOCATION OF SITE �dfO'�t'�/ .�✓✓ Water Supply: On-Site Well ✓ _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landsca e osition Slo e 7. � HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �- -�/ > �" Texture rou L' � C Consistence Structure � / Mineralo ' � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CL�SSIFICATION LONG-TERM ACCEPTANCE RATE , �_i ✓ SITE CLASSIFICATION: EVALUATED BY: � LDNG-TERM ACCEPTANCE RATE: � 5� OTHER(S) PRESENT: REMAR KS: 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 �;lay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR- V+�-y 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 �C--Sin�le grain M-Massive CR-Crumb GR-Granular ABK-MQular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�cy 1:1, 2:1, Mixed Notes liorizon 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 wate�' or inches from land surface to soil cotors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ftz DCHD (OL-901 ■���������������������n����nv�����i��n . ����n���n ■ ������������� ■�■�����■���������■����N����Y�������������■■�n��n���������■■ �� �\��������M�� �������������������■�■��������■�■���������■■■�n������■�■��_�����������■���■�■��■■ ................C::::::::�.::::::::::::::::::::::::_::::::.: '�: ':_:_::�::_::::_:: ■����������■■��������■��\■�����■�������N■����� ����■ ��� ■■ ■ ■ ■ ■ ■�■�■ ���� ■■ ■�������������������������■■■����■����� �����■=■■■n�i==���� ■ _ ����■������■����■ ■�■�■�■■■���������■�■�u������■�n����■�i���■���■�_�� �■ ■■ ■ ��_�■�_�������� ���■���■■���n�����■ ���■����v �Uv �u■■� u�� ■ �� ■�■ ��n ■�■ ■����■�� iiiiiiiiiiiiii=i�iiiii=iiiiiiiii��iii=i�iiii��ii�iiii�ii i i■� �� ■=ii�iiii=iiiiiiiiii ■������■■����� u�����■�����■���i�■ ,���=i�i�� ■ �i �� ■ ■���������■���� ■�����■■���■��_������■a�����N���■��i�u��n� �� _� ■ �������������■■ ��■■����u��a�����■����u���� ���� ��n ■ � ■ ��■��■ ����■ ■��������N�■■������u�■■������■■�\��� � ������������� ■���■��■■■����■■�����u�� ���U���■ � ■ ■ ■ ��i����������■���■�M�■�� �NW v�■ ■ ■ ��������■ �o�������������n�l������ �� �■����n ■ ��■■����■ ■��■■��n����■�■���n■ ���■■.��� ��� ■ ■ � ■����■�■ ■�������������■N�������N��\ �����■� ■����������� �����u����■����■■■ ■����� �■���� ����� � N����������� ■������v�������������N�������������� ■��N�����������■■�����■��� ■ ■�u ■ ���������■�■■ ��N������������■ ������ �����n�/■■■vl� o ������■■■ ■ in�■��������� ■�������� ����������■�N ■ ■�����■H�■ ■�������■���������■��■������������������ ■ N�����■■ ■���������■����������■ ■■�■ ����� ■ � /� ���■������■�����■��■■■������■���■������ ■���� I■ ■ i ■ � ■ ■ N�� ������■■�■��■ ■ ■�������■��■��■���■■n���■ ■�������■ ����� i a �_��� =��=�u�� ■�■����■■��■ iCiiiiiiii iiiiiiiiiiiiiiiii=iiiiii�'��iiiii=�= ■ ��n��� ■������■■ _ ■��ui�����_��� _���■�■�■■ ii�iiiiii�iiiiii i�f iiiiii i�iiiiii�iii=ni�iiiiii►�� �� � iii i�i =i�i�i�iiiiii�t � ■������■����������■ �■������■����■���■ ■�iu�����in--��� � �� ■����■ ��■ �������■��■ ■���■��■�����■���■�■������■�■���������■�������■��i=��■��� ���� ���������������■�■■■�■ ■��������������■�����������������■���■���i�������i ���������n■�����������■��■ ■■�����■ ■���������i������■����■��■���■�■■��������t�� ����1 ■M ���■� ���������������������■ ■������■����������■■��������■����������■l�������1 ■ ���������■■ �����������������n��■ ■������������������i��\��■������������■��l��u� �11��■�� ■N��■ ��� ■�� ■���������■■■■ ■�����■������������■�����������■���■���� t� ����11■ ����n����U��������v�■�■■■�����■ i�iiiiiiiiiiiiiiiiiiiiiiii=ii�iiii�iiii ��-ii�� ■ ������■ ��������■�■�����■�■��■ _ �i���3����■�i��i�������_���■�����������������■ ■_�■�����■�������������■����_ ■■■�■���■■ ■�■ ■������� ■■�����■������������■��������■ ........................■... ..... ..■.........■..._�........�........■............. ................................................... ._.■.... ...................... ....................................................5■ .....�........................ .................................... ............. . ■■.. ...... ........ ........ ..........................................�......_.. _ ..■._......�........�........ .......................................... .....�._�...._. ..............�.�....... ■���■�■�����■���������■�■�����■��■�■ ���■■�■����■ ■■ ■�� �■��■��������■�■ ■ ■����a■ ■�����■����������������■�����■�����■ ■������■�� ■■� ■■■ ■ �������� ■����■����■ ■��������■�����■�■■■�■������■�����������������=�i=�=■���� u�nn����■■ =�i���■����■�■ ■N��■�■■��■����■■�■■■���■�������������������■ ��� ■ ■�������������■■ ■■ ������■��■■ ■��■���■�����■�■��������������■���■������������■ ���\����������■������ ���■ ■���� ■■ ■�■■���������■�����■����������■��■���������■ ■���� ■■��\�����■�0���� �■ ■��������■ ■������■�����������■��������■■������/����■���■■������������v����■����������������■ ..........................�... ........... .............■ _.�....... .._......... .......................... ............■.........�......■. . ..■....� ........ ....................................�............ ........ ._.........■ .......... .......�.......................... .. .............■......... .....■�................. ■�■�������������������■■�■����■■■���n��■������������■■������������ ■�����■�■����H�■ ■����������������\���■�■��■�■��■�����■�■■��■���■■ ■����■�����u��������■�■����■�����■ ■����■���■����■�����■�������■��■��■ ■���■■■■���■��������������■■���■�N■������������■ ■■������■�����������■�■�����■■■������������■��■�������������■������������ ■������t� ■■�����■ ■�■■����������■�����������■ ■��■■ ■�����������������■�■�■����■ ■ ��������N