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373 Sheffield Farms Trail Lot 6iU RATION No 12 0 ? bAVIK COUNTY HEALTH DEPARTMENT -- {+' ` Environmental Health Section PROPERTY INFORMATION Pennrtte s P.O. Box 848 Nam �G Mocksville, NC 27028 Subdivision Name: % Phone # 04- 7634 87b0 `6 Directions to property: �'� `Section: Lot:%l AUTHORIZATION FOR / t I n z4 t4 I �! WASTEWATERCONSTRUCTIONTax Office PIN:# f+ry � SYSTEM 'A V441 SO Road Name.rqeMell **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 FomVAuthgrizafion Number should be presented to the Davie County Building Inspections Office when applying for Building Permits: X (In compliance with 'Article .I I of G.S. Chapter' 130A, Wastewater Systems, Section A 900.Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 'IS.VALID FOR A PERIOD OF FIVE YEARS. "ENVIRONMENTAL HEALTH SPECIALIST, . DATE ISSUED - 12 0 2 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permute Nam Subdivision Name:,. /421w� Id 414r 0 ctions to property:5�;/, > Section:- Lot: ,w f PERMIT Tax Office P1NA14;;7/ Y/ _rd/kV Road Name.r8beffieJIL—'Zip: UV **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 froduthis Department prior to the construction/installation of a system or the issuance of a building permit. compliance (In plian (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)- ***NOnCE*** 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 INSTALLING TEE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 14-1 # BEDROOMS ,_7 #BATHS jA&# OCCUPANTS GARBAGE DISPOSAL: Yes or N, COMMERCIAL SPECIECA77ON: FACILITY TYPE # PEOPLE — # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No OT SIZE 1/10/7C TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZF,&�E_GAL. PUMP TANK —GAL. TRENCH WIDTH ROCK DEPTH L LINEAR Fr. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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. OPERATION PERMIT bac SYST AUTHORIZATION NO. -JoIO2, oPERAnoNPERmrrBY:_ zeywl DATE: !/n,'n "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 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department D [E @ t5 Q W Environmental Health Section P.O. Box 848 JAN 3 0 Moog Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed (-"u (l .mLP ew p- f - Mailing Address ' OI L�,M If City/State/Zip U1 )rn15�oN -54 1 F m, N G all a7 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [LSite Evaluation ContactPetson CACLA P08bQ3 Home Phone L70 125-0-3-73 Business Phone ClIU 71(0- 419011 City/State/Zip []-Improvement Permit & ATC 4. System to Serve: []'House [ ] Mobile Home [ ] Business [ ] Industry L ] Other 15 : , 5. If Residence: # People— # Bedrooms `� # Bathrooms j - 5 [ ]] 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 [ N Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [x] No If yes, what type? p rr. EITHER A PLAT.OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT **O" OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: l ACJ21to WRITE DIRECTIONS (from M�occkksville) TO PROPERTY: Tax Office PIN: #qF1 Pr-Rq5,�i�•/L— Property Address: Road Dame S� FF i F Id Rd- City/zip R")ory1)S[1i 11£ NG R-iG If in Subdivision provide information, as follows: Name: hP ('Fire Id 1C/Q2(i) S , , Section: Lot#: i0 ! 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 Departyttent to enter upon above described property located in Davie County and owned conduct all Revised DCHD (06-96) THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: as necessary to determine the site suitability. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT_ Soil/Site Evaluation APPLICANT'S NAME B PROPOSED FACILITY SUBDIVISION DATE EVALUATED PROPERTY SIZE % /Ci ROAD NAME S/l N fes" Water Supply: On -Site Well _�� Community Public Evaluation By: Auger BorinPit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group G G Consistence r i Structure /G 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: UJ EVALUATION BY: IU LONG-TERM ACCEPTANCE RATE: !f 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 Moist VFR - Very friable . FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky i 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 (01-0)