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130 Starr Lane Lot 12UTHORItAlION NO: 0 8 9 8 DAMM COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pet2;i tree s 1 P.O. Box 848 t Name: Q oY0 R N e' - ��"\ �13� +t 11. q�� Mocksville, NC 27028 Subdivision Name: \ i1 Phone,#:704-634-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER LLq SYSTEM CONSTRUCTION Tax Office PI�N^:y# b - Sri 1 I fu 1.� tee.c�s sem-.a Road Name: J ` R�tY �N Zip: 10 D (a **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 l l of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systertis) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.- ), . ENVIRONMENTAL HEALTH SPECIALIST ,, DATE ISSUED zx .> r ,��,,r,,.�rv`, -^w � �'-:>k...,w.,_-�y-�-,:�-vr•n�,Maf;.„ror�.�.,rrn-,..,, �-.,J.-�'�1'Q + ° DAVIE COUNTY HEALTH DEPARTMENT n! T ' .`• IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION rY Naim epi trr� �t ti��'C C� N Rs ft. n t' Subdivision Name: ` Directiapstoproperty: "^ L;1 %U15 - Section: Lot: (- '(` .;... 1 - IMPROVEMENT - - Lv.�C'i *ys•n��iYs at 1� ; .? ,yLL PERMIT Tax Office PINA133 - Road Name: ��FIE'.<a F,ra Zip: .h UUiC **NOTE** This)Iinprovement Permit DOES NOT authoriie the constriction or installation of a septic tank system & any wastewater system An AU I I ORIZATION FOR WASTEWATER SYSTEM CONSTRUCITON must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pemnt. (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, INSTALLINGTHE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE ij—DS¢,# BEDROOMS # BATHS -�L # OCCUPANTS QL GARBAGE'DISPOSAL: Yes de COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE'_ # PEOPLE/SHIFr R SEATS. - INDUSTRIAL WASTE: Ye's or No LOT SIZE4.s-'.TYPE WATER SUPPLY w DESIGN WASTEWATER FLAW (GPD) bU NEW SITE V jREPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �U D GAL. PUMP •TANK - - - GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT ,':OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: N'^�• "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'. - - .. O ` 'SYSTEM INSTALLED BY: tipsa�d�.. \`\ F Al a qa� _qAUTHORIZATION NO.O D \� Od.J�J�7 DATE: '91-1 1 **THE ISSUANCE OF THIS OPERATION PERMITSHALLINDICATE. 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 BETAKEN ASA " GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.. - DCHD 05/96 (Revised) F 5 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC j Davie County Health Department lo' 00 1(!P Environmental Health Section / P.O. Box 848`/,A Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** �I THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 00AIA0E Contact Person O7o'AJ o4l-7 4fili- CASA Mailing Address 7 7 .�" M4050,5 S 5 i ouLd Home Phone 74 N^ City/State/Zip C'A.Cf r --VA Z-21 otlG -;7r$6S5-- Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 130 5:13dg 4Qefw9 City/State/Zip 3. Application For: DeSite Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [ ] House [JI] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms --,a-- # Bathrooms-- [� Dishwasher [ ] Garbage Disposal [)o Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/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 &N Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes Rj'No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A"I"LWOF THE PROPERTY MUST BE y1 SUBMITTED WITH Tj 111S APPLICATION. Property Dimensions: ti • S'a G ; WI T F DIREQ;IONS (from IMockfville) TO PROPERTY: Tax Office PIN: #I7%ta - - -53 -.3 q46 z1,'d I L:r -r,4' Property Address: Road Name l_30 n --AA /..fl t;5' .5,--A 649 city/zip aoPEiLT K :ry rt rU If in Subdivision provide information, as follows: �p P6TI S �1=iceL7 f+ S . Name: '544 fQ�0 I;q G/LF3 nn�aSection: 4` 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 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 DO lk Y -'E 112 VCi 1 Yom- to conduct all testing DATESIGNATURW Revised DCHD (06-96) THIS AREA AtAJ BE USED FOR DRAWING YOLR SITE PLAN: necessary to determine the site suitability. 9'' aR D /,.Of c _yNs �- Iron- $ 2 23 E—'– .ron found _ _ 6 --►45_g _ Ploced — -- — — 523.59 90 65 _ 0, on ° e 0.888 ACR S Si, _ 946.73 - _ E w CIS S 396 62 { LU C6°_ 35 55'w ,y PA CL`: r> l3 3 IRK cv tl . W WN,-. O_ - , ' a u s•, ?.e Fol ' . .. 94i 2 - ; �.�� � C R P 2 co ( to30 S. Ft.1813 1 toscm end-- c� 50 Iron Ptocetl S 14° 6'_30 • —\ Sp - 29 v9 S3 0 7.3- il k / may.' .•an - _ - �_ ib'D i Pin 7�l v 0,7� 59,_ w - -<�!S If20 y 3 .� r `�� oti1 38.89. S /Oo ` /o S F Ty l g Po`rni x'` pont �l (s ` p�`.�2 s6c\ yV "e \SS p _ - Poy t f \ a N % o� ss, sas`" 3.003 gCR % i x pm � '.S 5' V" 3 4 ES ry n 'point _ °, �84-15. 3 263 ACRES �NC710 t S 74"-58 cl cl)E -rot r / - _ - �14-28, po� d a ° t,) % /Do,nt ? �co rn l i N POIn , v N 3 . �® ACRES DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 1�`` ' ��ti DATE EVALUATED \ ` 1 PROPOSED FACILITY �c `� s PROPERTY.SIZE L1 IZE SUBDIVISION ✓Q''�%��� ROAD NAME 5_'S �gIAN� Water Supply: On -Site Well V Community Public Evaluation By: - Auger Boring ✓ Pit Cut - FACTORS 1 2' 3 41 5 6 7 Landscape position Slope % Com- a O -$a. HORIZON I DEPTH Texture groupL. Consistence 'z - T _ Structure - Mineralogy 1 \ HORIZON II DEPTH 4 W, Texture group (Z C Consistence F Z Structure �6K Mineralogy HORIZON III DEPTH Texture group Consistence Structure - Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralo SOIL WETNESS 5 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5. LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ' S "- ` EVALUATION BY: c Sys" LONG-TERM ACCEPTANCE RATE: \ — \ — p OTHER(S) PRESENT: 0 D N R _REMARKS: 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 - Veryfriable FR - Friable FI - Firm. VFI - Veryfirm 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) 0 0 0 " APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section wr P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 [I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed [— O� G t J Contact Person Mailing Address Home Phone City/State/Zip ,%Z) ✓ A (Vt6& A/0- Z') oA 6e Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ rSite Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: ['� douse [ ` <0bile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms-- # Bathrooms . [ ]Dishwasher'[ ] Garbage Disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/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 [&T1 ell [ ] Community �� 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes r) iso Tf vre what tvna9 - - - PROPERTY INFORMATION REQUIRED: *** I RTS Property Dimensions: Tax Office PIN: # 0 Property Address: Road Name Citymp If in Subdivision provide information, as follows: Name: Section: Lot#: EITHER A PLAT OR SITE PLAN *** XTA7RWOF THE PROPERTY MUST BE SUBMITTED WITH TMS APPLICATION. tITi, DIRECTIONS (from ocksville) TO PROPERTY: 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 Health Department to enter upon above described property located in Davie County and owned by conduct all Jestipg'pr gedures as necessary to determine the site suitability. DATE—2 •-.�Z L -zg*77 Revised DCHD (06-96) THIS AREA AIRY BE USED FOR DRAWING YOUR SITE FLAN: DAVIE COUNTY HEALTH DEPARTMENT ,i Environmental Health Section SECTION --L— LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION / ROAD NAME Water Supply: On -Site Welly Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2- 3 4 5 6 7. Landscape position Slo e % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON n DEPTH ti P Texture group Consistence r r Structure c 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: EVALUATION BY: t LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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 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 OR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 -tern acceptance rate - gal/day/ft2 DCHD (01-90)