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3622 Hwy 64W AUTHORIZATION NO: :0 5 04 'DAVIE COUNTY_HEALTH DEPARTMENT t Environmental Health Section PROPERTY INFORMATION Prermif,ee's ' P.O.,Box 848 Name: �� ,� Mocksville,.NC 27028 Subdivision Name:. , Phone#:704-634-8760 . Directions to property: .� Section: Lot: AUTHORIZATION FOR QiJ � C�/7<'•' luaWASTEWATER Tax Office PIN:# ��_ � SYSTEM CONSTRUCTION f 7 Road Name: Zip: **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 with Article 11 of G.S.Chapter 130AI-Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONM11NTAL HEALTH SPECIALIST DATE ISSUED Ai DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION,,, -Name: ��, ,� n,e�' Subdivision Name: 4 ibuect ons-toproperty y `r t'�" r Section: Lot: IMPROVEMENT e�"� ! _ �—� PERMIT Tax Office PIN:# -4 5 Road Name: r{r (-�• Zip: **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZATION 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) • , �•, ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRO NTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS r�#BATHS_/—#OCCUPANTS '� GARBAGE DISPOSAL:Yes o�f COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZEQ4 0-a, TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPDh�T NEW SITE A REPAIR SITE r SYSTEM SPECIFICATIONS: TANK SIZE `IdL/ GAL. PUMP TANK GAL.. TRENCH WIDTH ROCK DEPTH LINEAR FTq�Q(� OTHER 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(704)634-8760. OPERATION PERMIT YS NSTALLED BY: ZZZ�21� AUTHORIZATION NO.1 !. OPERATION PERMIT BY: /�"�[O DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PEI MIT _ Davie County Health Department [ [ Q Environmental Health Section D P.O. Box 848 Se 1996 Mocksville,NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed -VN J o n C-5 0)"141 e-t", Contact Person J/ Mailing Address lu--.5 t Home Phone City/State/Zip �� 'C�1�_SV.� P_ . Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ j Site Evaluation [ ]Improvement Permit&ATC [0 Both 4. System to Serve: [ ]House [1 Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #People _ #Bedrooms #Bathrooms_L [ ]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 4 Well [ ]Community r 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes ['�1]No If yes,what type? PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from ,M-ocksv/i�ll/e�)-TO PROPERTY: Tax Office PIN: # ?DY - o2 87-32 Property Address: Road Name ��• <L W S X»A--� City/Zip If in Subdivision provide information,as follows: er1-�-t./� 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 gHealth ,Department to enter upon above described property located in Davie County and owned by ��-�Zr,t�'H'`- �z��-� /�to/c�ond ct all testing procedures as necess to determine the site suitability. DATE q- 1 R ( SIGNATURE C� Revised DCHD(06-96) DAVIE COUNTY HEALTH DEPARTMENT t Environmental Health Section Soil/Site Evaluation NAME C , �G'/- DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position ,L L Sloe % 2 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH SQL Texture group Consistence Structure <4 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 RATEJ _ jV SITE CLASSIFICATION: S EVALUATED BY: LANG-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 Moist VFR-Vrs.-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 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 f s,A[ 0e (82.8 Ac.) F xN171,r �•�, toy,fZf)oq 7 IJ} a ►;� w 32.7 A 17 ' ... y— r 66 5r Ac (2 10 3 A, 1�lei ", j r ci i 14 IT. W r i ,t 30' 2.97Ac.� 0 mVk 85 \ , �, 3 Act +�, '1' .•:`�'� '1€ �ry �� +I �'�'"- 33.3Ac. All CO (20 .9 Ac. ) w , Is Q` 10.55 Aa ryL2V v2 c7 , 123 w 19 r 4hr 20 20 2Ac 7 � a A c o 3.03A �1 r ° ' ,: �sg6 �•< ;t �`.�`. '�� . ; 4. Sas. a loo •., • r 60A e " HWY "' 4 901 _21 I ate. ,' ' 2:2�SA0, Ir