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229-236 Chal Smith Rd,. . ,, ,- ,...->. , . . .. ; � ...• ,_�.;-.,' __, . � .� ;,,. ,. _ . ' � , _ ' ' ' - .� ✓�J� �_ auTxoRrzaTiorr No: Q � � 3 DAVIE COUNTY HEALTH DEPARTMENT 4 � Environmental Health Section PROPERTY INFORMATION Permittee's' P.O. Box 848 - Name: �;�, �11� _T��'�',� Mocksville, NC 27028 Subdivision Name: / '"" ,r , Phone #: 704-634-8760 Directions to property: �,!;�rr /--f�>7a �.i wr � Section: Lot: AUTHORIZATION FOR WASTEWATER �S�j _ '�,[.�' .� SYSTEM CONSTRUCTION Tax Office PIN:# � _ D 7� Road Name: � hn 1�ri, �`�1 ��p: � **NOTE** This Authorization for Wastewater System Conshuction 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 Counry Building Inspections Office when applying for Building Pemuts. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) . �y �, �, ,,. �s � �'. f **�`1vU'1'1Cr;*** '1'H15 AUTHOKIZATION FOR WASTEWATER CONSTRUCTION K. `�' v ±. : '''�I , •. �`�''; i � ,''�I' � / ' /'%' %� IS VALID FOR A PERIOD OF FIVE YEARS. -�� ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ._ t ;a . �.��;:. .._'I,� ,..: _ , .-.._ �;A�� '--. _. ,.,,., . �_ � , r . , � - . . , . .. . � � — ., 'i� . , .._ . .. � �• • . "�, V �� . .A f — `�. + , i .. . _ . �` � � � � DAVIE COUNTY HEALTH DEPARTMENT "� ��-':� �: f' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION � Permitfe�`s'f� Name:� �'� � :i';7-?. � �C ^ �'r':"// . �_ � t� s � , - l r , Directions`to property: %:'';-% .� ,.•f. ;�,•` �` Subdivision Name: Section;- - Lot: II�IPROVEMENT ,- PERMIT Tax Ofiice PIN:# `�'�!�'t� .��"~ �' � �t` Road Name: �', �� ,. % `� � � � � ��ip: "' � ,, ={ ;"r **NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construcdon/installation of a system or the issuance of a building pemrit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treahnent and Disposal Systems) * ,�'�,�,f � , .�� , , � "; �' j' '.r �';� � PLAN OR TF� INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING Tf� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE f�� # BEDROOMS �� # BATHS _� # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE /�!%t' TYPE WATER SUPPLY �i�� DESIGN WASTEWATER FLOW (GPD) NEW S1TE ✓ REPAIR SITE i; SYSTEM SPECIFICATIONS: TANK SIZE l% D GAL. PUMP TANK GAL. TRENCH WIDTH .� ROCK DEPTH f-� LINEAR FT. �% nU� REQUIRED SITE MODIFICATIONS/CONDITIONS: **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 830 - 9:30 A.M. OR 1:00 - 1;30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. I OPERATION PERMTT SYSTEM INSTALLED BY: //J/.!i✓! AUTHORIZATION NO. v/�J OPERATION PERMIT BY: �� DATE: J **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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OSN6 (Revised) � APPLICATION FOR SITE EVALUATION/IMPROVEMENT �� Davie County Health Department � Environmental Health Section • P.O. Box 848 � Mocksville, NC 27028 � (704)634-8760 � � c� c� o�� I,'1AR 2 01997 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed a- ' r Contact Person �'10�� Mailing Address o� � ��'I � Home Phone �� ^ � � / T �M 1, i ¢ City/State/Zip 1+ �0 CI�51% i�� .� a 7o�g Business Phone Q 0 `� �� 2. Name on PermiUATC if Different than Above Mailing Address 3. Application For: [] Site Evaluation City/State/Zip [ ] Improvement Permit & ATC � Both 4. System to Serve: [] House [� Mobile Home [] Business [] Industry [] Other i 5. If Residence: # People i # Bedrooms� # 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 �fi�- "-�'-^�T�- � �a-4 � /f%�'�- �� O �� 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes (�No Q%�p�� If yes, what type? EZTHEIt tl PLeIT OR SZTE PLttN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** ��'rOF THE PROPERTY MUST BE SUBMITTED WITH J�S APPLICATION. Pro erty Dimensions: � /� %�� ; WRITE DIRECTIONS (from�VIocksville) TO PROPERTY:, ' � ' ,�' , � ��/_sr� ��.�?� Tax Office PIN: #_s�� - �� - � �/ � ' �� . ��• Q7'�- Property Address: Road Name�G�� 1�'�1r��' �� •� � e rQ City/Zip ��C 1�510 ) ��E, C ; - 1"'�- Oc.- G� Y" If in Subdivision provide information, as follows: o� r%�� 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 incurred from this application. I, hereby, give consent to the Authorized Cl�epres� t ive�of l��aZi Cgunty Health Department to ent upon above described property located in Davie County and owned iGrit./ QN7Y�(�YL�C�l...Gz� 1—C� y to con 11 testing procedures as necessary to determine the site suitability. DATE � �� D � 9'7 SIGNATURE `Z� /7�� JGi ��-�-�� Revised DCHD (06-96) THIS AItEA Mfl� 13E USE� �OIZ �1trt6UZNC7 JOUIz SITE PL.tiN: . �� ,�; � �'a o -�a��'y � � � l�� v 7�Q�"°�' � O � 0 0 � `s'�/ .�%/ , Y DAVIE COUNTY HEALTH DEPARTMENT �' . � Environmental Health Section SECTION LOT ' SoiUSite Evaluation APPLICANT'S NAME G�I/�/` � DATE EVALUATED '��! ,�� PROPOSED FACILITY PROPERTY SIZE �D�G SUBDIVISION /�%� ROADNAME �//��'' �i�'/. �`� ��✓ --�— Water Supply: Evaluation By: On-Site Well o,� Community Auger Boring Pit Public Cut SITE CLASSIFICATION:_�� //ue ro �G EVALUATION BY: ��YR l� LONG-TERM ACCEPTANCE RATE: f 9L OTHER(S) PRESENT: REMARKS: DCHD (OI-90) 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineraloev 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 ■��■ ■■■■ ■ ■ ■��■■■�■■■■�■■■■■■�■�■ ■��■��■■�■■■■�:��■ ■��■�■ ■��■�■■��■■■�V��■��■�■ ■��■��■■■��■��■■��■�■ ■�■■��■■�■■■■■■■��■ ■�■■��■■��■�■■■��■��■ ■■■■■■��■■■■■■�■■■�■■ ■■■■■��■��■■��■■■■■ ■■■■■�■■■��■��■��■■�■■ ■■��■��■��■■■■■�■■��■ ■��■■��■�■■�■■■ ■■�■■■ ■■■■■■��■��■�■■■�■�■ ■��■■�■�■�■■■■�■��■�■ ■■��■■■■■��■■��■��■■�■ ■��■■■■■■■■■■■■��■ ■■■■■■��■■■■■�■■��■ ■■■■■■��■��■■�■■ ■■■■��■�■■■■■■■■�■■��■ ■■■�■�'��■■�■■ ■■■■�■ ■■■■■ir��■��■��■■■■■■ ■■�■■■■V��■■��■■�■■�■ ■■��■��■��■■�■■■�■■��■�■ ■��■■��■��■��■��■■■ ■��■■■■��■■��■��■■��■■�■ ■��■■■■■■■■■�■■��■�■■ �� ■■��■■■■��Gir��l��■■■■■ ■■�■��■e�■■■■1�■�■��■■■ ■■�■�■■��■�■1��■■■��■�■ ■��■�■■��■��11��■�■■■■■ ■�■■�■��■11�■■��■■�■ ■��■ ■��■ ■��■ ■�■■ ■�■■ ■■■■ ■�■■ ■■�■ ■��■■ ■■■■■ ■■��■ ■��■ ■��■�I�■��■■�■■■ ■�■■�I�■ ■■��■■■ ■■■■�II■�■■■�■��■ ■■■■■1��■■��■�■■ ■■��■1��■■��■��■ !�:i■�■�■��■■■■ ■��■■�■■■�■�■ ■��■��■■�■�■ ■■■■��■ ■■■■■■■ ■�■��■■ ■��■��■ ■■■■■■��■■��■�■■ ■■��■■�■��■ ■��■�■■■��■■■■■ ■ ■■■■■■ ■�■�■■ ■■■��■ ■��■ ■�■■ ■■�■ ■��■ ■�■■ ■■�■ ■■ � � ■ ■�■■■ ■■��■