2477 Hwy 801 S Lot 2213 S 2 �o, oo ,r,f��✓/^yo,
AUT. HIZATIygN NO: DAVIECOUNTY HEALTH DEPARTMENT
�1s"- Environmental Health Section PROPERTY INFORMATION
Pe; Yittee s ` P.O.; Boz 848
Nameaw'- Mocksville,.NC 27028 Subdivision Name:.) / V
Phone #: 704-634-8760n
Directions to property: A 1 Section: Lot:
,� �AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#�
'
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 116f G.S. Chapter 130A, Wastewater Systems, Section :1900 Sewage;Treatment and Disposal Systems)
***NOTICE*,** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
jcc IS VALID FOR A PERIOD OF FIVE YEARS
ENVIROWENT t'HEALTH SPECIALIST DATE ISSUED
r .;
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. '
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ix
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1. Name to be Billed
Mailing Address
City/State/Zip
a
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PI
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(��JOCX
(336)751-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PRO(
ALJ„ THE REQUIRED INFORMATION IS
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
R-fishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
❑ Site Evaluation
f� House ❑ `Mobile Home
# People
❑ Garbage Disposal
Specify type _
# Showers
# Seats
qu15�
MAY 1 219%
Contact Person
Home Phone q q 0 /7
Business Phone 'PAae R -7t-2—?107
City/State/Zip
Q yImprovement Permit & ATC ❑ Both
❑ Business ❑ Industry
# Bedrooms
D -Washing Machine
7. Type of water supply: 8--tounty/City
❑ Basement/Plumbing
# Urinals
❑ Other
# Bathrooms ?
❑ Basement/No Plumbing
# People # Sinks
# Water Coolers
Estimated Water Usage (gallons per day)
❑ Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
*** IMPORTANT
❑ Community
❑ Yes 2YN-0
HE PROPERTY MUST BE
WITH THIS APPLICATION.
Property Dimensions: '` ' 1 1 WRITE DIRECTIONS (from
Q .� q 1 MocksAlle) TO PROPERTY:
Tax Office PIN: # g / �_ �' 1Fec),A 6 qG o
Property Address: Road Name ey 1 5 1
plot--r�o,4 <70
t�
City/Zip a foo
1 ,
If in Subdivision provide information, as follows: 1
c �
Name:
Section: Lot #: ri 1 ��
1
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
and owned by
County Health Department to enter upon above described property located in Davie County
it
as necessary to determine the site suitability.
DATE 5A2 63-5/ SIGNATURE
Revised DCHD (06-96)
C
YOU MAY USE THE 13ACK Of THIS )`ORM FOR 1)RAWINQ YOUR SITE PLAN.
conduct all testing procedures
S
S 08019'50"W 1602.84-
130.00' I 167.84'
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38,190 sq. ft. f 35,220 sq. ft.
90.01' R=6565.32' A=40.00'^
=6615.}31' A=169.06' ra=oc
1
W
39,325 sq. ft.
1
149.00'
3 3
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cvj N 30,240 sq. ft. N 30,865 sq. ft.
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f
A=140.00' A=160.00' R=656
�• � A=191.79'
T
I0 31,445 sq.fC
b
tn .
m �\
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Marshall Lewis Swaringen, Jr.
D.B. 120-439
Zoned R/A
164.50'
Z
3 � �
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0 31,39 sq. ft. o
m
z f
a
R=6565-
A=189.06'
196.50'
I30, 4 sq. ft.
A=377.36'
R=6615.31' o OD
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42.545
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71.00 �P a!
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220.01' R-565.32'
210.22' N O
N 01°52'20' R_6615.31'Lp
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38v . ft.
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CERTIFICATE OF APPROVAL BY THE-PLANI
THE DAME COUNTY PLANNING BOARD HE
THE FINAL PLAT.
"Jo
30,5 sq. ft.
9oA
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h
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Preliminary
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
4-'..
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1.' Application/Permit Requested By S ho rnn \/ I� rhe +TanCk_
Mailing Address �•� • ��O>C ao Cfl3 �J Home Phone ctQs - 30 cr
PC1V0.ncC_Qc a'70c(o Business Phone 9CIS — 2Co l s
2. Name on Permit if Different than Above
3. Application for: GrGeneral Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5., If house, mobile home: Subdivision sknrAq Armf e, Section Lot #—
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Sinks
No. of Commodes
No. of Urinals
No. of Lavatories
No. of Water Coolers _
No. of Showers
Water Usage Figures _
7. Type of water supply: fflublic
❑ Private
8. Property Dimensions Sewage Disposal Contractor
COCtCS
9. Do you anticipate additi-ons/exffansion of the facility this sytem is Intended to serve? ❑ Yes
If yes, what type?
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ No
❑ Community
-NOTE: Improvements Permits shall be valid1119� from date issued. Improvements Permits are subject to
revocation, if site plans or the Intended use change., Effective October 1, 1989.
Directions to Property:
1D�5
PROPERTY INj=ORMATION REQUIRED:
Tax Office PIN: # 5189 — J-1 S__ Oloy 1
PROPERTY ADDRESS, as follows:
Road Name:u`~y 80l 5
City: Ad\yr n
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
�9�gal
DATE'SI TUR
CONSENT FOR SITE EVALUATION 1Q BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
'' ^^ Soil/Site Evaluation
NAMEy� /1`1� DATE EVALUATED �l9
ADDRESS PROPERTY SIZE
PROPOSED FACIH TY LOCATION OF SITE
Water Supply: On -Site Well Community Public t/ -
Evaluation By: Auger Boring Pit ✓ Cut
FACTORS
1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
7_�s t
Texture groupC
Consistence
Structure
&
Mineralogy
! A
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
r
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: —�
REMARKS:
DCHD(01-901
EVALUATED BY: A146�
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 loarn L -Loam SI -Silt
SICL-Silty <.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 -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
3C -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(suilable), 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/fu