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108 Prevette Rd ..�.°a -..y:;'-� ` .:;:; .�.'•�5.,.� �:,�`3.� „ �s�r C:='s�, f�jC:'•..w� fi y, .._,�1+��'5-��...t`L 1;...y�.�l y.t:' .. y . ` ,., . . . : �� . .. 's6t i . ., . 1 �iV 2'�'`f N_ ✓�h'�. k S' r. s�...t� �M�ir� �r)l .. '� �.�'� S. � � � ; � a ��� �; Au 'x�tRtzA'riON No: O 9�O DAVIE COUNTY HEALTH DEPARTMENT ' ' �. �=� '•�'� ' " Environmental Health Section PROPERTY INFORMATION Permittee's �/ P.O.Box 848 Name: ��Y1�� '!�'/�S Mocksville,NC 27028 Subdivision Name: / �`- Phone#:704-634-8760 Directions fo property:� r��r , r.r'i/l �� Section: Lot: ' AUTHORIZATION FOR �/ f ` ' WAST'EWATER Tax Office PIN:#d r! - �!'� - ���� ' SYSTEM CONSTRUCTION Road Name:�'"'rrt�.�"7�!'�/'o61.Zip: ���,� **NOTE**This Authorization for Wastewater System Construcdon MUST BE ISSLJED by the Davie County Environmental Health Section prior ' to issuance of any Building Per►ruts.This Forn�/Authoriza6on Number should be presented to the Davie County Building Inspections O�ce when applying for Building Permits. _ . (In 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 � �'' ��' �� . �'`'J � � IS VALID FOR A PERIOD OF FIVE YEARS. ... ENVIRONMENTAI;HEALTH pECIALIST DATE ISSUED ,. _ , - ' _ . � ..,,��.� ! �,��- w ya'v Y'�j^"Y"'Yrh�r�'"`�;� �g�,.:•� ,.;�.,��.�'�y�ar'eX �ce+r�.�r+'i.t *'''r r'*t''''?`Y ..`tc,:'r� i5i�",+"�jt;,,..,�y 4c`a.,;,r �.,•..�`�wl� ��•��tr...str��-�,-� 4` .. �.= ;, � ��, :, ' �:�� , �•� DAVIE COUNTY HEALTH DEPA`�t� F�1T; � � � ' 3 a U � +�-. . "� � IMPROVEMENT AND UPERATION PE�ITS .�'ROPERTY INFORMATION Permf�t�e's �,�,t. � `, � , ._. ; Name: ..�1`;���'�� ��t�,,� ySubdrvision Name: � -,Directions to property: E�����:��f' �`�': :�r7��"rv` Section: �. Lot: IMPROVEMENT . � ' PERMIT Tax Office PIN:#k�f�r _ .. � _ R+`-�,".'�� �'„, s Road�Iame:�":�i/��� lv..�.Zip: �/4-;� **NOTE**This Improvemerit Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wa#stewater system An AUTHORIZAT�ON FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this Department prior to the' constntction/installation of a system or the issuance of a building pernut. ' - z�;,�-' (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,r` A � r' � � � � • . ***NOTICE***THLS PERNIIT IS SUBJECT TO REVOCATION IF SITE �G �.��r ''..d � „ � ;'..�='s�..�'. .if;r'�i ;,•f,,:�'j+ PLANS OR TI�INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH'SPECIALIST' DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING Tf�SYSTEM. " ,_. , . , ____. . RESIDENTIAL SPECIFICATTON:BUILDING T'YPE�{ #BEDROOMS�#BATHS�#OCCUPANTS C GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICAT'ION: FACILTfY TYPE #PEOPLE #PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY�U DESIGN WASTEWATER FLOW(GPD) '�'��U NEW STTE � REPAIR SITE , /� SYSTEM SPECIFICATIONS: TANK SIZE GOl�GAL. PUMP TANK GAL. TRENCH WIDTH ,.�l ROCK DE LINEAR FT. JG � �•,n.�;_ : OTHER . .,._ ""�`�2EQUIRED SITE MODIFICATIONS/CONDITIONS: �•� . IMPROVEMENT PERMIT LAYOUT _ •+ . , , � ��r�;�� ����'�' ��1��%� -� �,1 ��'�, s`lr��,. fJC� �!vP� �� � � **CONTACT A REPRESENTATIVE OF TI-IE DAVIE COUNTY HEALTH DEPARTMENT FOR FIlVAL INSPECfION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON TI-IE DAY OF INSTALLATION.T'ELEPHONE#IS(704)634-8760. OPERATION PERMIT 1�cc� ` SYS M INS ALLED BY: ry � 3� � � /`S�° � 0 r �� 1 ~ ��n/1'o<. , `L � p('��' a � ,��5� � � P �•� � � �NQ� ���1 �OG� �` � � ( I r'`z.5 �$ 116C.� , {� � . .r�, � ,`,, E . . � . ' . ��R � ��11'� .' . . ., . � � . . . . � .L� A .' {.�' AUTHORIZATION NO.�� � O _ Q � l�, �J OPERATION PERMIT BY: � •�� M1- ►�-� ' � � � �����.�' � .i' DATE• / cU � 1 **THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT TI-IE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT TI-IE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96(Revised) j APPLIC�TION FOR SITE EVALUATION/IMPROVEMENT PE �n ; - ' ^ t • � Davie County Health Department � � � � V � ' � ' , - Environmental Health Section D � � P.o. sox s48 JUL ( 41997 ; Mocksville,NC 27028 + � (704) 634-8760 � � ****IMPORTANT**** THI5 APPLICATION CANNOT BE PROCESSED UNLESS ALL ' THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed � !(�meS ���Pf3 Contact Person .�Qt11Qri�hC� �etS MailingAddress e HomePhone C�3�1- Sy33 City/State/Zip ' Business Phone o(��" W��b � 2. Name on PermidATC if Different than Above • Mailing Address City/State/Zip 3. Application For: �Site Evaluation [ ]Improvement Permit&ATC [�Both : 4. System to Serve: [ ]House �]Mobile Home [ ]Business [ ]Industry [ ] Other / , 5. If Residence: #People r #Bedrooms� #Bathroomsy�_ [J�Dishwasher[ ]Garbage Disposal `� i - �J(]Washing Machine [ ]Basement/Plumbing [ J 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? EZTHEIZ A PLtIT OR SITE PLAN ' PROPERTY INFORMATION REQUIRED:***IMPORTANT***Ar��'�OF THE PROPERTY MUST BE � y SUBMITTED WITH 7�H�S APPLICATION. l I ' Property Dimensions: �C� �W ITE DIRE TIO S(fro Mocksville)T PRQPERTY: � Tax Office PIN: # � -�-���. ; `e C�• 7 � Property Address: Road Name i � �' , �� �r City/Zip�[�L�V���e 7��� � � If in Subdivision provide information,as follows: � � Name: ; I' Section: Lot#: � O"� � � This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s) issued hereafter aze 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 Dav' County Health Department to enter upon above described property located in Davie County and owned by d : to conduct all testing procedures as necessary to determine the site suitability. nA� 7-/y'9 � SIGNATUR � Revised DCHD(06-96) THIS AnEA Mt1J $E USEb �OR DIZf1WINC� �OUR SIZE YLftN: I � I _ _ __ -� wt � , -�. �R 3 2 t . '+;y�i�`.,��^,�. . .��, ? � # �� �Y i: � a y'.�r � n��y � � f?. v �`� .R' 4 A t.. �4� „� .�`; , �T -� i � . z k '�':` 'fi`� � f Z.9'. _ � ,Q,. k�g � :•� Ae r. 4 'y x4t � r����. � �.. � 3. z�( .� � S' � . ' °'�`.. A� �, x :.� ,� �..� . t .,. �' � � a�': C t '�.l+�r� �� 4 �;� • ° - �'s. � � � <.'�rsr ,,,� ���,.,�� f � ��e i � ,p ' � n,sk.fi � � �ks' '� `rrR,.,� yV;e .wg ' _ z, �r5 . �ei'�� . t r,�:. �,.„,4,. '� �l�,:� .Y`v �^,�i:�:!�`. ... . Wa, �?.�u=.. - 1• .d . L i;��" ax':,'�', � _ � "\�. .� 7f V R:95 . +. rN--..yu �,'+«a� �' . t�y,. . 1-�Y . 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S .O }x �. • S � ,/ 'p f 4 f * { / � -� �• S . �'�y;w' t 1 4� f �} ? �. .. f f _& ^ - . ;¢ r ��e�; � .a t�� � � � z ; ,�-_ r � � 1�,st �_�a r�, t `�' � �. ��r � „rs .._ . r . . _,., ._. . ,-i�. , ._ r _._ . _ _ � � -_... .�'� e- _ . ,. . � . . , x 3s� 1 . .r ' ` • � � DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section sECTiorr r.oT 4 SoiUSite Evaluation APPLICANT'S NAME f�j!�S DATE EVALUATED �— /�I"� PROPOSED FACILITY PROPERTY SIZE ��G SUBDIVISION f��! ROAD NAME v Water Supply: On-Site Well Community Public �� Evaluation By: Auger Boring t� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition ,L ,�,� Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH " p� Texture rou G Consistence i Structure l� �- Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �� " EVALUATION BY: ,��� 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 Mois 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineralogv 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(OI-90) . . ■■��■�■���■■■■���s���■■��■■��■��■�■����������■���■�■■■■�■■������■■ ■■■���■■����■■�■■�■■��■������■�����������������e�■■�■■��■��������■ ■■��������■����■��■■�■■��■��■■�■ ■�����■��������■��■■��■■������■■ ■■�■�■■���■�s�■■��■■�■■��■��■■���ii�����■■■���■��■■■�■■�■■■����■�■■ ■■�■■■������■��������■■��■��■■��■�����������■���■■��■■■■■■���■��■■ 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