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186 Shady Grove Lane Lot 714 311, `AUTHORIZATION NO DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pe; ,i/�P.O. Boz,848 Name 4 Mocksville; NC 27028 Subdivision'Name:, Phone #: 704-634-8760 r Directions to property: / ✓P Section:__. Lot: / AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# Road Name:ip: A 7046 **NOTE** Tbis Authorization for Wastewater System Conswctiion MUST BE ISSUED by the. Davie County Environmental Health Section prior to issuance of any Building Permits. This Fomi/Authorization Number should be presented to, the Davie County Building Inspections, Office when applying for Building Pemuts. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) j�� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION / IS VALID FOR A PERIOD OF. FIVE YEARS. „;ENVIRONMENTAL HEALTH SPECIAL IST:j;;DATE iSSUED '";� ':,'" ;,' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT NA 9 U U R O Davie County Health Department F Environmental Health Section Vq -5 1 P. O. Box 848 rust Mocksville, NC 27028 (7 -a., p,L I! (336)751-8760 ?'f ; f.'!!`-111 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS , I jr mALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed�aVen doe �on5 T1 iIr {-ftYl. n['- . Contact Persok� —Mr-) j — 7��� N Mailing Address FAD RnY 1;1q1:2( -)n Home Phone ` c?f-43q City/State/Zip A V n , 00 0-76(D6 Business Phone SCLrn c- 2. Name on Permit1ATC if Different than Above INFORMATION Property Dimensions: V. �7�6 / %0 X �.3r� t' a J 7� � Tax Office PIN: # t7`n-e y 5A,do �S - & Property Address: Road Name Vr',do &OUC ,Cane City/Zip A4—VCt.e'1Ge o27004o If in Subdivision information, as foil ws: Name: Section: 0)0O Lot #: 71 *** A PkA�THE PROPERTY MUSTBE SUBMITTED WITH THIS APPLICATION. WRITE DIRECTIONS (from Mocksville) 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 t and owned by &f) /1 9f"e- as necessary to determV,,ethsite suitability. DATE 5� S Revised DCHD (06-96) Department to enter upon above described property located in Davie County YOU MAY USE THE BACK Of THIS FORM FOR DRAWING YOUR SITE PLAN. conduct all testing procedures Mailing Address City/State/Zip . 3. Application For: -WI-ite Evaluation Improvement Permit & ATC ❑ Both 4. System to Serve: Rouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. ice: # People # Bedrooms # Bathrooms L :Zsbwasher❑ Garbage Disposal 13 Washing Machine ❑ Basement/Plumbing O B ement/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: 0' County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? INFORMATION Property Dimensions: V. �7�6 / %0 X �.3r� t' a J 7� � Tax Office PIN: # t7`n-e y 5A,do �S - & Property Address: Road Name Vr',do &OUC ,Cane City/Zip A4—VCt.e'1Ge o27004o If in Subdivision information, as foil ws: Name: Section: 0)0O Lot #: 71 *** A PkA�THE PROPERTY MUSTBE SUBMITTED WITH THIS APPLICATION. WRITE DIRECTIONS (from Mocksville) 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 t and owned by &f) /1 9f"e- as necessary to determV,,ethsite suitability. DATE 5� S Revised DCHD (06-96) Department to enter upon above described property located in Davie County YOU MAY USE THE BACK Of THIS FORM FOR DRAWING YOUR SITE PLAN. conduct all testing procedures DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION ✓ LOT . Soil/Site Evaluation APPLICANT'S NAME V� PROPOSED FACILITY SUBDIVISION d DATE EVALUATED PROPERTY SIZE ROAD NAME Water Supply: On -Site Well Community Public C� 1 Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG 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: A EVALUATION BY: 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 SII, - 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 tructure 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 MHD (01.90)