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268 Ijames Church Rd Lot 4 AUTHORiZATION NO: , 1305 DAVIE COUNTY HEALTH DEPARTMENT E vironmental Health Section PROPERTY INFORMATION Permittee's LIo_ •-94) P.O.Box.848 Name: !""44-M— - Mocksville,NC 2702E Subdivision Name: (VAROOK Phone#:704-634-8760 ` Directions to property: t k)Vl,nti*J i - Section: r Lot: AUTHORIZATION FOR 1jIlLP tie,► ' fG�+T.': WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: I,V Alt s co a0zip: **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 applyjng for Building Permits: (In compliance with Article 1,1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) h ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION l IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRON a E AL hEALTh SPROiAbST DATE ISSUED * .y �►['k4.P ..f y r ,��, .Y:,ny rY,,,' -�'Y i+' a h,+....,.wr�•J; YJ. J'.•'°'1 '4..:. y r i t.. ' � } ` > t. 7" 1305 DAVIE COUNTY HEALTH DEPARTMENT PR VE ENT AND OPERATION PERMITS PROPERTY INFORMATION r - 0.99 Subdivision {SDA Subd' Name: TA? R4W 64 �reCiiOns to pioperty: t,?fl,-r`1.j ' ` Section: i Lot: t t v : • n -y-1 IMPROVEMENT AI LC PERMIT F 6°to_ + r`s 7 Tax Office PIN:# i i Road Name: i.'A M( 0,', 1 `r-)zip: C �L **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 pnior 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' .ti / , PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONME 'tA- HEALT I SPE ALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE i INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE 10vilee #BEDROOMS_ ' #BATHS 2—#OCCUPANTS GARBAGE DISPOSAL:Yes o iQo . COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE a" TYPE WATER SUPPLY 0-bddl DESIGN WASTEWATER FLOW(GPD)314 NEW SITE ✓ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE D-22GAL. PUMP TANK GAL. TRENCH WIDTH r ROCK DEPTH (Z 'LWEAR Fr. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: '-,\1S1tM ot)T t?F -Ar-a}A& I��d �' 1 � c�F� t-Ioo- 9 IMPROVEMENT PERMIT LAYOUT C=l Vr u I cx)' _ 'o.c. c r 2 V �c +c , "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 l( YSTEM INSTALLED BY: r VV p;c/ lJ i AUTHORIZATION NO. �OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM 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) �o 4 (APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI - aV Davie County Health Department l 1 Environmental Health Section P.O.Box 848 Mocksville,NC 27028 MR 27 I (336)751-8760 UNIRONdMITAL HFIJr.J ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE "SIE C0111T11 ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 9,q'ict h/1� �I��F Contact Person Mailing Address �f�� (��rr� �C�. Home Phone City/State/Zip 401Z,•4NCta Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address `City/State/Zip 3. Application For: �ite Evaluation Od Improvement Permit&ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms L3 # Bathrooms Ci Dishwasher ❑ Garbage Disposal IN Washing Machine ❑ Basement/Plumbing O'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 ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes &-o`N'o If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PfagM THE PROPERTY MUST BE n/ SUBMITTED WITH THIS APPLICATION. Property Dimensions: If �Ff'� 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # �� 1 Property Address: Road Name ��(/(A.r�tS 1rk 10 City/Zip 1 If in Subdivision provide information,as follows: Name: Section: Lot #: 1 1 • 1 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.1,hereby,give consent to the Authorized Representative of the Davie County Health Department to to ent/err upon above described property located in Davie County and owned by�/AJ&;e�G• L��/ ��/y,r �1 )X, �aFGf' to conduct all testing procedures as necessary to determine the site suitability. DATE �� SIGNATURE Revised DCHD(06-96) YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. ry� a APPLICATION FOR SITE EVALUATION/110PROVEMENTS PERMIT Davie County Health Department JUL I .I Im Environmental Health Section P. O: Eo:c G65 Mecksville, NC 27028 _ ENVIRONMENTAL HEALTH DAVIE COUNTY r. 1. Application/Permit Requested By. >�4Z,pi l �2Y Malling Address -��,��'� � 70 LZ Home Phone q%Z`r 2 Business Phone 2. Name on Permit if Different than Above S. Application/Permit for: E?IGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: M- ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business O Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision �� L�IJ/� _ -__ Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms _ ❑ Dishwasher Dwelling Dimensions f ��L�� ❑ 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: P Public ❑ Private ❑ Community 8. Property Dimensions---� �fT lj--OAS Sewage Disposal Contractor _ 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? 44es ❑ 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: #1&cav0.4v 6 Q — o� i �'►i/�'t/ GLI'f'�t%�/ (il� ��Ct-A�' �2E'//1�1'LLG�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. 4 12 c U Cl b At E SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. &an-R,L ❑ 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 representativ of the Davie Cou i Health Depa ment to enter upon ab ve des ib 7 property located in Davie County and owned by to conduct all testing procedures as necessary to d e mine said site's suitability f ground absorption wage treatment and disposal system. ATE (J- SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Ofi Environmental Health Section Soil/Site Evaluation c f NAME DATE EVALUATED ADDRESS �� PROPERTY SIZE PROPOSED FACIILTYLOCATION OF SITE . Iia Water Supply: On-Site Well _ Community Public Evaluation Byr'l Auger Boring Pitc Cut FACTORS 1 2 3 4 Landscape position .S Sloe is-\5o HORIZON I DEPTH &`' (p" Texture grouL L Consistence Structure R- Mineralogy Ilk ` \ HORIZON II DEPTH � Texture groupe L Consistence 'Cr "C- Structure Alk Mineralogy ' \ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS RESTRICTIVE HORIZON — SAPROLITE -- CLASSIFICATION g LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: , , EVALUATED BY: LONG-TERM CCEPTANCE RATE: OTHER(S) PRESENT: No NA .REMARKS: y � IN n-rtl�►� -��.C►:a 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-V+--.-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 .3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloey 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 ■■■■■■■�.■■■■ e■■■■■■■■■■■.■■■■■■■■■■■■■eee■eeeee■eee.e.eee.e■■■■■■ ■■■■■■■■■■■a�V■ME■E.■■■e■■■■■■■■■■■■eeeeee■eeeesoe■= eeeee■■■■ee■■ ■■■■■■■■■■..■■■■.■■■EE■E■MMM.■■■�■.e■■e■eee■■■■■■■ ■ee■■■e.■e■■■■ ■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■ ■■■■W■■ce.eeeeeeRee■■■e■.■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC'■CCCCCCCCCCCCCCMEMMOME NOON ■■..■■■■■■■■.ee■■■■■■■■■■■■■■.■■■■M■■■■.e■,e�ee.CC'C'C.■.C�..e■e ■■ ■■■■.■■■■■■e■■■■E■■■■■■■■■■■■■■■.■■■■■■■■ ■■■ ■ ■ ■■. ■■Ree■ ■ ■■■.■■■■■■■■ee■■■■■■■■W■■■eeee■■.ee■e■e■ Ree ■ MINN ■.■■■e■■■ee■eee■e■■■MM■■■E■ee■e■■■Wee■■e■■e■e■eeeee■ee.ee■e■eee■ ■e■■■■■■■■■■■■.eee■■■■■■■■EWER■ ■■■■■eeHeee■e■■■.■■ee■■■■e■■■.■ ■■■■■■■■■■..■■■■■■M■■■■E■■■■■■■■■■■■■■■■eeeeseeCC =.eeee..■eee■ee■ CCCCCCCCCC�CCCCCCCCCCCCCCCCCCCCC�CC MEMMEMEMCOMMOMMEMSE man 0CC'C ■■■■■.■■■.■■eeE■eee■■eWM■■■ee.■eeeC■.eeeRee■■ eee■ee�■ee.Wee=.eC= ■■■■■■■■■■■■■■■■■■■■■■■■..■.■■■■ ■■■■MEEu�■■■■■M■■■■■■■■■■■■C■■■ ■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■ ■■■Mee■■ ■■ u■t■■■��■EEEE■E■■ ■■■■■■■■■■■■■■■■■■■■■uEE■■EEEEEE■■u.EEEE■■M■C�■■■■I■11■■■■■■■NMI MEN........uM■■ME■■■............................... .WE mommom ..►. ...... ........■.....■................................. 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