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258 Ralph RdAUTHORIZATION NO: ,S Z 4A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee'r, �- S P.O. Box 848 Name:(atr✓1A N�c��=Cc Z-' �� Mocksville, NC 27028 Subdivision Name: Directions to property: (�f1 e ., Phone# 336-751-8760 ��,,LSection: Lot: AUTHORIZATION FOR Ltr,.r'fi ��. = WASTEWATER Tax Office PIN:#57&? _ ?> _:'?11412— SYSTEM CONSTRUCTION Road Name: 6121IL&I 4-'� k zip: G 7��Z **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. ENVIKON (NTAL HEALTH SPECCIA� DATE ISSUED t� P -j 5-1P - I Z: C3 a1,A DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION .Permittee's,. .' ? - Name: Directions to property: Subdivision Name: Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# -`!.'1 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/installation of a system or the issuance of a building permit. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ENVIRONMENTAL EALTH SPECIALIST DATE ISSUED ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE +# BEDROOMS /- # BATHS ?.. # OCCUPANTS T 3 GARBAGE DISPOSAL: Yes o COMMERCIAL SPECIFICATION: FACILITYTY.P`E # PEOPLE # PEOPLE/SHIFT # SEATS ,INN`DUUSTRIAL WASTE: Yes or No LOT SIZE Stlr TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)Ci NEW SITE r REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE l] GAL. PUMP TANK GAL. TRENCH WIDTH �—� ROCK DEPTH (Zit LINEAR FT. ZCX01 OTHERCTP_If�,yTI Q "1 REQUIRED SITE MODIFICATIONS/CONDITIONS:, �� �'�� �"~��17�� i4=� �n' Ur'ti` 110A� , VAZ � �O U{F IMPROVEMENT PERMIT LAYOUT0PEOVED EFFLUEUT FILTE11D &HS::II(S) IF G" CELO`:: FIIIIS"sIED 62ADE& IA,, "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 J794 ,I 4.4,7{¢�, �"� r► —1R7 -.+"t OPERATION PERMIT SYSTEM INST � LED BY: t 2 A") WIDA 1 Z 1 AUTHORIZATION NO. (� 4 OPERATION P ` DATF-4 1 44 "`*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH ST DES IBED ABOV BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT ND 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) A'APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT' _ 0 h _ �Davie County Health Department @ [E OUR jsEnvironmental Health Section D L5 P. O. Box 848 JAN 3 Mocksville, NC 27028 0 , 1� C RUQ- ou.^4' �.-S • (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED -UNLESS J ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed D M*5 G • M g� 010 V/S C l-- Contact Person Roddy WC4"xv w -I Mailing Address 0 - 190 x -2-77 Home Phone !JLO V,6 7 -7 0 6 / -" City/State/Zip / V t��� �LL'�. ,y C 270 2 k 2. Name on Permit/ATC if Different than Above Business Phone / �rn Mailing Address City/State/Zip q -s I'S g- 3. Application For: Site Evaluation 0' Improvement Permit & ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People J-- # Bedrooms y� 7 # Bathrooms Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: # Commodes If Foodservice: 7. Type of water supply: Specify type # People # Sinks # Showers # Urinals # Water Coolers # Seats Estimated Water Usage (gallons per day) ❑ County/City '%� Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes VIN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE „_ a 4&t, Q czJ �rCj1� SUBMITTED WITH THIS APPLICATION. Property Dimensions:AC PB %Ac� 1 WRITE DIRECTIONS (from n/_ Q Tax Office PIN: # lig / Y I —� �+ ` �� G p�Q � '- '1 ice-- 1 Mocksville) TO PROPERTY: _� 1 - 1 1 64 eafd Property Address: Road Name PA1 City/Zip K5 Ly S u If in Subdivision provide information, as follows: Name: +e - Section:#: 1 I 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 AuthorizedReprese ative of the Davie County Health Department to enter upon above described property located in Davie County and owned by 0.14W r'-, to conduct all testing procedures as necessary to determine the site suitability. DATEh�s� SIGN Revised DCHD (06-96) Prg,9- � ^' C ,U. lo5I' VV e -"c 66- Jr • <11 N4b; co -kAt 12-9 i.cre's '7.000 Lcres '..t 459. i /t" 0 0' 3.()Oo ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME /� i�if7�1/9if! S DATE EVALUATED CW! &.— PROPOSED FACILITY PROPERTY SIZE T'5_iqo SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring 6/ Pit ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position.4— ,L Slope Slo e % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH jr)( Texture groupG Consistence Structure �J( 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: LONG-TERM ACCEPTANCE RATE: ` REMARKS: DCHD (01-90) EVALUATION BY: J&X OTHER(S) PRESENT: 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 c Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 ■E■CE ■MSM■ PENN= ■E■O■ ■E■■■ ■E■E■ ■E■E■ ■■■E■ ■■■■■ ■■■E■ ■E■E■ ■MOM■ AMEN ONE ■E■E■ ■E■E■ ■■■■MEMS■■■ ■MEM■■■M■■■ ■■M■■■■M■M■ ■EMEM■E■ME■ ■E■■■■■■M■■ ■E■E■EM■ME■ ■EE■■■ESS%■ ■ESE■■■IEE■ ■■■■MW%EM■■ ■Emma■■■■■■ a■■■O■M■■E■ ■■■■MEMO■■■ ■EMM■■■■EM■ ■■MEMOMME■■ ■■■■■■■OM■■ ■OM■■■■■■M■ ■■M■■■■ME■■ ■■MMOMMEM■■ ■E■■EMMEM■■ ■■■■■■■EMM■ ■M■■■■■■■E■ ■■■■E■EME■■ ■■M■EMEMEM■ ■ ■■■■MM■■MO■ ■■■■E■E■EE■ ■■■■■■■■M■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ME■■ ■■■M■■■■ . Davie County Health Department andHome Health Agency Environmenta[Health Section P.O. BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 February 18, 1998 Thomas C. Meadows, Jr. P. 0. Pox 277 Mocksville, NC 27028 Re: Site Evaluation/Ralph Road Tax PIN: #5769-33-9442/Site i Dear Client(s): As requested, a representative from this office visited the aforementioned site on February 13, 1998. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable installation of an on—site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd Enclosure(s) cc: Zoning Office ,8ullarct �,q 9,)