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196 Shady Grove Lane Lot 81.j, _ �� DAV Environmental Health S .. . Petnuttee's COUNTY HEALTH DEPARTMENT * .;I-ame: ection PROPERTY INFORMATION P.O. Box 848 FhD Y C Directions to property: Mocksville, NC 27028, Subdivision Name: W�S 44 of Phone#:336-751-8760 Section: Lot: AUTHORIZATION FOR Lj , ewAlC,> E�.b, c„) 'S4� WASTEWATER YSTEM CONSTRUCTION Tax Office PIN:# - - �► I ' Y AUTHORIZATION NO: 002829 A Road Name: lio t- �' Ipc�>: '� 7cA, !, **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 f wilding Permits. (In complian'c6(vith I of G.S. C ter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) THIS AUTHORIZATION FOR WASTEWATER IS VALID FOR A PERIOD OF FIVE YEARS. DA RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS Z # BATHS a—.<_� # OCCUPANTS 4� GARBAGE DISPOSAL: Yes or No, COMMERCIAL SPECIFICATION: FACILITY TYPE � �� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOTS[ZEO•I�--TYPE WATER SUPPLYL.VL*)r'TDESIGN WASTEWATER FLOW (GPD)��NEW SITE '1 REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL.. PUMP TANK GAL.. TRENCH WIDTH �---T.O, i ROCK DEPTH 4ALINEAR FT. ' t A / REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Wi FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30- 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751.5760. OPERA 10 PERMIT gAPIEW 'C. �� Y SYSTEM INSTALLED BY: '"l l rd VA AUTHORIZATION NO. � OPERATION ., "THE ISSUANCE OF THIS OPERATION PERMITSHALL IN {i 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 NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02M nt.vIe ) 44A.di-r2Stnt1 Tn1UV''1.) 2+/SR DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to ro verty: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: tl AUTHORIZATION FOR WASTEWATER Tax Office PINN SYSTEM CONSTRUCTION AUTHORIZATION NO: 002591 A Road Name: 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 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 1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS,. - ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS(J9 #BATHS. *7 IL #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOTSIZETYPE WATER SUPPLY FLOW (GP DESIGN WASTEWATER D NEW SITE_ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE _G1 PUMP T4 \G TRENQk,'WIDTHI�-Z� ROCK DEPTFJ,4&— LINEAR Ff -�7 OTHFR __ e REQUIRED SITE MODIFICATIONS/CONDITIONS: 4�p FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30A.M. ON THE DAY OF INSTALLATION, TELEPHONE # IS (336) 751-8760 7--]l SYSTEM INSTALLED 0 j F AUTHORIZATION NC� OPERATION PERMIT BY: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION. 1900 "SEWAGE TREATMENT AYE GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY-GIVEP Dan) 02/02 (ReVlnd) y 101 Z5 DATE: 4201A D ABOVE HAS BEEN INSTALLED IN COMPLIANCE , SYSTEMS", BUT SHALL IN NO WAY BE TAKEN ASA IF TIME, ° ^C Environmental N 'althDSection EPA `PROP \ DAV)IE OUINTY HEA H DEPARTMENT , „)' l,/ , ,;•' -- PROPERTY INFORMATION .k; ✓ f; /'vY P0Box148 * S.Dlrechonsto"prpperty F'/ r �1 «,' F Mocksvi'4 ', 27028 Subdivision Name YJo4i)(4, Pllone #. 336 51.-8760 _•--.� ,.� t ' Section:—Lot . -- UTHORIZq I ION FOR WASTEWATER Tax Office PIN:# ., `S TEM CONSTRUCTION - _ AUTHORIZATION NO: 002591 A ) Road Name: Zip:' - a *.,` OTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Sectiotf'prior to issuance of any Building Pemuts This FonTdAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. ' (In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section .190(�Awage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � /1•jSISVALID FOR APERIOD OFFIVE YEARS., ENVIRONMENTAL HEALTH SPECIALIST q.ATE ISSUED I RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS R BATHS j1 # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ R PEOPLE/SHIFT _ ;' # SEATS INDUSTRIAL WASTE: Yes or No., LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD),,— /I NNEW SITE - " - REPAIR SITE SYS7Iv1 SPECIFlCATIONSi 'I;AN,K SIZE - GAL. PUMP TANGp L, TRIENCH WIDTH,.?<_: ROCK DEPTIj ,LINEAR OTHER ./�O' L."!id/ /// /i,✓F''I �J �C U L� REQUIRED SITE MODIFICATIONSJCONDITIONS: 14 , Gr f - oC..r+ i �>.! /✓r - IMPROVEMENT PERMIT LAYOUT , i. L_ F FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30.9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (3J3366) 751-87600.. OPERATIONI/ 0 PERMIT ..� j�/1A � YG1' JC P J 1~ SYSTEM INSTALLED BY: AAA e L L Ju X , XN h J �\� AUTHORIZATION NO., / 1 OPERATION PF RMITAY: r •. **THE ISSUANCE OF THIS OPERATION PERMIT SHA _ ICgTE'CHAT THE SYSTEM�DESCI WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISK GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN'PERIi DCHD 02(02 Wvi a) Q'J y –r.. ,'TI i.,,.i DATE: 22,22A [AS BEEN 17�S++TALLED IN COMPLIANCE '; BUT SHA U INNO WAY BE TAKEN AS A OF TIME. '- - / - i 'T• -C�i1R 1 ' , L_ F FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30.9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (3J3366) 751-87600.. OPERATIONI/ 0 PERMIT ..� j�/1A � YG1' JC P J 1~ SYSTEM INSTALLED BY: AAA e L L Ju X , XN h J �\� AUTHORIZATION NO., / 1 OPERATION PF RMITAY: r •. **THE ISSUANCE OF THIS OPERATION PERMIT SHA _ ICgTE'CHAT THE SYSTEM�DESCI WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISK GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN'PERIi DCHD 02(02 Wvi a) Q'J y –r.. ,'TI i.,,.i DATE: 22,22A [AS BEEN 17�S++TALLED IN COMPLIANCE '; BUT SHA U INNO WAY BE TAKEN AS A OF TIME. '- - / - i 'T• -C�i1R JTHORIZATION NO:, 0696 Directions to property.��/! � i?C D,AVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Mocksville, NC 27028 Subdivision Name: r .�J Phone #:.704-634-8760 irV•4 Section. % Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# ' 0 _ SYSTEM CONSTRUCTION Road Name tt� l�Ov:�':7dd6 **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 NInspections umber should be presented to the Davie County Building Office when applying for Building Permits. I (In compliance with Article I1 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 SPE IAC LIST" DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pp mttee s J Naive UGJ/,''.'S /1)n/1. SubdivisionName�r Direcho$s to property: �/J,°sem' !�/r^�� .0 �L a Section: IMPROVEMENT r PERMIT Tax Office PIN:#:410 1 Road Name: �� c� to t T+ 4V �2'1p:� �e **NOTE** This Improvement Permit DOES NOT authorize the conshuction or installation of a septic tank system or any wastewater system. An i. AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the constructionlnstallation 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 SPE IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE, INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE/I - # PEOPLE _ # PEOPLEISHIFr # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE , 7 AC TYPE WATER SUPPLY 6 y - DESIGN WASTEWATER FLOW (GPD) yEd 45 NEW srm Z/IREPAIR srm SYSTEM SPECIFICATIONS: TANK SIZE DOD GAL. PUMP TANK GAL. TRENCH WIDTH " ROCK DEPTH ,LINEAR FT.3C0 OTHER REQUIRED SITE MODIFICATIONSXONDITIONS: - -' **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) 6348760. SYSTEM INSTALLED BY: 1x1 0 1,h T7KL> - /Sa�Y/2'�. r ljpl `� F2en1T n AUTHORIZATION NO. VA(Q OPERATION PERMIT BY:LeDATE: 1? •*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 05196 (Revised) �. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC �p Davie County Health Department D O v Environmental Health Section . P.O. Box 848 FEB 2 81997 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 12 V S v[r ivy. Contac[ Person Mailing Address Home Phone City/State/Zip iI U0 rie eA.) C 2 %n0& Business Phone gI/o 4303 2. Name on Permit/ATC if Different than Above Sfln Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [-jimprovement Permit & ATC [ ] Both 4. System to Serve: [ ouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residenc-e—# Pe ple # Bedrooms-_ # Bathrooms [ ishwasher [ ]Garbage Disposal [ ' ashing Machine [ ] Basement/Plumbing - [ ] BasementlNo Plumbing 6. If Business/Other: Specify type I# People #Sinks # Commodes — # Showers # Urinals # Water Coolers If Foodservice: # Seats '' Estimated Water Usage (gallons per day) 7. Type of water supply: [td-t-:ounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *M&EL,�.T OF THE PROPERTY MUST BE MSUBMITTED WITH TS APPLICATION. � Property Dimensions: ✓ 19e Vt WRITE DIRECTIONS (fro) Moc�ks�vill�e) TO PROPERTY: Tax Office PIN: #�9 - 'q,5 -J - 7,399 CZys —G1 r a�p Ad l -k Property Address: Road Name / c 1:4 06u P(/ '< City/Zip 22=i If in Subdivision provide information as follows: i Name: Section: 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/�Z �e t'S �sx 5T. tiC to conduc all testin procedur s asnecessary to determine the site suitability. DATE SIGNATURE 2 Revised DCHD (06-96) THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: I r'` C '.. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section // Soil/Site Evaluation NAME _ � `� DATE EVALUATED A ADDRESS PROPERTY SIZE PROPOSED FACI LTY - - LOCATION OF SITE Water Supply: Evaluation By: On -Site Well Auger Boring, Community Public_. FACTORS 1 2 3 4 Landscape position L 4 Slope Z .41 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH + p f Texturegroup Consistence Structure �� S 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 c LONG-TERM ACCEPTANCE RATE: REMARKS: Landscape Position :EVALUATED BY:�z 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 clay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist 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 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(01-901 �iiiiiiiiiii�■iiiiiii�■ii .■■.■■■■■■ ■■■■■■■■■■■■N