119 Old Oak Ln Lot 9 r �-.:- 5. ...,1 t.._;area: .�• . � •p•.�nw'a�f`"iY 4p •y :�.• 'l .rzyiy,. •^C'.•...�, w:. `1��.�i: #y •..,eti:..pa!r4`K.riq. M�:.ir..,4;mcf:.M.,vo-rW:7.w `F4*-"°i lF �'.;.i-y;..yj3/v't.,'
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7-40-11 2�bO
AUTHORIZATION NO".l 6 9 9A DAVIE COUNTY.`HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee_.ti.�'`" P.O.Box 848 �% � ( .�J�i:•
Name:.- tt ✓1��yC4'IA06d ��y� Mocksville,NC 27028 Subdivision Name:
t Phone# 336-751-8760
Directions to property: ✓ r J � �'i` Section: Lot:
AUTHORIZATION FOR
IlY��t� J J WASTEWATER
i'AS7• � Tax Office PIN:#-`J���
SYSTEM CONSTRUCTION
Road Name: Zip: 7 X25
**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.
an compliance with Article,I I of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRO NTAL HEALTH P 1ST- D TE 1 SUED
j 5 DAVIE COUNTY HEALTH DEPARTMENT
Sr 1 b IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
r.
Name:' j .A is 41 M�1VO C r1� � •
Subdivision Name:
Directions to,propertv:' f B :i: Section: Lot:
IMPROVEMENT
?d ►!. t,r:} e � `"I% PERMITTax Offi
ce PIN:#-C7%'l
Road Name: Lf t' l,�l 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***TIIIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
• - SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRO. MENTAL HEALTH SPFCTALIST DATE ISSUED
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE M►i #BEDROOMS _#BATHS 2 #OCCUPANTS GARBAGE DISPOS :Ye .or No
COMMERCIAL SPECIFICATION: FACILITY TYPE__ #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZ> �G29 ATT�YPEWATER SUPPLY W��l_ DESIGN WASTEWATER FLOW(GPD, NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH Lnfo ROCK DEPTH 12 LINEAR FT.
OTHER_
REQUIRED SITE MODIFICATIONS/CONDITIONS: � r. -Took I ^`u;' -SJ' t- ✓�: �t=i-lr- + � Inv � '"
IMPR+ V^ERMrrLAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 6'' BELOW FINISHED GRADE
ULW60
� � 2
120'
**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(guX60448MOX
(336)751-8760
OPERATION PERMIT ..S
'SYSTEM INSTALLED BY:
--l- 'DAVE 2.-2ti
A-
1 Z:5,
•' s
5 b...
AUTHORIZATION NO. I- 1 A OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S TEM DESCRIBED OVE HAS BEEN INSTALLE 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)
l APPL�CA 30N FOR SITE EVAWATION/IMPROVEMENT PERMIT
Davie County Health Department l5
Environmeofof Health SmWon
P.O. Box 848/210 Hospital Street "7 W9
lsoakaville, NC 27028
(336)751-8760 ENVI ONMFJITAL HEALTH
IlAV1E COUNTY
***n PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AT THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for-- instructions.
1. Name to be Billed i'Y! Q o Contact Person 11 M b r L,(�^{��l�� a o
Nailing Address (R 7q ig 2- ( LCV I /� I1� Hama Phone -7
YV
City/state/ZIP � S i NC, 22101-2 Business Phone oZ-oZ S 1
2. Name an Permit/ASC If Different than L Q r
41-110
Hailing Address S-7 Z_1 TV0 M a Vdu ek City/state/Zip W—J A/(--(-- 14- /102
3. ]►pplication For: U Site Evaluation lklimrovement Permit/ATC 0 Both
4. system to service: 0 House kk Mobile Home 0 Business 0 Industry 0 Other
a. If Residence: # People # Bedroom 3 # Bathrooms
Dishwasher )(Garbage Disposal t washing machine 0 Basement/Plumbing 0 Basement/No Plumbing
S. If Business/Industry/Other: specify type # People # sinks
# Commodes # showers # Urinals # Nater Coolers
IF FOODSERVICE: g Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 0 County/City Well 0 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? X(Yes 0 No
If yes,what type? (9io - ('
***1MP0RTANP** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN A1UST BESUW 11TTED by the client with THIS APPWCATION.
Property Dimensions: ova 0 : 0 Q -I DIRECTIONS( m MockrAlle)to PROPER
b(� W Ire r-c S+t-4 oh
Tax Office PIN: # -59 13 R 9_3 S /`17tODi M � �d ` i nferSeG'�S • 6 0(
Property Address: Road Name tea( roX j i
City/Zip KkoCQ UtW i IQL- r�10� cq:•i �.. `E' '� !I��n� h-b►•�
If In a Subdivision provide information,as follows:
Name: LLJ q�r ou kUj- &'V-C V on 1-e J
199 Section: Block: Lot: Date Property Flagged: - _
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pennit(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 responsiblefor all charges Ineurred fi+om
this application. I,hereby,give consent to the Authorized Representative or the Davie County Health Department
to eater upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability
DATE 7- 9
I reSIGNATURE �!� Za
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).
U
0
Account No.
1
('_0 7-
Revised DCHD(07/98) Invoice No. y
1�7 ----------- ._ .. .._ __....._._.
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MOM 117Im ti}{ RAIS m of mm rr V. 4 -
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otttti]N
ON= R OMnE Cmem IKAINp CvvAn a*
TAX Urr 3L"
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172-331
\ ROGER L DALTON \\ /
V. GENTLE G \ 174-773 JQSE A Ga7<Z
62-16 / \ \\ 176-008 // TAX LQT 3Lo8
?3-6" \\ \ // JOSE RLFO CABRfRA
Y \ \\ / 181-274
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&
Davie County Health Department
Environmental Health Section SEP 2 7 1996
P.O.Box 848
Mocksville,NC 27028 ENVIRONMENTAL HEALTH
(704)634-8760 DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed L Aft 'R e.C Ce Contact Person //
Mailing Address 1 1 L U h:e.. Crass 6. Home Phone r1 i 0—36 6"y 3 G b
City/State/Zip SLA. rm , N. C 7o i 7 Business Phone 910--
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: R"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _,> # Bathrooms .—
Ud"Dishwasher ❑ Garbage Disposal Y 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 Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 2-INo
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
�fI p SUBMITTED WITH THIS APPLICATION.
¢. y �0
Property Dimensions: WRITE DIRECTIONS(from1
• < 3'�,��.d 6"3 1 Mocksville)TO PROPERTY:
J Tax Office PIN: #
Property Address: Road Name
City/Zip �'�r�.� `G. OA� S�a�� Kd�• �3a9 1
1 -�-' 0
1
If in Subdivision provide information,as follows: 1
a C1Name:
1
1
Section: Lot #: 1
10}�t 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.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 J� V A P. to conduct all testing procedures
as necessary to deermine the site suitability.
DATE SIGNATURE
Revised DCHD(06-96)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&AT
l Davie County Health Department
Environmental Health Section SEP Z 7 ����
P.O.Box 848
Mocksville,NC 27028 ENVIRONMENTAL HEALTH
(704)634-8760 DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed L�i h y, 'R- C C(e U.
Contact Person �-►
Mailing Address �g L. U h;p.. foss' [ted►. Home Phone q 1 D-3 - L/3C6-
City/State/Zip D A bS0 N . C 7017 Business Phone 910" Zan
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: 2""Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: 2"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People _� # Bedrooms _2 # Bathrooms —�—
TrDishwasher ❑ Garbage Disposal 2"*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 Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 2""No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
p' r� pry SUBMITTED WITH THIS APPLICATION.
Property Dimensions: lZe Q- \ o����/'d / �I WRITE DIRECTIONS(from
.� ��S �•���a'y "%f d..3 I Mocksville)TO PROPERTY:
J Tax Office PIN: # -
o., I 1
Property Address: Road Name r U.s. ay (^n Zt C.1,;`Or ens 1 1
City/Zip 4(3h.' Zpq,& S�ak-c a. I
1
Lo
If in Subdivision provide information,as follows:
u . uncl
Name: n �� l�� r ny 1
1
Section: Lot #:
qL&- 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 Health Department to enter upon above described property located in Davie County
and owned by ti ''"2 to conduct all testing procedures
as necessary to det rmine the site suitability.
DATE SIGNATURE ,
Revised DCHD(06-96)
DAVIE COUNTY HEALTH DEPARTMENT /`"" q
Environmental Health Section SECTION LOTu_
Soil/Site Evaluation
APPLICANT'S NAME Lynn M. Reece DATE EVALUATED
PROPOSED FACILITY House PROPERTY SIZE
SUBDIVISION Oak Grave ROAD NAME Highway 6010.
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 1 �i
Texture groupG' G
Consistence
Structure /l k
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: is v� /0�// = W G�( eo+.�°I". � Lr'� 10-
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 loath 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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