700 Deadmon Rd Lot 1 s�,�a.a_ Y;r{°': -i,'•.(�.^'�':'�YY }1 '��`I i"1.:c�F. 'r b e.v rr .✓.... +s•; i._- _ .. --- - '�,
p a _` ,.i w t .t�� yk P aK, <tl ;� t"� - "ttt ,�:y.Y , n n• w. -«..�.5
AUTHORIZATION NO: $ ' DAVIE OUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's ....,�, P.O.Box 848
Name: t`���'�"°. , r' Mocksville,NC 27028 Subdivision Name:
/ Phone# 336-751-8760
Directions to property: 'Section: Lot: T
AUTHORIZATION FOR rs �.,t
WASTEWATER' Tax Office PIN:# fcot :
SYSTEM CONSTRUCTION
Road Name: ' hoz-
P —
**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 withArticle I I of G.S.Chapter 130A,'Wastewater Systems,Section.1900Sewage Treatment and Disposal.Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
rSfj(• ? %,'f /`%l IS VALID FOR A PERIOD OF FIVE.YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
tiyys,rnr'�w;•",'.'a'S-�Tr��..r,.,,y.-; i-ii rcise ,iw�.«{ �,�'«,'',�.:�*`n��.a:+n-`4i J `'"i;;�n..yi...t}:-r' ..�cry F;;�'q•�sx-.�a 's+!^ `*t'"" _ -..,T,� ' �,.. .- ✓ -.
18 ' DAVIE OUNTY HEALTH'DEPARTMENT
. "' IMPRO, EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's.
Nariie .,. .+ '' • Subdivision Name: S fes' A,04. ve
Directions to property:
" Section: Lot:•
IMPRO y
PE Tax Office PIN:#•
Road Name:
**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 DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE '
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS _#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE' S TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE !/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK ` GAL. TRENCH WIDTH,.]�_ ROCK DEPTH LINEAR FT.&'a
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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:
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)
r saY",Fy. h.. "�,Y1 'F�%',Tr..art r+;:y} t.4,!t:y"-mwr`w.r'Q ��• ... .. - .. .. ,;y t :y•., r „
18 15 DAVIE COUNTY HEALTH DEPARTMENT
r .•�-'""
IMPROVEMENT AND OPERATION PERMITS PROPERTY I ORMATION�
Permittee's ,
Name:`- 1-' �. ' � Subdivision Name:
Directions to property: �` r-' Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name ; Yin�'��` '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***THUS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE-y`�` #BEDROOMS #BATHS _#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE ke0 REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/L�GAL. PUMP TANK_GAL. TRENCH WIDTH:?e ROCK DEPTH e/ UNEAR FT.ti G`U
s. OTHER
r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
"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:
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 I 1 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05196(Revised)
APPLICATION FOR SITE ENAWAMON/IMPROVEMEN1 PERMIT&ATC
Davie County Health Department
Enviranmenta/Hea/th Setion
Q
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 NOV 2 5 19M
(336)751-8760
***ZHP0RTA1ft'*** THIS APPLICATION CANNOT BE PROC SSM UNLESS ALL THEUMN
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for ons.
1. Name to be Billed STEy�� ����5/ Contact person 5TE`�/C •cT ?rIQ�S
Hailing Address ���rlP/j//� /ri1�///T//j�,/ em, e� Home Phone J��O 999 — 0-1 3
city/state/ZIP /!'/OGA�J ,'Ile it /f I e, 7-70 Z Business Phone 3�(0 - 2��4- VV-(9/
2. Name on Permit/ATC if Different than Above `--
Hailing Address City/state/zip
3. Application For: U Site Evaluation wli;prcvement Permit/ATC 0 Both
e. system to service: 11 _
House Mobile Home ❑ Business 0 Industry 0 Other
5. If Residence: # People _ # Bedrooms 3 # Bathrooms z-
0 Dishwasher 0 Garbage Disposal Q N hing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/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 0 Well 0 Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes G,4-0--
If
,4-0If yes,what type?
***IMP0RTAN7***CLIENTS MUST CVMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION.
13
Property Dimensions: //8,03 - 2410.57-1S3.Z 0-Z WRITE DIRECTIONS(from MockMlle)to PROPERTY:
Tax Office PIN: # 57'Y-7 82 - 38Z -P) 60/ S - % 7��iio�/
Property Address: Road Name PERQAIy6t�
City/Zip10C/CS(//GLE;
Z?oz 8
If in a Subdivision provide information,as follows:
Name: (�U57 ?/S ,Fey"t/
Section: Block: - Lot: Date Property Flagged: l�� z 14-9e
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 He tlth Department
to enter upon above described property located in Davie County and owned ky._111!'
to conduct all testing procedures as necessary to determine the site suitability.
Xs"
DATE ��— Z 3 — 98 SIGNATURE
4,11—
THIS AREA MAY BE USED F'OR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No.
Revised DCHD(07/98) Invoice No.
X30 6�
LOT #4
AREA = 0.691 ACRE
0
o 0.0,9
CD
2 118�3 •
LOT #3
AREA = 0.872 ACRE
Cyti
LOT #2
AREA = 0.700 ACRE �c
LOT 1 - - -
84'4S AREA = 0.857 ACRE �n i
O ti
I k
k
r
1 S3 c'0
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental Health Section l5
P.O.Box 848 D
Mocksville,NC 27028 JAN 1 3 R
(704) 634-8760
' ****IMi'ORTANT**** THIS APPLICATION CANNOT BE PROCESSEA
THE REQUIRED INFORMATION IS PROVIDED.
i, 1. Name to be Billed / �� '��'L ���5 Contact Person
" Mailing Address l 2 ,(JiU4 G L/ 5? �C-� . Home Phone
City/State/Zip�I�OC,CS[�/��t% , �//�G�, z'OZ� Business Phone
' 2. Name on Permit/ATC if Different than Above
` Mailing Address City/State/Zip
3. Application For: [ ite Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve: [douse [r.]-Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage.Disposal
[ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Busiaess/Other:Specify type #People #Sinks #Commodes
#ShoN,--rs #Urinals #Water Coolers '
f. l i
�. If Foc .-service:#Seats Estimated Water Usage(gallons der day)
7. Type of water supply: [1,]-County/City [ ]Well [ ]Community,
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No
1
t If yes; (ihat type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPQRTANT***'XMyI'OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: l �Q-�(�" '� WRITE DIRECTIONS(fro Mocksville)TO PROPERTY:
T Office PIN: # 5 21117 - 9?-
Property
ZProperty Address: Road Dame ` k� IN67i/ 4l-X 0"/71/ a&
d City/ZipG>��Sl�/L-G�
i If in Subdivision provide information,as follows: ��
Name: 4 0 S T�/L `� sept./(/ _.
Section: 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 tr :uspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
{ changed., also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized �
y RepresenWative of the Dave County Health Department to enter'-upon above described property located in Davie County and owned
by ju'C to conduct all;testing p ocedures as necessary to determine the site suitability.
DATE^ �'> g SIGNATURE
Revised DChD(06-96)
THIS AREA MAY BE USED FOR DRAIVINC YOUR SITE PLAN: `^' N
'V
Tf
H r
1
Y - _ , � � �
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT_
Soil/Site Evaluation
�I t�inr
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION �s�c>'�n ROAD NAME .DE6e'Oii� „I
Water Supply: On-Site Well Community Public t--"*'
Evaluation By: Auger Boring Pit 2 Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L ` .4-
Slope
4-Slo e%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group eelC
Consistence r-
Structure s A:-
Mineralogy
:-Mineralo
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 L
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: /
REMARKS: z — 51SC Fly%-- r�'�✓
4EGENEF
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 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■M■■■e■M■■s■■■■■■■■■■MM■■■■■M■a-.pec■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■■■■■■■
MENNENMENNEN ' �MEMNONMENEENflosommumMOMMEM
■■■■■■■■■M■■■■M■■■MM■M■■■■■■M■■M■■■■■■■■■■■■■■■Oce■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■MMM■M■■MM■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■MEMO
■■MEMEE■■EE■■MEM■E■■EM■EE■■E■■E■ ■■■EEE■■■E■EE■MEM■EE■■■■■EEE■■■■
■■■■■■■■■O■■■■■■■■■■■■E■■■■O■■■■■O■■■■O■■■■e■■■■■■N■■■■■■■■■■■NEON