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727 Richie Rd AUTHORIZA-Th.QN.NO:- Y. 7►`0DAVIE COUNTY HEALTH DEPARTMENT ` PROPERTY INFORMATION Environmental Health Section Permittee's` P.O.Box 848 Name: �Ast ,� ` � Mocksville,NC 27028 Subdivision Name: J Phone# 336-751-8760 Directions to property: �(D�✓� 7!7 Section: Lot: d AUTHORIZATION FORMRll �"` f Sr. A 7o . WASTEWA SYSTEM CONSTRUCTION Tax Office PIN:# � - (O rirQl}E Road Name: Ow , 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/Authorizati6n Number should be presented to the Davie County Building Inspections Office when applying for Building Permits: (In compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900Sewage'Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALIDFOR PERIOD OF FIVE YEARS. ENV R V"N L IfEALTH SkCIA�t T DA ! SUED F r(-5-.\. ..J.1- ul�`i.A ,+�� 'V P'G' V` i.ti a.i. + 4J F. 1. �1: �f�♦ . • 3 +1 ''Y^ l 16 5 DAVIE ` OUNTY HEALTH DEPARTMENT TMPROt EMENT AND.OPERATION PERMITS PROPERTY INFORMATION ermttte -9i" # ; Name':`' Subdivision Name: c ` Directions-to property:t 1- llti'� 41 Section: Lot: -IMPROVEMENT "-�'✓l�tL" `,=1� Ic PERMTax Office PIN: V1 t� t •',y t• Road Name: Zip: D **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 �, `• ,` `" _ ; ., ., t PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRO t ENTAL'$EALTH SPECI6I IST DA SSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ; INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE��'+#BEDROOMS.J #BATHS 2- #OCCUPANTS _GARBAGE DISPOSAL:Yes No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No 11 Nl�4C[CS LOT SIZE)� TYPE WATER SUPPLY W tU- DESIGN WASTEWATER FLOW(GPD) NEW SITE �""'A REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE I�QGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 3� OTHER 1 D]STM t TI o n) � REQUIRED SITE MODIFICATIONS/CONDITIONS: (�SII\l�- Da C"T�Q, kc-c Id off- rzzf)r Q.T'u,t �: , vac-P.,I� FQUM 1,Jtll. IMPROVEMENT PERMIT LAYOUT � S ,�,,'' �, ` ►coos n F q0j 7D �oR�✓ �U• f/C.tl � V "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 PERMIT SYSTEM INSTALLED BY: �� nns It7 ilS . VT _ i 9v �: AUTHORIZATION NO. I�w OPERATION PERMIT T I^ DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 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 05196(Revised) 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM Davie County Health Department Environmental Health Section lel P.O.Box 848 ` Mocksville,NC 27028 .AUG (704)634-8760 lt. ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS UN , w ALL THE REQUIRED INFORMr,A-TION IS PRO 1. Name to be Billed Sw 1 Q Te*6,0 LimbD Contact Person (Ilen Mailing Address 65q k/d IN Td ' Home Phone 9qg q&q q City/State/Zip oc I�S�ne ML VDll Business Phone 751" ZZZ1/ 2. Name on Permit/ATC if Different than Above q 6y) SyltI Tz er Mailing Address Sf3 Mk,/ 06 (MOON' City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit&ATC R' Both 4. 'System to Serve: Gf House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms 7, C;(Dishwasher ❑ Garbage Disposal 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) t 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 OINo If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: /90 X 323 261 X 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # �$Z _ /b _ (ogZ� 1 t- E v I)Av Property Address: Road Name 1 mo) I Z��11 (� 7i2D2 � SCI••fCD t -7a /Zr�•f l� 2b City/Zip M �n h 1 1 t ox Zia�r - l Sr 62AvF If in Subdivision provide information,as follows: a nJ l "7" .SCZ Name: Section: Lot #: j SIE,N 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 __� bbi o I;irato conduct all testing procedures as necessary to determine the site suitability. DATE 1 q SIGNATURE Revised DCHD(06-96) 70 � 5561 g Naq 29 (1.06A1 029 8117416 RICHIE ROAD 91 noel Haag 341 $ 11.22A) (6 77A) flaw 245 � 343 5197 2185 ry a � N b (1.13A) 421 w7e ,. � 3048 321 5062 x 328 M 176 8040 323 S Co c (1.09AJ " - N 1,464, 8973 tae 5848 ^ � (A 95A) 682 si see — (f $ (1.OOA) N 8891 n 6 A $ 1709 29 5704 029 2783 306 See ape N /5.50AJ N m r 7534 �dpr te20) (6.04 AJ I � qL nli� Pf Q l° �Jl �a Scale:1" 781 Aril 20,1998 3:59 PM DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 'V4A'VDATE EVALUATED PROPOSED FACILITY {w w' PROPERTY SIZE • 4 4C1P S SUBDIVISION ROAD NAMEL Water Supply: On-Site Well '� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% o HORIZON I DEPTH - S� p Texture group G I- Consistence 5 r Structure Mineralogy 1; 1 HORIZON II DEPTH Texture groupC Consistence Structure Mineralogy 1:' t" HORIZON III DEPTH - Texture groupG k Consistence r - ssv I Vr S5.5 Structure iL MineralogyLs HORIZON IV DEPTH Texture group Consistence - Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE n. SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �• OTHER(S)PRESENT: REMARKS: Y . C.= ;> St Uy e1 T I I 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 Mois 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-Thickne'ss 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(O1-90) ■■.■.■..■■■■.■■■■■■■■■■■■■■■■.■■■■■■■.■■■■.■....■■■.■■.■.■■■■■■■.■ ■■■■■■■■■■■■■niiiiiiiiiiiii�ii�i iiiii��iiiiiiiiiiiiii�7■■■■■■■■■ ■.■■■■e.■■■■■■.■■■.■■■■■■■■■■■■■ear,i■■.■■■■■■■■■■■■■■.■■i.■■■■■■■■■■ iiiiiiiiiiiiiiieiiZ=MENNENiiiiiiiiiiiiMONSON ■■■■■■■■.■■■■■■■■■■■■■..■■■■■■■■�'i■■i�■■■.■■■■■■■■■■■■■I.■■Illi■■■■.■■