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188 Northbrook Dr Lot 20 gvy.t.,t r^'�) »d .'i° rAPy l'. J Yi�_,': r:!°a 1fr'^a�s'i':w t v i t y ':� 41:1'w:iy i+yl+tat 9 ,.y{'.y. t..,. ✓ ."+" ` ,:.} ,s rag k AULTH,( i;I3ATIQN N0: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION PermitteeP.O.Box 848 `- Name: 1G �1�.� e � Mocksville,NC 27028 Subdivision Name- t��►© 1D"z.Oof. Phone#:704-634-8760 ~'�`�~ Directions to property: ��1 �� Section: La.- Lot: d ` , AUTHORIZATION FOR 7L' IN, WASTEWATER : Tax Office PIN:# , SYSTEM CONSTRUCTION Road Name:- 1 �✓J.Zi **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of anyrBuilding 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 +, r�.ir+"�o„`*"'°',-vw1.rt ”{,V"''3`� .Trt"gj . •:ta'� eti" _ :' ��.,,,,..�r r�:. -r/+ .,� .: ..:.,_ , l.5�.. ..., .. ... ,..,. 00 f DAVIE COUNTY HEALTH DEPARTMENT x: IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION errmUd x SubdivisionName :,,,K�'0&�0 p lNt Du�clio`ns to property: Chi Section: Lot: PERMIT Tax Office PIN:# { _ E 3s i- ma Road Nam P� **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 ENVIRONMENTAL HEALTH SPECIALIST DATEISSUED SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE ii`` INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUII.DING TYPE C�ts��sq #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes&W. COMMERCIAL SPECIFICATION: FACILITY TYPE `#PEOPLE #PEOPLE/SHIFI #SEATS INDUSTRIAL WASTE:Yes or No 75i. X uso .X LOT SIZEyO4 �3 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD, NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK' GAL. TRENCH WIDTH ROCK DEPTH L1 LINEAR FT. �b � P REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT"L!AYOUT ) A Y "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 70 SYSTEM INSTALLED BY- ;D AUTHORIZATION N6_110_39!9! OPERATION PERMrIr BY: DATE: *THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM 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 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC Davie County Health Department — c� � o� � Environmental Health Section P.O. Box 848 Mocksville,NC 27028 ; AUG 1 81997 (704) 634-8760 u ****IMPORTANT**** THIS APPLICATION CANNOT BE PROC THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed fX C1-1Ae D Contact Person 1�1� Mailing Address,3 X/2- 5 51 L ilel CI-14410 l�� Home Phone ��0 �-� �G -� City/State/Zip li'-'A /y, C, Qr /0'/ Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: [4-]'House [ ]Mobile Home [ ]Business [ ]Industry [ 1 Other 5. If Residence: #People_ #Bedrooms #Bathrooms [%')'Dishwasher[ ] Garbage Disposal [& Washing Machine [-fBasement/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: [-I"C'ounty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes 1-T<0 If yes,what type? PROPERTY INFORMATION REQUIRED:***IMPORTANT***A3WAX0F THE PROPERTY MUST BE SUBMITTED WITH T �APPLICATION. Property Dimensions: '7 5-4eo�✓T 4(00j4G'�C y Y-? WRITE DIRECTIONS(from ocksville)TO PROPERTY: Tax Office PIN: #Z Property Address: Road Name/d�PTN �QO� ; 7Z7 iyO,e?f��ROO -2 C1 City/Zip/.YeeaVl4LE CUL IJ'F-SPgC If in Subdivision provide information,as follows: Name: &,9 A rH Section: Lot#: 6zo 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 owned by,�,ca-I �] Dri9,�1/NA _ST�/ /LS to conduct allsting o edures as necessary to determine the site suitability. DATE J SIGNATURE CGrl� �a Revised DCHD(06-96) THIS AREA A(AJ 13E USEb FOR DRAWING YOUR SITE PLAN: 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department w Environmental Health Section SEP ( 8 19Z r P.O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL DAVIECOU 1. Application/Permit Requested By Mailing Address xadlzzo a� �s Home Phone !29,9#71 7 Business Phone' ' 2. Name on Permit if Different than Above 3. Application/Permit for: P/General Evaluation ' ❑ Septic Tank Installation 4. System to Serve: Vouse ❑ Mobile Home ❑ Place of Public Assembly € ❑ Business ❑ In Other R ❑ Unknown ap 5. If house, mobile home: Subdivision ��� v�a��Sefion a Lot # � ❑ 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: . M'Public 'Z ❑ Private ❑ Community 8 Property Dimensions 1 �1°a 4A(z . aX2ZLQJ Sewage Disposal Contractor 7 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: 0 a/111 (� a,yye,y C�V I►�~ �� p�ifr �le'Jr.,�i •�°� �y?�Z�in,c.7,r.�i � � l�—�5'. �,DO G`G��i 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. f496, DAT SIGNATURE 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. DATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 5DATE EVALUATED A ADDRESS R,�'�� PROPERTY SIZE 7b' XX \t�� PROPOSED FACIILTY `Cs LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By. Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S Sloe % - HORIZON I DEPTH Texture group L Consistence ' Structure C Mineralogy1 HORIZON II DEPTH Texture groupC, C Consistence Structure Mineralogy14 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION � LONG-TERM ACCEPTANCE RATE .� SITE CLASSIFICATION: S EVALUATED BY: �1 LONG-TERSCCoEPT CE RATE: �� OTHER(S) PRESENT: \"a (L REMARKS: tT V X CM7� 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay • CONSISTENCE Moist VFR-Vu-ry 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 Structure 3C-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 ■■■■■■..■.■.....■..■..■.■■■■.■■■■■....■.........■�.......■ ONE .■ ■■..■..■■■■■....■.■..■..■...■..■ ■■■...■■.■.■■■■■■ .■■■■■■■■■■■■■ ■■■....■.■......■■..■.■■■■.■..■■ SOMEONE MEMO EMEM lEmm ■■11■.■...■....■■.■..■■■.■■...■...■..■■■■..■..■ ■■■■■■Nm.■■■■■■n■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■i�SEEMOMENOMME■ENNON M_NNEN��■� iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii=iiiiiiiiiiiiiii�i■�1■■■■■ ■■=■�r=■ ■■7■........■.■..■.............. .......■ .. 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