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659 Sparks Rdrte: a� AUTHORIZATION NO: l A 5 6 DAVIE COUNTY HEALTH DEPARTMENT vX o Environmental Health Section PROPERTY INFORMATION Permittee'.S - t ( P.O. Box 848 Name: Z7 La4�--Apfr-1 t1 IL'Lr4l" Mocksville, NC 27028 Subdivision Name: Directions to property:Phone #:704-634-8760�fi �`c`> Section: Lot: AUTHORIZATION FOR ap ,,A SYS�TEV CONSTRUCTION ASTEWATER Tax Office PIN:# - 0 i - s%80:Z- eA C - G dr C.'C."i ��,. U �l!•^ '� Road Name: ,�1�F14� I�+v' Zip: e�%6U(O f - **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 1.11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) r V a } �-- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION P r .' ✓ r.. ---�._ , `'(� IS VALID FOR A PERIOD OF FIVE YEARS. JIRbNMNTAL'HEALTIi;SPECIALIST DAT ISSUED I : DAVIE COUNTY HEALTH DEPARTAENT 'IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION 4 Permittee; s --' Name: '4 Directions to property: IMPROVEMENT � % i. r 3 � '� f. }.� ."f � r:'r3 #: 6 z ,. i :*•; r �� l j�.�. fir-" F, v f PERMIT ... ,�-�+-rti� x.tlet�i �� iW�1ti �.'. ) :�: 1'.I 1.._g/. ''4;' 1p`l. i (� .. �'�, I•,. n.r"f. Subdivision Name: Section: Lot: Tax Office PIN:#='?�1535 Road Name: ,�j f D — 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) 7 ***NOTICE*** TILS PERMIT IS SUBJECT TO REVOCATION IF SITE / '.-;•', i_. t' ; PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENT L HEALT%I SPECIALIST DATA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE -- INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE - t ;t irk # BEDROOMS 2 # BATHS ';-' # OCCUPANTS I GARBAGE DISPOSAL: Yes or Ioo COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ZMA5TYPE WATER SUPPLY 11)aLl..- DESIGN WASTEWATER FLOW (GPD) p NEW SITE ' �- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE G% GAL. PUMP TANK GAL. TRENCH WIDTH �-O ROCK DEPTH ?. LINEAR FT. -' OTHER 1 T Y"t 5TC. ! 60 T, -'\ 6 K REQUIRED SITE MODIFICATIONS/CONDITIONS: ,��?� b 4 - o ,�,) IMPROVEMENT PERMIT LAYOUT+ A K 4 "a "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 I;`_ \ IV SYSTEM INSTALLED BY: -:44=� Q-� " �� wo00� i�L ' AUT 0MATION NO. � OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT T M DESCRIBED ABO 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) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT Davie County Health Department C e ` Environmental Health Section P. O. Box 848 n J Mocksville, NC 27028 ((3'X60 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNL ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed A22��/—Gj'�'1 Contact Person I111i� Mailing Address C h Home Phone I I u -W y City/State/Zip C� �� e E'— %/ `-- �S "/�� Business Vnone 2. Name on Permit/ATC if Different than Above 4-- Z/ Ile(Z/-- Mailing Address /`%n � Gird �*ity/State/Zip �� 3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC 5y� Both 4. System to Serve: ,/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If R sidence: # People # Bedrooms _ # Bathrooms U Dishwasher ❑ Garbage Disposal Q]/ Washin Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing g P g 6. If Business/Other: Specify type # People # Sinks # Commodes If Foodservice: 7. Type of water supply # Showers # Urinals # Seats Estimated Water Usage (gallonsper day) ❑ County/City S Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** APJgkT0WTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: d, QC- • 6 6 WRITE DIRECTIONS (from 0EIlax Office PIN: `� - �� - 920 Property Address: Road Name X20, )r kS 74L - City/Zip %W& b d If in Subdivision provide information, as follows: Name: Section: Lot #: This is to certify that the information provided is correct to the best of my knowledge. I Mocksvillq) TO PROPERTY: . . . _ 12t-- l o7lt r5 ,,stand that a p rmit(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 as necessary to determine the site suitabilit, DATE Revised DCHD (06-96) � l n a % W 1`1 - to conduct all testing procedures YOU MAY USE THE $ACK Of THIS FORM FOR 15RAWINC7 YOUR SITE PLAN. I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 4N -d DATE EVALUATED l o PROPOSED FACILITYytoog PROPERTY SIZE SUBDIVISION ROAD NAMEg��s 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 % c HORIZON I DEPTH O —/v— D —P Texture groupGL L CL Consistence SS S V CTS P Structure CIA CIPZ� Mineralogy ! ; 1 ' 1 I' l HORIZON II DEPTH 1 fi t Co 14-50 Texture group C r Consistence Structure k Mineralogy1:1 HORIZON III DEPTH Texturerou -� $ S Consistence $ IC Structure S3 S6 t� k Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION j S LONG-TERM ACCEPTANCE RATE 0.4 o. 0.44 1 SITE CLASSIFICATION: (2-1Z) EVALUATION BY: ')� �-lh LONG-TERM ACCEPTANCE RATE: 0' OTHER(S) PRESENT: (�I►�'{�A� • 43,3 rn REMARKS: Lo Gam, �' (� &COD 51 �y2cS 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 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD (01-90) ■ ■ ■ NONE NEON SOME NONE SEEN ■O■■ ■ ■MEM■ ■EES■ ■ENE■ ■E■■■ ■E■■■ ■ENE■ SEMEN ■■N■■ ■■■■■ ■■■E■ ■■■■■ ■ENE■ ■EES■ ■■■ ■ ■ ■ ■■■■■■ SOMME■ ■■■NE■ ■ENN■■ ■■■■E■ ■E■■■■ ■MEMS■ ■ ■M■■MMMM■II N ■M■■MM■MMII ■ ■EM■■E■■!II■ ■EM■■EM■WIM ■MEM■■■■■11■ ■MMM■■■■MIUI ■■■■MONE92111 ■■■■■■■NIIII■ ■■■■■■■I■1III ■■■EEE/MM1I11 ■■MME/IO■E1111