P1812 Cookson Lane Lot 5AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name: _ !a ��`" -fid Mocksville, NC 27028. Subdivision Name:
�/. Phone # 336-751-8760
Directions to property: t G < /cf�✓ s^-� Section: % Lot:
f AUTHORIZATION FOR , .
(�C WASTEWATER Tax Office PIN:#Av-
��.
' -.
SYSTEM CONSTRUCTION
Road Name:—/. �a��,.'�Zip: r
**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 .1900Sewage Treatment and Disposal Systems)
r- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
! l ` ♦ f "� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH S KCIALIST DATE ISSUED
1812 DAVIE COUNTY HEALTH DEPARTMENT
.�IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: �t r,.rk�? .11 r?, ,.: 1A/ Subdivision Name:
Directions to property: Section:
/ Lot:,.,. o -
IMPROVEMENT
Tax Office PIN:#- 'r -
PERMIT d�
RoadName: z .ri/'.��1 Zin:
**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 SiIECIALIST DATE ISS ED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
/,IN STALLING THE SYSTEM.
r
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 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH —2;< ROCK DEPTH,z_ LINEAR FT:_Y
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:
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)
1812 DAVIE BOUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittees
Name: Subdivision Name vi: .;°�
r;� r
Directions to -property:
Section: Lot:
IMPROVEMENT J �~
PERMIT Tax Office PIN:#'''
Road Name:v., 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/instaIlation 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 _ # BEDRQOMS — / # BATHS / # OCCUPANTS —_/—GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE �.�il PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY !� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE �lil/U GAL. PUMP TANK GAL. TRENCH WIDTH ?�ROCK DEPTH LINEAR FT;
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
Q
**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
AUTHORIZATION NO.
OPERATION PERMIT BY:
SYSTEM INSTALLED BY:
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 05/96 (Revised)
APPLICATION FOR SITE EVALUAHON/IMPROVEMENt PERMIT do A
Davie County Health Department
Envftnmenia/Health Settfon
'. P.O. Box 848/210 Hospital Street NOV 2 3 19%
Mockaville, NC 27028
(336) 751-8760
ENVIRONMENTAL HEALTH
***IlWt7,RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed (I - r bc2k�o AJ Contact person 7 / P/i�iYJ ( dISI-)dI
Mailing Address L��Q /f� �',( g!�/ R L) Home phone '7 9
City/State/zip ) i , Y�f�{W7 Oltii �� T/Business Phone
Z. Name on Permit/= if Different than Above
Mailing Address City/State/zip
3. Application For: 0 Site Evaluation Improvement Permit/ATC 0 Both
4. system to service: House 0 Mobile Home 0 Business 0 Industry ❑ other
s. If Residence: # People 1 # Bedrooms _ -Z # Bathrooms
Dishwasher 0 Garbage Disposal trashing Machine 0 Basement/Pluubing )dBasement/No Plumbing
6. If Business/Industry/other: specify type # People # sinks
# Commodes # showers # Urinals # hater Coolers
IF rOODSERVICE: # Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: 0 County/City I't Well 0 Community
e. Do you anticipate additions or expansions of the facility this system is Intended to serve! 0 Yes >No
If yes, what type'
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PIAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: RC'12za WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: #%f,� fc�� `" 7-1
Property Address: Road Name 44 to �d P�
City/Zip Z �f�C�t►s �w E
If in a Subdivision provide information, as follows:
Name: 4f11�1 L°- rGLs
J Z
Section: Block: Lot: 5
Date Property Flagged: / / -of 5 70V
This Is to certifv that the information provided is correct to the best of my knowledge. I understand that any permits)
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 ani responsible for all charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health De artment
to enter upon above described property located in Davie County and owned by s�yj o- r -CL C' _ ��► o k5 d
to conduct all testing procedures as necessary to dete f&- u -i a tme'late suitabilijy. s _
DATE I I l -o{ J`\`7 a SIGNATURE
THIS AREA BE USED R DRAWING YQUR SITE P (Include all of the following: Existing and proposed
property lines dimensions, ructures, setb -. and septic 1 tions).
t/ J
� J �
Account No.
Revised DCHD (07/98) Invoice No.
i
i
to
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address _ 10 9 ,�
5
Home Phone sil
Business Phone
2. Name on Permit if Different toan Above
3. Applical on t x: General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly
a 6-9142anL
❑ Business ❑ Indus ry ❑ Other ❑ Unknown
5. If house, mobile home. Subdivision 7Section Lot #
No. of People _
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Sinks _
No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public ❑ Private
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ No
❑ Community
"NOTE: fmpn" ments-Permio-shalt-be-valid-feF-a-pefiied-ef-b-yeas-frer late-isetred. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989. 1 1
Directions to Property:
60
�tj.'t -
n / �� u
PROPERTY INFORMATION REQUIRED:
Tax Office PIN #
Road Name Q v
Box # (if availabl
city `oj& f Y!G
This is to certify that the information provided is correct to the best of my knowledge,
interred from this application.
TE
for all charges
4'
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. L� 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized repre native of the ie o t ealth Depart nt to r p n above descr' ed
property located in Dav' ) County and owned
to conduct all testing I)rocedures as necessa j date ine sa' site's uitability r a ground a sorption sewage treatment
TV disposal system.
DCHD (1/93)
TE
SIGNATURE
�A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section 7 S
Soil/Site Evaluation
NAME �t%C'SL7Y�
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE AOA el
LOCATION OF SITE
Water Supply: On -Site Well t/ _ Community Public
Evaluation By: Auger Boring f/ Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence l -
Structure h
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: �S
LONG-TERM ACCEPTANCE RATE:—(X
REMARKS:
DCHD(01-901
EVALUATED BY: �Ida //
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 <;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+.. -y 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
3C --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
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PARCi _ I
PAUL Y HENDRIX
D. B. 75-281