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151 Hinkle Dr
' ) Permitteesf .' c ° y fDAVIE COUNTY HEALTH DEPARTMENT) Name;^,ari' `-1=�-' Environmental Health Section PROPERTY INFORIvIATION_- `i't� P.O. Box 848 Directions to propert-' Mocksville, NC 27028 Subdivision Name: -^.,,,t�! t.,. �• Phone #: 336-751-8760 - Section: Lot: tt AUTHORIZATION FOR t WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO: A Road Name: ' � � j,�a>�r Zip: .' 7✓2k, **NOTE**.This Authorization for Wastewater System Construction 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 County Building Inspections Office when applying -for Building Permits. (In compliance yvith;Article I 1 pf G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatinent and Disposal Systems) .r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ZL, Z", ., - {; .. IS VALID FOR A PERIOD OF FIVE YEARS. ENVI120NiIv1iNTiklFIEALTH SPECT LIST DATE SSU D RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS Z' # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ✓ SYSTEM SPECIFICATIONS: TANK SIZE GAL.. PUMP TANK GAL. T•RENGH WIDTH ROCK DEPTH f 0 LINEAR FT. OTHER [' ,.O REQUIRED SITE MODIFICATIONS/CONDITIONS: Fa -b d�W 1""i � 10_ � 1 a � o, ar IMPROVEMENT PERMIT LAYOUT _ l **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY H ALT DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE AIL F INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 'tCj AUTHORIZATION NO. OPERATION PERMIT B DATE: V �� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE ST DESCRIBED BO E S 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 07/02. (Revised) n� Y.7 9 2 j P t'tee's ° rDAVIE COUNTY HEALTH DEPARTMENT` Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to .. is ert : i. + ., , P P Y Mocksville, NC 27,028 Subdivision Name: ry .,.ltit 1 „t t. t,• L.{ 1 Phone k 336,jyj-C7,60� Section: Lot: i AUTHORIZATION FOR 1 WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO: A Road Name "# Pw1ie tr +r Zip: *NOTE**. This Authorization for WastewaterSystem Construction MUST BE'lSSUED by the Davie County 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 pf G.SX—hapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) `" + +i fi, • ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRU TION IS VALID FOR A PERIOD OF FIVE.YEARS. ENVIIFO e ENHEALTH SPECIALIST ': DATE SSUED-77 +!! RESIDENTIAL.SPeCIFICATION HUILDING TYPL� ^ �`��`" 1 #BEDROOMS ti� # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #,SEYTS INDUSTRIAL WASTE: Yes or No lour,, LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) w rd •` NEW SITE REPAIR SITE �r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SI4[ODIFICATIONS/CONDITIONS: _ J L Nc.t,� L'. -]t, f' ' E:� . �-!.t ,y � , � �' ICC '' IMPROVEMENT PERMIT LAYOUT . ,� 1. t r..Z � �-•.;.; t � i •' yam' t. **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY H AIT DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 1:30 P.M. ON THE AY F INSTALLATION. TELEPHONE # IS (336)751-8760. , OPERATION PERMIT SYSTEM INSTALLED BY:-[�nJtH t 16 - t AUTHORIZATION NO.� OPERATION PERMIT B DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DESCRIBED BO E S BEEN INSTALLED COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTE S", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02l02 (Revised) NAM "j�WO Pmt -a 1`` AALC- i�rs 2�-.,fib 00 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) PHONE NUMBER ADDRESS '/�� SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED 7i SNA E SYSTEM INSTALLED UNDER lk� TYPE FACILITY • lf NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED —f INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 PF DAVIE COUNTY HEALTH DEPARTMENT } IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage.Systems j' - r Perlmitmer 4 Z'673 2 Name / Date, Location 1 - 7 Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business _— Speculation No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES ❑ NO p Spacification� for System: ' Auto Dish Washer YES [h NO ❑ „�. ''t' Auto Wash Ma shine YES ❑ NQ ❑ y �% Type Water Supply __— *This permit Void if sewage system described below is not installed within 5years from date of issue. This permit is subject to revocation if site pla s r the intended use change. i f7� Improvements permit by _— — *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 day of completion. Telephone Number 704-634-X5985. r Final Installation Diagram: System Installe_T� d by � i r r, 'i i r Certificate of Completion' �"r� Date *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as.4 guarantee that the system will function satisfactorily for any given period of time. ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERg1Yj,� � r E r.ED Davie County Health Department a Environmental Health Section n r T J 7 J0Q1) P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested Bya�t Mailing Address 9 t V 13 ,'L/e. N. C. a% d Home Phone �, 3 3 V Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No. of People C12 - No. of Bedrooms 3 No. of Bathrooms �- Dwelling Dimensions ❑ General Evaluation E Mobile Home ❑ Other 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers 7. Type of water supply: ❑ Public No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 2'1:5-rivate 8. Property Dimensions ��T / a-0-4-, _ Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing [9 -Washing Machine ©-Dishwasher ❑ Garbage Disposal ❑ Yes C -No ❑ Community *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property:JZ 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. DATE SIG ATUR CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: E 1. I OWN the property. ❑ 2. 1 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 County Health Department to enter upon above described property located in Davie County 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 DCHD (12-90) SIGNATURE F DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME afl DATE EVALUATED 2 ADDRESS PROPERTY SIZE PROPOSED FACIILTY -a-,LCL LOCATION OF SITE 1Z�45_ Water Supply: On -Site Well ICommunity Public Evaluation By: Auger Boring c� Pit Cut FACTORS 1 2 3 4 Landscape position L Slope % — -- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i. Structure -< __ 7 '577, 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 1 SITE CLASSIFICATION: P EVALUATED BY: )Va, /� LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscave 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 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(01-901 ■■.■..■.■■.■■■■■■.■■■ ■■■■■.■■■.■■■■■.■■■■■■■■.■■■■■■■■■■■.■■■ ■■■ ■■■■.■.Ha...■■■■..■■■.■.■...■■. .....■...■■■■■■.■■...■■■■■■.�■■■ MEMEMEOMMEEM'I�iMEMMEMEMEMMEM MERMiiSiEMEMME�MEMEN n ■■■■■■■■■■■■■■■.■■■.....■■■■■■■■■■■■■■.■■ MEMO.■■.■ ■EM■ENEMSENEME CCCCCCCCCC�CCCCCCCCCCCCCCCCCCCC"CCCC'MEMMEM■'i'M ME MOEN MM MMEN ......................................■■........ ■........... 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