214 Bowood Church Rd Lot 6 .f to li3 � �• y t Y 1 t . or �. .•3 s vrt ,. ,�, � t. ., # • p ?,;' :ct t s 'Y.r�
AUTHORIZATION NO '' 3` � D"IE OUNTY HEALTH,DEPARTM NT o
Environmental Health Section PROPERTY INFORMATION
Permittees ,l P:O.Box 848
Name: G �^ ��" Mocksville,NC 27028 Subdivision Name:
A
Phone# 336-751-8760
Directions to property.. ?/ `1 y L1�C clC Section:. Lot:
f77AUTHORIZATION FOR
1
. 46ale.46tWASTEWATER' Tax Office PIN:#�
SYSTEM CONSTRUCTION
Road Name:
*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. .
(Incompliance with'Article I 1 of G.S:Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) '
r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR PERIOD OF FIVE YEARS.
ENVIRONMrAL HEAL IALIST DA ISSUED j
;.
y �' f W ^..V.e b x��'�µ ,7•J'vn..rp'°*y.�` y.,�• - ra ,. t ✓.r ,� r �=,, ,, : ....-. „:.. ..... r
;dam �, •� '" = DAV _ .
IE OUNTY HEALTH DEPARTMtNT
•
PROPERTY INFORMATION
IMPRO, EMENT AND OPERATION PERMITS
Permlttic' i
NameSubdivision.Name: l. t`
Directions to property: `L f 17"-t -.00.J) Section: Lot:
IMPROVEMENT •'
t •.lIt t , f���,j. Mfr .' PERMIT Tax Office PIN:
fry Road Name: 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/install of a system or the issuance of a building permit.
(In compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
> x ;,,•` ,_ r' '1 PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEAL PECIALIST DPS ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE M H #BEDROOMS_ #BATHS LZL#OCCUPANTS GARBAGE DISPOSAL:Yes or 100
COMMERCIAL SPECIFICATION: FACILITY.TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE��ZTYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) Dy NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1 oO0 GAL. PUMP TANK GAL. TRENCH WIDTH 'J /ROCK DEPTH 1 L LINEAR FT. ,
OTHER t//ST I�f1T/0
REQUIRED SITE MODIFICATIONS/CONDITIONS: I S I lI(.l- �/V C.�G�V/O(/ �L /' Q� l�l� ' G/i✓G
IMPROVEMENT PERMIT LAYOUT
Fl
T
'7
t.3. **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 (336)751-8760.
OPERATION PERMIT ;
M INSTALLED BY:
.4
�vor'Cah.
oar
;fir ► 7
AUTHORIZATION NO. L13OPERATION PERMIT BY DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT E Y TEM DESC BED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREA AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA .<,
GUARANTEE THAT THE SYSTEM WILL.FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised) ;.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A R
� � Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street lone8
Mocksville, NC 27028 40 14 W
(336)751-8760
�4iYf"OII?'HJT HE91iy
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed Contact Person
Mailing Address /lu/t�t, /�n Home Phone �(J`f'• �1 7 y /
City/State/ZIP l�ix�f(\X,c� ! !l/ pC (f�l Business Phone
2. Name on Permit/ATC if Different than Above
Nailing Address City/state/Zip
3. Application For: 0 Site Evaluation M/Improvement Permit/ATC . ❑ Both
4. system to service: ❑ House dly-*,-'.le Fame 01 _2 �ne:w.c.: y u ¢ :,_h.er
5. If Residence: i People i Bedrooms 3 1) Bathrooms
LYDishwasher 0 Garbage Disposal 6'Washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People 1) sinks
# Commodes M showers 1) Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: IV/County/City 0 well 0 Commmni.ty
s. Do you anticipate additions or expansions of the facility this system is intended to serve? O.Yes it, o
� te5 /C
***IMPORTA **CLIENTS,11USTC0,11PLETETHE REQUIRED PROPERTY INFORMAT10K.PEQUES?[EC
BELOW. Either a PLAT or SITE
PLAN MUST BE SUBJIITTED by the client with THIS APPLICAT.10F.
Property Dimensions: d X Z75
f bo(o'P�WRITE DIRECTIONS(from Mocksvilie)to PLO(P�ER?:Y:
Tax Office PIN: # 6-765- .20-3350 `. �QASC 1�D0�
Property Address: Road NaJou 00 d- l✓Y!ULW• /)'„
City/Zi J?0
U , .20
�f'I ✓l�h- - X.0 `�'
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: l0
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. 1,also,understand that I am responsible for all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Davi County Health Pepartrpent
to enter upon above described property located in Davie County and owned by 6e1tg,, _
to conduct all testing procedures as necessary to determine the site i dity.
DATE 9-a-?'19 SIGNATURE ,/��
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN `7
Application No.
Invoice No.
Revised DCHD(07/98)
7 APPUCA1.10N FOR SITE EVALUATION/IMPROVEMENT PERMIT I5
01 ° 9� Davie County Health Department
Is' �,/� Environmental Health Section
�� y�• n_ a�" � P.O. Box 848/210 Hospital Street
99 14
Mocksville, NC 27028
(336)751-8760 { ;�;'O'�PtF1lTA1 HEALTH
A COMM
*** ORTANr*** THIS APPLICATION CANNOT IM PA0=SSED UNLESS ALL THE REQUIRED
INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be BilledA-IV 19 7� Contact Person oaq p-, 1
Mailing Address tuk Iy Bome Phone V�8t[•a-)0
City/state/ZIP [,QLuk IBX k, pBusiness Phone
2. Name on Permit/ATC if Different than Above
Hailing Address Citty//state/Zip
3. Application For: ❑ Site Evaluation L`1 Improvement Permit/ATC ❑ Both
4. System to E^ar-rice*. ❑ Uoi!.SE �M! '�.e rr ❑ ;.a�.not 1�1 .a.h.a r ..`'
5. If Residence: # People # Bedrooms # Bathrooms �-
YJ Dishwasher O Garbage Disposal Ir"
Washing Machine U Basement/Plumbing O Basement/No Plumbing
6. If Business/Industry/other: Specify type # People # sinks
# Commodes # showers # Urinals # Water Crolers
'4
IF FOODSERVICE: i1 Seats `� Estimated Water Usage (gallons per day)
7. Type of water supply: Cl County/City ❑ Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 040
.t A FS" c�- a I Yt' .
**'tIMPORTA **CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST BESUB,1117TED by the client with THIS APPLICATION.
Property Dimensions: �'�J / X .1-7 t l
0O ,WRITE DIRECTIONS(from Mocksvilie)to PROPERTY: _ 0
Tax Office PIN: # X55 _l�- 3350 1 j�nv�UO� �t 2 C�
Property Address: Road Name eo"D 0"0( l�t"I�ok
"" ���� a�o�Q (LA ' oma, Jkiq
City/Zip (�rtUUlp � p L
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot:
O �
This is to certify that the information provided is correct to the best of my knowledge. I understand tha:Ln7l 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. .1,also,understand that I am responsible for all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Da 'e County He' h De artment
to enter upon above described property located in Davie County and ed by
to conduct all testing procedures as necessary to determine the site ui ility.
2'7'1C21-d-
DATE in r i u SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
Application No.
Invoice No. a o
Revised DCHD(07/98)
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,a'�:..> ��-• •L�� .. 'L:Qi�.S �:;1:•;. �., .•lei' .� Sd 4.=�_i -hh .• r v
PI/ r(G APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE1 M
Davie County Health Department u O v
Environmental Health Section
e P.O.Box 848 MAY ( I M
San,/ Moo ksville,NC 27028
�b4 xxx
(
(336)751-8760 ENVIR0N1-1ENAL HUW4 K�
)AK MW
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ��` TN Q�LL lA C CX Contact Person /'�/�
0 b,�A
Mailing Address ZOO V0013 41✓4c-&) kc A i7 Home Phone
City/State/Zip /00 CVQ l!iL L6 t\)C- Business Phone 33(o ' 75
2. Name on Permit/ATC if Different than Above O S t t= A C Q i S
Mailing Address 2100 C3clX JOO t7 C&I v 04 '2 Q City/State/Zip 1A d(-LJ J'u.c, )\)C- Z7O Z8
3. Application For: R(Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: Y House 1-4/Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # 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: fO County/City ❑ Well -/ ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? lY Yes ❑ No
If yes,what type? IJ t3 10-.-,11 S 10 tJ L-0-r 5 11 4 1 S 1 ,0
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A W)6j"THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: T T'&•O IA 4 t-) FFL�-T 1 WRITE DIRECTIONS(from
Mocksville)TO PROPERTY:
Tax Office PIN: # 15 7 5 S - Z O _ 3360 - 1
1 0.5 fool so v't M
Property Address: Road NameAXZZ"d-r- , 1
U 4 1 FtdM TvJAKO
City/Zip 1
1 s�Us li✓n Pin CcL ,S
1
If in Subdivision provide information,as follows:
1 La CA r00 600
Name:
1
1 SovT�► oe a0x. %A/ocl
Section: Lot #: 1
C,4vf-C6-1 4(lA0 0o LL;r l'
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.1,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 described property located in Davie County
and owned by R i c NAR-Q a cZ1L &—f m- I to conduct all testing procedures
as necessary to determine the site suitability.
DATE
S - 11. '5b SIGNATURE
Revised DCHD(06-96)
YO MAY USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
r
✓ s DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT__L
Soil/Site Evaluation
APPLICANT'S NAME 14 AE L L 7 DATE EVALUATED Iia✓/
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION S ROAD NAME _92X:�Z_kde�_ (1/ _
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence i
Structure S
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
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
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(01.90)
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