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326 Deerfield Dr� , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,, P. O. Boz 848/210 Hospital Street Mceksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001619 Billed To: Todd 8� Beth Cassidy Reference Name: Proposed Facility: ResidenCe Tax PIN/EH #: 5853-68-0845 Subdivision Info: Location/Address: Deerfield Road-27028 Property Size: 10 + aCres : :3� ATC Number: 1215 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHOWZATION 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type Y! (�l.�l-. #People `'� #Bedrooms `�' #Baths �'� Dishwasher: � Garbage Disposal: d Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � �+n�s Type Water Supply ��-�-�- Design Wastewater Flow (GPD) `"7'�� Site: New � Repair ❑ r� , ' I�,�^ + System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width�� Rock Depth �2� Linear Ft. `� Other: 2 �l �'1� � �Tl o � �:c`� ��J�T�QI.i. L 1�-S � a .C, . M � �•,1. Required Site Modifications/Conditions: `�5T�4,1� b� CA�T��Q_ 1�' ��r o� �� ,�t' �f �'"'�' L IMPROVEMEIYT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** A�►2�7x-. ►30• Environmental DCHD OS/99 (Revised) � L1A�ayc . �� --�� 2O' .�. � � o �- � _. � G � _ � �� N i t's Signature: —IaJ'n F�P U rJ.� � F'E�J� �-t�1�.S I�J e�Q.L�`iZ �`�ufh�1►�l� 1N�ST � t-leib 1.��c�N �sb,,�� o �.��►� ��rC�at� A, P�7 .�'Ti-1 tS �1t�:� �.�'�'„' ' �JP� o�r. � �S�J�fl Zf z� �a� I ✓ D • � . � Account #: 990001619 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Billed To: Todd 8� Beth Cassidy Reference Name: Proposed Facility: Residence ATC Number: 1215 P. O. Boz 848/210 Hospital Street Mocksville, NC 270Z8 (33G)751-8'760 Tax PIN/EH #: 5853-68-0845 Subdivision Info: Location/Address: Deerfield Road-27028 Property Size: 10 + acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Trea� nt and Disposal Systems). THIS AUTHORIZATION FOR WASTEVY9TEg CODdS��;�iN IS VAILID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit 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. Septic System Installed By: Environmental Health SpecialisYs Signature : DCHD OS/99 (Revised) �U�� !� , '�3� ,. i� '�� .. �\ ,� �N� ✓ Date: D . � ` � APPLIC�ATION FOR Sl7�E EVALUATION/I1�iPROVE1iENi' PEfiM1�{F Sc ATC Davie County Heaith Department G, Environmenta/Hea/tfi Se,cb�on _Q�" P.O. Box 848/210 Hospital Street �V� , Mocksville, NC 27028 (336) 751-8760 (� � [� � �� [; �i �� ► � -�+� ENV I R 0 id �1" ENTA L_ H EALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALI, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. r�v��7 / J '�/,�/�E�1. ame to be Billed � Ddi� �i- ��0..rJ5� Contact Person ��(1 rL�t.S �� .�5� Mailing Addreas $GG (=a�M� n4-I�/L I�. 8ome Phone -{ {.pi`T!�'[ !/ �Q � �Ly City/State/ZIP �Bi�s �%�1 i1.� � l� �-�62 0 8uainess Phone "� 2. Name on Permit/ATC i£ Difforent than Above Mailing Addreas City/State/Zip TRAns �e,� Pti•�+� d- s. Appiication For: � Site Evaluation � Improvemen� Permit/ATC ❑ Both 4. Syatem to se=,.i�e: �House ❑ Mobile Home ❑ Business ❑ Indus�ry ❑ O�her 5. If Residence: � People _�_ � Bedrooms � # Bathrooms 3•5 MI Dishxasher lY Garbage Disposal M Washing Machine ❑ Basemant/Plumbing 6. If 8usiness/Industzy/Other: Specify type A People _ # Commodes � Shoxera � Urinals 'hS Basement/No Plumbing N Sinka U Water Coolora IF FOODSERVICE: # Seats Estima.ted Water Usage (gallona per aay� �. Type of water supply: ❑ County/City �Well � Community s. Do yoa anticipate additions or eapansions of the facility this system is intcnded to servc? If ycs, what type? ❑ Ycs H'i�10 ***IAfPORTANT*** CLI�NTS MUSTCONiPLETETHE RLQUIRED PROPERTY INFORMATION I2�QUr.STEU BELO�V. Either a PLAT or SITE PLAIV A1UST 13ESUBMITT'ED by the clicnt with THIS APPLICATION. /_y�- roperty Dimensions: I �'F '��S WRIT� DIRGCTIONS (from Mocksvillc) to PROPLR7'Y: �7 Tax Office P1N: # �� r� �^ p�'�� Propecty Address: Road Name �'�'""�-�� 'J � City/Zip lf in a Subdivision provide informalion, as follows: Namc: Sectioa: I31ock: I.at: Date Property Flagged: ' 2 This is to certify tl�at the information provided is correct to the best of my knowtedge. I understand that uny permit(s) issucd hercafter are subject to suspension or revocation, if t6e site plans or inteuded use c�ange, or if tt�e iaformation submitted in this application is falsiiied or changed I, also, understund lhat 1 am responsible for all charges incurred front this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departtnent to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to detertnine the site suitability. DATE �J � S 1 Ci I SIGNATURE �1 �� Gc.4d-�� THIS A.REA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) � � � �� Gl�_- ; Z� k3 �' '�� 1Z' � Sitc Revisit C6argc Date(s): Client Plotilication Date: EHS: Account No. � ` ! r Invoicc No. , l7 fY 6,��W� ,; _ , ; _ , ,.: „ . . ..: �,; , ., s_ .: . _ . :. . ,. , . , �._ . ,..: , . , � AUTxoRizaTiorr rro: `� �� DAVIE COUNTY HEALTH DEPARTMENT - -,; ;' Environmental Health Section PROPERTY INFORMATION Permit��e's � P.O. Box 848 Name: �''' �� _��G�d'4� F- Mocksville, NC 27028 Subdivision Name: . ,. Phone #: 704-634-8760 Directions to property: � �� L- -1 � � C.� �, Section: Lot: %� AUTHORIZATION FOR �T t}<r� rfi,,,� . i�t1�. � t �l . C.�% ,� WASTEWATER ,� �e.,�,..a �:3� +;�� , C� �t t_ r. c1 Tax Office PIN:#.�r-'� '� t��' 1� - l'�.�r� --� ' NSTRUCTION - �1 uC..� � oJ %�f< a►� ,� �.,- =J �'`� �.�"� � � � � � , � 'i E�`d`,� f�,�'�` �.1 � � � •n r t� Road Name: �'��t"�',�'w,,�.l � �� Zip: �- �1 "� r{,�;� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pemuts. 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) , : `/" . i '°"" ^�'� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .....��Tw � � ��.i� . � A .."�'"..,- � ,�., . � IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONIvI�NT HEtCLTH SPECl/�LIST DA E ISS ED .__-:fi_,; .;.� _ _ _ ._. . .. ,� - --_. . ; ; , . , .;` - -- "=" . r ,. ::� '" '� � � � DAVIE COUNTY HEALTH DEPARTMENT ''" '+- .. . . . �,•r:F�:", "':>�r:�;;�-�_�°' :. ," TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION • ti �";P.�rmitt� s, � l`� ' � -:,t 's �w1Va�e �''" � �� •_��:��. ��`� ..� . �.PVy.� .. ./ �:.:t � t <�' ' i .�. Dire,�tio�►s'to property: � � �.- � 1� ;::��,;�,,_._� . _ : �� ,� �' �' � ' _ °� ;'.� .�, . �' t 1,' � t �� v ��ii Z K. : rJ� � .. , ` �: e. ��{ � � � , Y t � + i � ��,t + , ...te � . N Il1�PROVEMENT Il P PERNIIT �# t� 4. 6. 1 L�. ;., 3��. i', .... ,,. 1''I..1•. ' . � �... Subdivision Name: Section: Lot: +� "i ._.ry : r , y . l, ;;' Tax Office PIN:#--� � '"•� = Er' .: _ �-f ,�>.=-' �� r� A .� ,y� Road Name: i� E� M;; F=, �= L�^ , F� �., Zip: ��- ;',_ F�i **NOTE** This Improvement Pernut DOFS NOT authorize the const�uction or installation of a septic tank system or any wastewater system. An ALTTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the ' construction/installa6on of a system or the issuance of a building pemut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �, ., �,:: "� , t a ***NOTTCE*** TEQ.S PERMIT IS SUBJECT TO REVOCATION IF SITE '•;s , �„' �::�"� �=� � PLANS OR Tf� INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL.-HEALTH SPECIALIST DA'I'E ISSUED SYSTEM CONT'RACTOR MUST SEE TI�.S PERMIT BEFORE INSTALLING Ti� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE US� # BEDROOMS �/ # BATHS _` # OCCUPANTS �- GARBAGE DISPOS Ye or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No I/�n l [�C, LOT SIZE �D'�T"�-�Y E WATER SUPPLY �'��" DESIGN WASTEWATER FLOW (GPD) /[�IU NEW SITE �REPAIR SITE �� SYSTEM SPECIFICATIONS: TANK SIZE �� GAL. PUMP TANK GAL. TRENCH �DTF-I': �"�� ROCK DEPTH � LINEAR FT. �� / "!�" '` OTHER 1 �'I``T��? t�JT�� -��C /� � � REQUIREDSITEMODIFlCATIONS/CONDITIONS: �"�ST�i�L r�nl �_l7►��j()�J12,�d_L=1 ,� ('F� �or1.�. iL'c1:.{ �J�i_� %(.�[l ��1�; IMPROVEMENT PERMTI' LAYOUT � Q �.-�iJE C�.i'¢P.�7io� � `U.0 . **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. I OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED BY: 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 OS/96 (Revised) .. :. � . . . .; ..� ... .,. _..,..-..'�„ '. . _ ._ .. . ..._. _ .� �.. . . , . - , . ra ., . .�.,,:a. . a. . � .�' '.. '._' .. ..._ . . .. .. . . _ . J .-.. ._ _ .. .. . . . . . . -. ... ,.. �•♦ , W. g f fi �7 i"s . � ,� � ;� DAVIE COUNTY HEALTH DEPARTMENT �+ >: .„ ,`�� ''">-�m � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION f ` Permit�ee'sa f � �`i �. ...�1Vame: .. � 1 ; �', f � � � � : ; . » t � ; p,;,`3 _. �� . .:.-- Directions�to property: i �„-- ,� � � ; �... ,t�. �. � � � . �. ��1 Il1�PROVEMENT PERNIIT '�., ��. , , Subdivision Name: Section: Lot: Tax Office PIN:#-, � �', �; �'' ` � ' '� r � RoadName i�''r�'j;T�� t_-t.. ,r'��' Zip: .' '� **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a sepdc tank system or any wastewater system. An ALITHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Sys[ems, Section .1900 Sewage Treatrnent and Disposal Systems) � � ***NOTICE*** TIIIS PERMIT IS SUBJECT TO REVOCATION IF SITE " LL_.: ,�;:'%�' :`"� ��" PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DA'I'E ISSUED SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 1�' }115� # BEDROOMS �# BATHS ��"7 # OCCUPANTS �- GARBAGE DISPOS . Ye or No COMMERCIAL SPECIFICATION: FACILTTY TYPE # PEOPLE # PEOPLFJSHIFf # SEATS INDUSTRIAL WASTE: Yes or No 1 f(/ � �^/'+��' � (%', LOT SIZE �r✓ �� -� j� TYPE WATER SUPPLY �U�=«' DESIGN WASTEWATER FLOW (GPD) �,�C� NEW SITE +-�''"� REPAIR SITE �� ,1 � �' SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK GAL. TRENCH�V� TDTH`��-" ROCK DEPTH I? LINEAR FT. tC7 OTHER l��,��,.,,�,.�' 1�,t1�� t�;� ��. 1`�(>±� �-.' , � REQUIRED SITE MODIFICATIONS/CONDITIONS: i�•�e.��.l l. ,�:1 C l; n.�l! r��,� �L•: l:� ��``, ' F� �-Zc: t>�+�. �� F1: {!-'i � t- ) C t % t.,l,:��' IMPROVEMENT PERMIT LAYOUT , 1 � � � f �'-' ��`' �. .. - G� � ..: + __..._.._ �--.�. .._ _ . _ ._. ��! �� M / �� `�(r— %f_G� X'(._ tcJ� 41 ffi . �.." �x.....�;.� . ...,�. �.�. -a , __. r��; g � _ >ci:� _. ' � � i ..,� � �=� � ,.,..., � � .� -.-.-• >� � � �. t� ; (.. s,�,._:.-.,.,....�,.�' .....�. ..._.. f,.� �._._.. .�',., �... .�s�•_ �' f .. t =� 1;,, �:r'. ,. E-1�cr,:,T f,r'� s r' � t... �a w:..�C.,,.a% **CONTACT A REPRESENTATIVE OF THE DAVI� CflL BETWEEN 8:30 - 9:30 A.M. OR 1;60 - 1c34P.,M. C �3:...: a �h� . , . .e . .��i. OPERATION PERMIT f �•-� � % 1 ,; � � 9�� (,,.IA�I:. �k:��.G��T/.�n� F`% �C��C � . . �.;.:. HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS S1�STEM E DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. .�,�� y _,,... � '�^+,..`*,l� � 4� �'`�. � SYSTEM INSTALLED7 � �., `.�„' ` ,`r�,`"°'� ,�� +.y� r.. `'�„� ,,q� `"„� : � t C , y ; . ,._.... . .�, .. � � � ..... ` ��::>tt 9 � -, . , x � _ __ _ '. .. _ \ � `> ' i ; ; ; � ; AUTHORIZATION NO. OPERATION PERMIT BY: -�` 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 OSN6 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC • - , : ` Davie County Health Department ' Environmental Health Section �� P.O. Box 848 �, ��'' �.�Mocksville, NC 27028 � '�� 704 634-8760 �rjG' ( ) � '�***IMPORTANT**** THIS APPLICATION CANNOT BE PROCE5SED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 1 � � Ma n Address ��i��\lu� oy City tate/Zip 2. Name on PermidATC if Different than Above Mailing Address 3. A lication For: [�Site Evaluation � Im rovement Permit & ATC [] Both r n�� PP P I Ia�s-r- ��`Ga�-ct- 4. System to Serve: [�House [] Mobile Home [] Business [] Industry [] Other � 5. If Residence: # People � # Bedrooms� # Bathrooms j' [� Dishwasher [� Gazbage Disposal .,16p W [�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? E Z TIiER tt PLAT OR S Z TE PLtIN PROPERTY INFORMATION REQUIRED: *** IMPORTANT **'�'�T�'� OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �Tax Office PIN: e Property Address: #.� Road ; WRITE DIRECTIONS (from Mocksville) TO PROPERTY: ; �-�O -• �-,� -� �� C�c� �- •, t_._ � CC�aCI _ �C3� '� � �` �.�. \\� rc � . _, � City/Zip 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 incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above desc 'bed property located in Davie County and owned by t co� ct all tes proc ur as nec ssary o determine the site suitability. DATE SIGNATURE i Revised DCHD (06-96) THIS t1REtt htAJ LiE USEb �OR DI'v1WINC JOUR SZTE PLrtN: -� �� c� �u DEI.LA S. COLLETTE DB 94 PG. 417 _._. YADKIN COUNTY �AVIE COU�VTY a ._, APPROXiMATE LOCATION _ . ' �_ _ �PPtZo)C1 M�T� l00-7 #:. I-1�2'� P 11 F L �o D tt-h �.� L 1 t�1T - � - i�9.06. 3� E I' O. D. N:P ,`'� ' • 27� Z . 3' NORTN Of FENCE � 4 3/9' O.Q EIP Pt � AT N 02 21' 46' E--0.2 ' � ''—'-S 87° 38' I 4` E 612, 55'=—a � p� Y�� > � `t. � I-1�2' O.D. E?P � Gj� p �' S �� N �-�� ; � � i ��.--� N � I � � � � , �� 10.58 4 A c. ; t PROPOSED� � � . • 1 4 5o ft. EasEMENT • �1 �s. �'0• i N 88' 45' 08' W I 0 IT. 85 ' • � II' O.D. NIP . �ia' NIR � �� I N �� . �, . �� Q io.o24 a�. - ' �=W � - , i � � N �1 ' / / � 20 ft. � ,L . / � S 89' S2' 34' E s�g. �7:1' — - !ia' NIR � IEXiS ING AX�E , t Pp� � o O 1 0.�� I� � TODD NAYLOR _ `.� �i DB ! 3 � PG. 36 I ' v'� / C � �' �. �., i % JESSE YORK et cl �c`;o" D$ 294 PG. 653 �,AS�~ �� , a� o D8 282 PG. 2 I2 � a1..,.�tiP� . o 'L .'L"' �� 'e � • °' �� . O �o• � 22� 5� g1 • ti`Q *. ati 'l g �L �, �. � . O �c. rr.�Q i _ � O?' `,�j `�` ` �� 'L o °' t�, 'i3O 4, ` . � 2� ��y . �L6 5� � / , ' `� 5 �' ,�a� ,��Q 5 4ti �`. D�p,' ti � p • � .=1 � . +' �,�� ti1 _.:,_.._ ' -I�_ O.D 596 9 ; � `LC' .'� a°`y6 �� 52. .. `Ao2 • _ / 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 � , � �� ` �°�., -- l'r�� Application/Permit Requested,By j w ��- `� Mailing Address %�2�1`� �a� �b z Home Phone �� - '�i� p r��..zl� ?7�'', � %d � � Business Phone 2. Name on Permit if Different than Above 3. Application for: �General Evaluation 4. System to Serve: I� Nouse ❑ Business ❑ Industry 5. If house, mobile home: Subdivision � No. of People No. of Bedrooms _1 No. of Bathrooms � `� Dwelling Dimensions �ptic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly � Other 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ 7. Type of water supply: ❑ Public �ivate 8. Property Dimensions ��_ Sewage Disposal Contractor ❑ Unknown Section Lot # {� BasemenUPlumbing ❑ BasemenUNo Plumbing ❑ Washing Machine p Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No i If yes, what type? p Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to I revocation, if site plans or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. � � �� .G v " " � � -�- _e-----� � DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I OWN the property. O 2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie Counry Health Department to enter upon above described property �located in Davie Counry and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE OCHD (1�93) SIGNATURE - `. � "` } ` �` DAVIE COUNTY HEALTH DEPARTMENT " '"� Environmental Health Section ,• Soil/Site Evaluation NAME DATE EVALUATED _ ��7�/9� ADDRESS PROPERTY SIZE� '' PROPOSED FACIILTY ��Ct LOCATION OF SITE �C Water Supply: On-Site Well /� Community Public Evaluation By: Auger Boring ��_ Pit Cut FACTORS 1 2 3 4 Landsca e osition Slo e % HORIZON I DEPTH % � << " Texture rou .f' S.C. Consistence Structure Mineralo HORIZON II DEPTH '� � t Texture rou e Consistence i -- Structure / S ./� Mineralo .'/ , 'i HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASS.LFICATION LO;IG-TERM ACCEPTANCE RATE �r/ ,�/ � SITE CLASSIFICATION: EVALUATED BY: LDNG-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 c:lay loam� SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moiat VFR-Very friable FR-Friable FI-Finn 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 Stru cture ;iC-Single grain M-Massive CR-Crumb GR-Granular ABK-AnBular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralagy 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 watet 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(01-901 ■��\��■��■ ��t� ■��■■��■�■�■��\��n��■��\��■�� S ■■��■��■��■�� ■��r��■��■��■�0��■■ ■��■��■��■��■■��/��■ ■��■��■��\■��■�\��■��■�■��■��■■ ■��■��■��\ ■��■��■■��■�■��■��■��■■/��■ ■��■��■�� ■��■■■��■��■■■■ ..........................................C...................... ................................................�................. ................................ ................................ ................................�l................................ ........................... ................... .................. ...........................C........�.�v.......�.........■........ ::::::::::::::::::::::::::::C::::::�:�:::'::::�:':'::::�::::::":: ■��■■��■��n��_��s��i��■ ■��■��■��a��■��■��■�■��►i��■ ■��■��■■��■��■��■ � ��■��■��■�■��■��■ ■��■��■��■��■■��■�� ■r�■��■■�ri��■ ■��■��■��■��■��r��a��■��■��■ ■��■��e��r��■��_��i��■ ■�■��■��■��r��t�ri�� i��w�r�� ■�� u��r��c!,�.i■ � ■��■��s��a��,�i�■��i��n��C��r��_■ ■��■��■■��■��r,��■��u�� :�� ■ ��\�■��I��:��i��■��N�� ■��N��i��,�r��N��t��t�� ..............................�.��►...................._...�......� ..............................�..�:.................�...... ...... ■��■�■��■��■��■��r��■ ��■►��■�� ■��■��■��n��■��r��■v��■�►��■ ■��■��■��■��L��Lkl��a�� ■��■��r�ai��uu��, �� ■��■��■■��■��■��+� �� ■�� ■■��■��i��■�� ■��■��■ ■��a��i�� ■��■��■��■��■�i��■��■��■� ,.�::�� ■�■■��/�i�■��:Gi��iii�i�r�iiiiiii..��.�L��A� ■��\�■■��■■��H��!�i�l� ��n��■��■ ■��■��■��I1��\��■��■ ��f��i��.■��■■�� ■��■■��■��GiT"i:�i�ii�iiiiiniii�� ■��■��i��■��/1�� ■�� \�� ■��■ ��e��.c�...��_��.��■��■ ■ �� v ��■ ■��i�� ■��ii�=�� ■��■��■��t� �� ■ :::::::�::::::::::::::C::::::::��:'�::' ' ::C:C::C=:::�:� ........■....................... ... ...... ..■........ .... .................................�..... .�....� .........■.�.... iiiiiiiii iiii■ii�iiiiiii��iiiii�i�ii ■ ��a� �� ■ C .....�. .......C......� ■��■��■�i�■N��n n � ��C��■�■�� ■��1��:■�� H�� ■��■��\�■��\��■��■��,��■ �� ■��v��■��■��1�� . ��■�� ■ ■ ■ �� u�\��u��1�� ■ ��N��\■ ....... 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Spillman Rt. 2, Box 402 Mocksville, NC 270�8 Re: Site Eval��ation Deerfield Rd. /F�ruitt Dear Mr. Spillman: As requested, a representative from this office visited the aforementioned site on March �3, 1994. Based upon the information provi��ed on the application for a site evaluation and after the evaluation was completed, the site was fo�.tnd to bP provisionally suitable for• �he ins'c�llation of an on—site sewage disposal system. If you have any questions, please feel free to cont�ct this office. Sincerely, ,P�� 5- Robert 6. Hal l, Jr. , R. S. Environmental Health Section RH/wd Enclosure