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129 Northbrook Dr Lot 11 ^�`-" X1 is Y��+•`3°�-� "? Y. 'a-��+a. ",`.`+''�tt a'• �^+t �. .. s�� 7 .- 'a:,,a r .._ ..p 4..} ,i-'.\¢t i," i cps. `^*.,Y.,f yJ:+.ca �""'�'"''"� �3'F.� .5+ a..,`iw ,�'t Cas �+ . '�:• �'�i• ��'�'�"� ":rr=^:i te'�.'4twYa"'"+rt'E-vy'wwd''Lc:.c q'pYt-.i.r.'=p+°i+�-�3'-f+i?^3�� AUTHORIZATION NO: ' J DAVIE OUNTY HEALTH DEPARTMENTt/?Co Environmental Health Section PROPERTY INFORMATION Perm�iItee's ,r'/ _ P.O.Box 848 Name: t �' Mocksville,NC 27028 Subdivision Name: 0 l Phone# 336-751-8760 Directions to property: `�J�sJ/ Q�� Section: Lot: AUTHORIZATION FOR -� WASTEWATER Tax Office PIN:# � � SYSTEM CONSTRUCTION Road Name. 'o ''A01 �d 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 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH,SPECIALIST DATE ISSUED` 1633 -DA OUNTY HEALTH DEPARTMENT ,1S IMPROi EMENT AND OPERATION\PERMITS PROPERTY INFORMATION Pe " 'sok y. I9 l : + N� � Subdivision Name: Directions to pioperty: PdPROVEMENT Section:- „�_Lot: PERMIT �_ ". _ Tax Office PIN:# Road Name d, `t�r'�� Zip: **NOTE**This Improvemerit Permit DOES NOT authorize the oristiuction orinstallation of aseptic tank system or any,wastewater system.An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the constrd0on/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) t ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER. ENVIRONMENT HAL EALTH SPECIALIST DATE ISS "ED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING=SYSTEM. RESIDENTIAL, SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS _ #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) U U NEW SITE � REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEZGAL. PUMP TANK ` GAL. TRENCH WIDTH ROCK DEPTH _ LINEAR FT: �_�" OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUTi�� 'i **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 PE 1T SYSTEM INSTALLED BY: fn,t.J► _ fie,r-� t-1S' N ti AUTHORIZATION NO. OPERATIO - BY:. DATE: / **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DESCRIBED AB HAS BEEN INSTALLED IN COMPLIANCE WITHARTICLE I I 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 EVALUATION/IMPROVEMENT PERMIT& U ' Davie County Health Department Et7vinvnmeJ7W Health Section -9 1998 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***Il P01ZrANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PR DED. Refer to the INFORMATION BULLETIN for instructions. ( 1. Name to be Billed � iI Contact Person G Mailing Address �� ILnO ,�-/ f_? l/V Home Phone 957' y'n city/state/ZIP rJr Sv,�/e /✓.e. a70a it Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC E Both 4. system to service: lQ House ❑ mobile Home ❑ Business 0 Industry ❑ Other S. If ]Residence: # People 599C RUUTA_ # Bedrooms y3 # Bathrooms U]R Dlshaasher 0 Garbage Disposal {7 Washing Machine O Basement/Plumbing. 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: IJ-County/city ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tai Office PIN: # o?d — 31- 60/ /Vd-44 64� 0,17 _7- Tfax.n d.h46�� Property Address: Road NameX'-1l S.ibr_k ae. Xr oey Ala,-d kot ek 4"( Lof al Z, - City/Zip /!?�'l 4%r­ /Z cP),d3 k If in a Subdivision provide information,as follows: Name: ka'-� Section: Block: Lot: Date Property Flagged: 7-1d-/70""- 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 described property located in Davie County and own by to conduct all testing procedures as necessary to determine the site sui it DATE / " 7` ° SIGNATURE 110Z0'R 4 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. 9(v �y M APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department SEP a Environmental Health Section P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAI,t ,ta DAME COLI 1. Application/Permit Requested By Mailing Address —ma CS Home Phone 19F#7 17 Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: VGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: house ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ In Other Q ❑ Unknown vRa�lC PP�� 5. If house, mobile home: Subdivision NO 1r, Section a Lot #f/— ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Ei"Public 7. ❑ Private ❑ Community 8. Property Dimensions 62AA ,rk k a4a,44Z Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? '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: 4 O I � �� tel/ (� �j/ pa 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. J44&i�u�/9f 9 M' 2 DATff 0SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 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. ,t DATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT �p i • Environmental Health Section Soil/Site Evaluation NAME sue3 DATE EVALUATED ADDRESS S ACc�.� PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation &k_L✓ Auger Boring Pit I,,"" Cut FACTORS 1 2 3 4 Landscape position Slope R O HORIZON I DEPTH Texture group Consistence �- Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 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 EVEC SITE CLASSIFICATION: � - •'' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 4 OTHER(S) PRESENT: N� REMARKS: EGEND 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 :lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V+_-.-y friable FR-Friable FI-Fina► 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 .3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralolly 1:1, 2:1, Mixed Notes Iiorizon 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) ■■■■■■■■■■■■■■//■■■■■■■■■■■■■■■■■■■■///■■//NOON■■ ■■■■■■■■ ■■fl■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON■■■■■s■■■■■■■■■■ ■■EE■■■■■■■■■■■■ ■■■■■■■■■■■/NOON■/NOON■■■/NOON■■ ■NOON/NOON■/NOON/■■■■■■■■■■■■■■■ ■■■■■■■■■■■■/■■■■■/■■■■■■/■/■■■■�■■■■■■■■■■�/■■/NOON■/■■/■■/NOON■ ................e................................... ............■ ■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■i■■iE■iEi■■■i■■iN■i■■i■■iN■iE■i/■i■/i■■"E■N■iN■i■■i■■ie■iE■i�■ii■i■i■i01 ■■ ■MEME■' ■■■ ■ _ ■ MINE s ■ IN ■■ iiiiiiiiiiiNEON ■■■■■■■■■■■/■■■■■■■/■■■■■■■■■/■■AW■■■■■■■/■■■■■■■■■■■■■■//■■■■■■■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii i'ri■iiiiis iui■iiiiiii iiiii ■■■E■■■■■E■■■■■■■■E■■E■EEEEEO■■E■■�■■■■■■■■■■ ■■■■■M■■■■■ NONE IN iiiiiiiiiiiiii�Niii'/iiiiiiiiiiii'���"■iiiiiiiii=i'/'/'/u■iiiiiiiii=iii ■■■■■■■■■■■■■■■■■■■e■■■■/NOON■■■ ■■■■■■■■ ■■N■■■■■■■■■■■■■■■■■■ ::iiiiiiiiiiiiiiiiiiii'■i:iiiiiiiii::iiii:ii:i::'MEN MEN mmmmiil■ ■■■■E■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■■ sE■■ ■■ ■s■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■EEENEE■N■■E■EEN■■iE■■■■■■ NOON■■■ ■■■■EEE ■iiii'■i'Eiiiiiiiie L k Fss s. • �`� LOT #14 LOT #15\ .�° (1.084 AC.) (1.096 AC.) ob LOT #32 \� rq (2.329 AC.) ti"jr 0060 fro \ 0 Sc�� LOT #13 i o� (0.753 AC.) i 2k Y 0 Q LOT # GF���`� Q�• LOT #12 (ossa A ���• �1 (0.747 AC.) • <v Z 48"3e• w LOT #31 ` N q LOT #11 (0.796 Ac.) • / r (0.695 AC.) z � EASEV REAINAGE �i�f / 63,00 _� I, ,d ,� 100.00 100.00 100.0 rCONTRO CORNER` I. I C 21 S.-00 I 1 I I I I LOT 1 LOT 2 I LOT 3 I I 1 LOT 4 I I I I I I I 1 I OX 70 S. E. IOX 70 S.E. IJAAM3 CHUB CH ROAD >317)