The URL can be used to link to this page

125 Tom Crotts LnP Permittee's D _ VIE COUNTY HEALTH DEPARTMENT ` Name: t Y' i'� G +�-') Environmental Health Section PROPERTY INFORMATION <' L //,, P.O. Box 848 Directions to property: �� v Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 _ Section: Lot: _ J ) AUTHORIZATION FOR //115 �Cr �0 `� WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION t; ti -k C:, P -.-l I �: f S (- AUTHORIZATION NO: 00297,14 A Road Name: Zip / `0 -� 776�i ,,6 **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 I,1 of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) . i ` r 0 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FORrA PERIOD OF FIVE YE RS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ` b � , ,1 vI ^' d 'd C1 t CA RESIDENTIAL SPECIFICATION: BUILDING TYPE :5 # BEDROOMS � # BATHS # OCCUPANTS 4Y GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS; INDUSTRIAL WASTE: Yes or No rY ( / -r 5 r ;7 (G1 • 7,'0 � u f � "�o ir. /366 LOT SIZE TYPE WATER SUPPLY r� DESIGN WASTEWATER FLOW (GPD) / NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK / -AGAL. TRENCH WIDTH ROCK DEPTH 'j' LINEAR FT. ( " As stated in 15,4 t24C 9UAAC"3?(5 OTHER cccco:cd Svotcros inav info b�, lisr,(� REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT r I I 1 1 � I s FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: Kik 34 3i 11006q_0� z► kBY:j/,*1',4L� AUTHORIZATION NO. OPERATION PERMDATE: r V " —6 "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. DOW 02/02 (Revised) b d Pennittee's1 i DAVIE COUNTY HEALTH DEPARTMENT Names=^s' Environmental Health Section ?' P.O. Box 848 PROPERTY INFORMATION Directions to property: / Mocksville, NC 27028 Subdivision Name: .'„ ..., t, , ` f , l�/ �.� Phone #: 336-751-8760 ! Section:” Lot: 1 / AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO: 0 0 2 ` , A Road Name: � 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/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 YE RS. �.s ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED` - s RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEAT'S `_ INDUSTRIAL WASTE: Yes or No .2 ��IC� i ��«% ��, 4,/ 3G6 %7U % LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE t/ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH';' LINEAR FT. �`7 r REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT j ti f j i5�h�ty / i FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: IBY:., AUTHORIZATION NO. �` OPERATION PERM = DATE: ll "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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 02/02 (Revised) 0.. .- ' � DAVIE COUNTY HEALTH DEPARTMENT' ` `p Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT V REMODELING ❑ RECONNECTION ❑ Name: (1, 07yu Phone Number: (Home) Mailing Address: /.2.5 %d.49 �r c � �,¢ NG S -3n - _79 _ /-Slly _�Lll (Work) Detailed Directions To Site:�/ S % ��/" �r�� %% Property Address: /.?J_ % In 4i a7YJ IX .y E' Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: &rR/% 407'1S Type Of Dwelling: Date System Installed(Month/Day/Year): 5J'/ 9j Number Of Bedrooms: 2- Number Of People: z. Is The Dwelling Currently Vacant? Yes ❑ No ®'" If Yes, For How Long? Any Known. Problems? Yes ❑ No fl^" If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: AZvte-- T Number Of Bedrooms: 3 Number Of People: �4 Requested By:, Date Requested: 3 -35'2 -92 For Environmental Health Office Use Only Approved 9'' Disapproved 0 Environmental Health Specialist Date .✓1�'�.�-_ __ Date 'The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ®Money Order ❑ # 2 74 _3 Amount: $ Date: � 2/) '12 Paid By: 1 _, _v1 t t- t ' Received By Account #: 1' i' Fi �� Invoice "e AUTHOR4iF.iftbN NO: 1942 DAVIE CUNTY HEALTH DEPARTMENT Tnvironmental Health Section PROPERTY INFORMATION Permittee's «•'J �af ;P.O. Box 848 Name: d' 1"75 '&S Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to roperty;i%i �. `, Section: Lot: AUTHORIZATION FOR r f WASTEWATER Tax Office PIN:# tr `�,/-• % SYSTEM CONSTRUCTION ``'�' 47 -- Road Name r'=i1';1 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/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.] 900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ✓ t.�1942 DAVIE CPUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS ' PROPERTY INFORMATION , Permittee's 'Name: f" 1,7 �'./ ri . ` Subdivision Name: j Directions to property: ` • r Section: Lot: IMPROVEMENT PERMIT Tax Office PIN: `#�."�'�'�- ) ***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 1A # BEDROOMS _ # BATHS 2 # OCCUPANTS � GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE C TYPE WATER SUPPLY 1,Ve- DESIGN WASTEWATER FLOW (GPD) �//) NEW SITE "'/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE c% 0 GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTHz LINEAR FT.Jd�) ` OTHER ;211 del- `! ( d1r REQUIRED SITE MODIFICATIONS/CONDITIONS: "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: l AUTHORIZATION NOI O y2 OPERATION PERMIT BY: DATE: 7 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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) APPUCA110N FOR SITE EVAUlAl1ON/IMPROVEMENT PERMIT & AT Davie County Health Department Enviivnmenial Health Seclfon P.O. Box 848/210 Hospital Street JAN 2 11999 Mockaville, NC 27028 IM (336)751-8760 ENVIRONMENTAL HEALTH ***33MORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED --T INFORMATION IS PROVIDED((. /R�efejr.�-to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �' , /pyJ C(b'' 1 S Contact Person Nailing Address X1340 N )M r, ,, ll � /J� � Home Phone � (p - 7 51 137 Op City/state/ZIP l "(OGCSN t �1 e, . meyl ofZ F Business Phone 3's(, 2. Name on Permit/ATC if Different than Ab— __&t Nailing Address _ . 346 Al M G.n S+ City/State/Zip 1"l W ke'Ui lle Uc ?qo2 6 p 3. Application For: (Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: 0 House &'Mobile Home 0 Business 0 Industry 0 Other S. If Residence: # People 2- # Bedrooms Z # Bathrooms -2- 0 0 Dishwasher 0 Garbage Disposal lrxashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Rater Coolers IF FOODSERVICE: # Seats Estimated hater Usage (gallons per day) 7. Type of water supply: 0 County/City 0v'Well 0 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? &-Yes 0 No If yes, what type? ,N'� fM tel, 4-a b,,JJ e, Xoy-S-P I oA W 3 ***IHPORTANT*** CLIENTSIIIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: q Gt/tQS WRITE DIRECTIONS (from Mocksville) to PROPERTY: -V, Tax Office PIN: # �1 y b ' Lc'7 - 46 Z P doo 401 Let+ eve r-c�rnay. �Ci.. iTo Property Address: Road Name 1-6m C• i vt• rjyy,'Va _-o en ahDj City/Zip I bnk.Svj `fe , OC V102e -}D %Dyv, C. Ln. r-Tj y y� If in a Subdivision provide information, as follows: ctzwy< <i1,v we Name: et i v�� e �c Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best or 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 J ani reVensiblefor all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the D 'e C rat a th Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 2U �J � R�^-��, ct'R SIGNATURE XTHIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimeusions, structures, setbacks, and septic locations). 3&3. (aD �� N_ r � c� _ a (�► ` I+ouSR � �3zq.01 Revised DCHD (07/98) Account No. Invoice No. 3 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY SUBDIVISION PROPERTY SIZE le`4 C ROAD NAME / i ZA Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r ✓ Structure S Mineralogy` l 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: s '{ LONG-TERM ACCEPTANCE RATE: X REMARKS: LEGEND DCHD (01-90) Landscaue Position EVALUATION BY: A_e OTHER(S) PRESENT: 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 MEMO ■EM■ ■E■■■ ■■■■■ ■E■E■ ■■O■■ ■E■E■ ■E■E■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■