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181 Shady Grove Lane Lot 16,.. 'r`�'t'F'xS•di':'Tb+*v R'N'i jlYpv 1 Yi ati ^`l R.t"Yt$.,ivtt r•,+s", x av o -_ ,._ a•„ X0� ' 01.6 Z� AU'� IIpRIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Periiuttee P.O. Box 848 � Name ted.�Fjd (Ce�.[du� : Mocksville, NC 27028 ' Subdivision Name: I " Phone #: 704-634-8760,' Directions to property. ' r n Section: : AUTHORIZATION FORWASTEWATER Lot:', , SYSTEM CONSTRUCTION Tax Office PIN:# .�Z�. Road Name• t ' 6ip: C2 to 04 . . 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 witli'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 YEARS ENVIRONMENTAL HEALTH SPECIALIST >' :DATEISSUED .�:-r s 'li 4YT^r.`n :. �t•y' - ,"+kASry,vx y+;'•.Nn rxh dx�,It,May YwW+•.,•... .-.,rrr. ._ ... .✓.r....,..�!/(/' 016 DAME COUNTY HEALTH DEPIRTMENT �' G / 7 IMPROVEMENT AND OPERATIO�hPERMITS . PROPERTY INFORMATION -FNae Subdivision Name: Directions to propertyar�i+/7r ",.,,+r %Ry Section: Lot: IMPROVEMENT ;d PEST Tax Office PIN:#,ACr? – W - Road Name• r 4 P' ' ..:N 'p: Iyeez x. **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 building petrint. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE H INT PERMIT IS SUBJECT TO REVOCATION IF SITE ,y, �" 1�. 7,z:/! /Y�: ° • �'_ ,j -�� PLANS OR THE INTENDED USE CIiANGE.':YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST.' DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 33 RESIDENTIAL SPECIFICATION: BUILDING TYPE S BEDROOMS IT ' # BATHS -1 # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No COMMERCIAL. SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLE/SHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No LOTSIZE-9fZL TYPE WATER SUPPLY 1h DESIGN WASTEWATER FLOW (GPD) yf4 NEW SITE L/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE, DP- GAL. PUMP TANK GAL. TRENCH WIDTH (5/ ROCK DEPTH LINEAR FT. d O .. OTHER — - 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 (704) 634-8760. OPERATION PERMIT STALLED BY: �A,3t. V 1-) R raltws/1 . . - IN r >o 10 -. o fU it STon1� S - 1L frt9aT AUTHORIZATION NO. I OPERATION PERMIT BY: 71 DATE: "*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S STEM 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 NOWAY BE TAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. - DCtm0196 (Revised) - APPLICATION FOR SITE EVALUATION/IMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704)634-8760 D [Ec��o�r ^1 AUG - -81997 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed `, . 1—]M qCk COW ST . a -A C_ Mailing Address % � P 1ceo 1 ew 2s:> City/State/Zip Q otl�� me— 2702'K 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person 'Jas p -o a)q!] C JZ - Home Phone q l b - 9 9,R- - a 6 I's- Business s Business City/State/Zip 3. Application For: [ ] Site Evaluation 1-] Improvement Permit & ATC 4.. System to Serve: [House [ ] Mobile Home 1 [ ] Business [ ] Industry [ ] Other [ ] Both 5. If Residence: # People # Bedrooms --3— # Bathrooms g X] Dishwasher [ ] Garbage Disposal X] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: K County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes b<j No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** rY7FL�OF THE PROPERTY MUST BE 1SUBMITTED WITH APPLICATION. Property Dimensions: 1 twee /t, rr'%e&f71 i WRITE DIRECTIONS (from ocksville) TO PROPERTY: Tax Office PIN: # 98 3S -fJS3S �°�E A7nie#Fri Property Address: RoadNamtt��tlU e`` S�ki RT4 131LUV@ VgKv- City/Zip RM Ce Q . 47006 If in Subdivision provide information, as follows: Name: Section: Lot #: 16 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 conduct all t5ong procedures as necessary to determine the site suitability. Revised DCHD (06-96) THIS AREA MAY BE USED FOR DRAWING JOUR SITE PLAN: hr ra, f 'c10,i it 7A -NN Al L ; t I '.�•. a Jp , �, 4(` •��t+,i S� ', � '•',�'J \�f .�q� t- 0 1' r 011 ^ / 4 01�p �y � i '� � ep I Ifi .l � � SJ. � �r � y•, �V '' w a4, / / O � E M, • , iF ,`�' /bb r'C9i ,, Han l9 'o.. /,1 !'•rin'I Y� .� � N"" s J a�uP ~I I aN� ti s q o t,_ I �j• I I b ,,/' v Y� iii a 1 S^ h'III JI M RAI 70 ?09.79 __ Y •g~�t '- A -"� N +t� ,; � f� 'i•,n � y43 7J 1 �,� I i� .. -- e, 1' 0,. �N� �.:. a/-��(/)yj Ar + tt ir.�,�'�� 8 ,,,;., v, . /�/ / P ,{, �' / �.. / / y4' ,. SOC + • ,• 1 i,��` I •Je' 490 • f ; .40 84 Y��'�'1' ' �i'� �i+ + I t 11 ./'' \/ � � 0, '. /�•" S uo ;i Hyut) a '!+ "••Gr/ i OyOb` � �. �G4N{,7y�, �� t �}tt, f / y /1, / Isip i /'" ' �'. / �� ,�/%: S a4�JO 0 ,' l/,ll�'•��\�.rllt'��."��r yya� y�l• '" ��• , �/. t�. ' /f'_:'./ ,p'. Z'. 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NAMEcli ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED PROPERTY SIZE LOCATION OF SITE-5�� Gr�✓e Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit fCut FACTORS 1 2 3 4 Landscape position L Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Gf V /- 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 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:1/ LONG-TERM ACCEPTANCE RATE:- t REMARKS: Landscaoe Position EVALUATED BY: OTHER(S) PRESENT: LEGEND 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 r:lay 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 -Finn 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 chrome 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ftz DCHD(01-901