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758 Sain Road Lot 7..rvv; -vv .- .. -w�:1 � _ ., r.' _t _ �-- ��•-•v-- '"'"K^X.�.w''�^'�—e . zP•r-�--v.sv.1P:{,.-...-T-...-.�{. , �. M.,,. �.r - ... _. r,� 14 Peintitteer ,�, DAVIE COUNTY -'HEALTH DEPARTMENT Naive:Environmental Health Section PROPERTY INFORMATION ,�, P.O. Box 848 AIJ Directions to Property: Mocksville, NC 27028 Subdivision Name_ : 1 a Phone.#: 336-751-8760 i Section: Lot: i AUTHORIZATION FOR WASTEWATER Tax Office PIN:#" SYSTEM CONSTRUCTION - AUTHORIZATION NO: 0026,17.:A Road Name:. NO C Zip: 2-2020 **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 co Ii ce v ith, clerl I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) rzllljl_� .'l ^ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. RESIDENTIAL SPECIFICATION: BUILDING TYPE A _005'w_# BEDROOMS 9 # BATHS 3 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ��'j]� LOT SIZE ' /" TYPE WATER SUPPLY YDESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE --GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12- LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT - a. Ent CA; rJ C f6TI AA04lo)f fir. �� W-bTtk 1tj G 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. 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 IMA, 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. MW Lol Aye,9�99aoo�� Ntr. �o Pe�i yTtee'e DAVIE COUNTY HEALTH DEPARTMENT N�e:ti r Environmental Health Section PROPERTY INFORMATION P.O. Box 848 r.. r Directions to property: Mocksville NC 27028 Subdivision Name 1"j+ b Phone #: 336-751-8760 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION AUTHORIZATION NO: 002817 A Section: Lot: Tax Office PIN:# Road Name: 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 Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen -nits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) r : ` # 1 ^y ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIR(?NMENTAL'HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE i I QC � # BEDROOMS 0 # BATHS :" # OCCUPANTS Z`t GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No lx-AA,� - i ;; , LOT SIZE " �" "R`�TYPE WATER SUPPLY %(' 'DESIGN WASTEWATER FLOW (GPD)O NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH - LINEAR FT. -- < OTHER `r REQUIRED SITE MODIFICATIONS/CONDITIONS: ! ('' r, +r'�I` Fol )j) h,) 1'�"� r ~'yt:i 7 k.�I�- �` { . } tlj} IMPROVEMENT PERMIT LAYOUT -.� !_„t; a„i :. f -r:'1 -i, '-SYR `l�3�" -.- "`.�'.•.,... ~ r 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: 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 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BETAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD %OF TIME. DCHD 02/02 (Revised) Jl {�{?. J: L i' % G�O 7 —P �J 1� • 7 li^ ZL,i'� o � C� 2 � 2p01 Df ON-SITE WASTEWATER CERTIFICATION FOR DWELLING DAVIE COUNTY HEALTH DEPARTMENT ► Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 (Check One) REPLACEMENT ❑ ' REMODELING ❑ RECONNECTION ❑ Name: �&dq ..-u b b Phone Number: lq6 � �_Ao 7 q (Home) Mailing Address: d Aamd Ale (Work) 5 d -e— Detailed Directions To Site: L6 d `/ LO A O Property Address: '75 /N ��fit ��UdV '`AaW17P- uJao �,V/ l 20t z? &_4466 Lo f #' Please Fill In The Following fInf rmation/!A�/bout The Existing Dwelling: Name System Installed Under: �J� ��t T� Type Of Dwelling: Date System Installed(Month/Day/Year): 1461 Number Of Bedrooms: Number Of People: Is The Dwelling Currently Vacant? Yes ❑ No ❑ If Yes, For How LongZ Any Known Problems? Yes ❑ No ❑ If Yes, Explain: Please Fill In The Following Information About The New Dwelling: IVP B& /&Ai/V qk 6^(d Type Of Dwelling: lio #4) Number Of Bedrooms: Number Of People: Requested By: I For Environmental Health Office Use Only Requested:.e Z !v —o % Approved ❑ Disapproved❑ y �y / ('nmmonfe• I A i%%ii )t,:_.r1/�Yl P 's► PGi 1 i %S003 -b 1 I' 1 1 � 1 v &9V LAQC:..f Environmental Health "The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a euarantee(extended or limited) that the on-site wastewater system will function properly for any liven period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: r'm06 051 Invoice #: GoMAPS - Davie County NC Public Access Page 1 of 2 http://maps.co.davie.nc.us/GoMaps/map/print.cfm?CFID=11225 &CFTOKEN=54428949 10/31/2007 APPLICANT INFORMATION w�> Water Supply: Evaluation By: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Community Auger Boring r' " Pit PROPERTY INFORMATION Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH —Ho Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure $ - Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS �- RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION J LONG-TERM ACCEPTANCE RATE D. SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: L EVALUATION BY: 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wki 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 05/05 (Revisedl bAVIE COUNTY HEALTH DEPARTMENT z �= �IMPROVEMENTS 'PERMIT AND CERTIFICATE OF" COMPLETION *NOTE` Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c_ " ISewage 'Trgatment and.. Disposal Rules (10 NCAC ,10A .1934-.1968,) Permit Number, Name g Date 4194 •� Location Subdivision Name Lot No. 7 Sec. or Block No. " Lot" SizeHouse Mobile Home _ Business Speculation No. Bedrooms"' No. Baths No. in Familyf Garbage. Disposal YES ;E N0 Specifications,for,.System: Auto Dish Washer YES q NO < Auto Wash Machine S E] NO fl Type Water. Supply • n , *This permit Void if sewage system described below is not installed within 36 months from date of'issue. Improvements permit by ' `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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by • J � it ' Certificate of-Completion The signing of this certificate shall indicate .that the system described above has been .i stalled in compliance' with , the standards set forth in the above regulation, but shall'in NO'way be taken as a guarantee that the systemVill"function. satisfactorily fo,r,any given period of time:. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By —Business Phone 2. Address 3. Property Owner if Different than Above Address 67��/ It/ Qom. 4. Permit To: a) Install 'Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House rr Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensi Bed Rooms 2- Bath Rooms / Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures commodes lavatory dishwasher urinal showers sinks 8. a) Type water supply: Public /l Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions b) Land area designated to building site c) Sewage Disposal Contractor garbage disposal washing machine 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Cld 121 )-G Date — Address Lot Size 4 S'o. iJ 6j. 64-44-7 it ZIZI-M, FAr.TC)RS AREA 1 ARFA 9 ARFA .1 ARFA d Topography/ Landscape Position S S PS S PS U �j U U !) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S S -SPS S PS S PS U U U I) Soil Structure (12-36 in.) Clayey Soils S �S P S PS S PS U U U Soil Depth (inches) S PS S PS U U U U )Soil Drainage: Internal S� , 5 S S PS U U U External SS JOS PS S PS U U U i) Restrictive Horizons Available Space ,S t.r�J S PS S PS U �' U U 1) Other (Specify) S PS U S PS U S PS U S PS U I) Site Classification U—UNSUITABLE Recommendations/ Comments: S—SUITABLE QPS—Provisionally Suitable s—-------------------- - Described by ��l/ Title SITE DIAGRAM DCHD (6.82)