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109 East Chinaberry Court Lot 26i -'--mywWSFm.v..�,.r .ye.. nrrc�vF�ar �..:n u{'-sr'Y'>N r irCN u f }Y fi•_�.. . ,- ,.. .�.. - -, v t AU4 H9RizA tON NO: Q 6 Q 6 `` DAVIE, COUNTY. HEALTH DEPARTMENT Z C `..• Environmental Health Section PROPERTY INFORMATION Pettt ` `\ ^� _P.O. 130i 848 Naine'11111) t2 A CL\ \•�bPl A� CSO htaoS �ST� Mock ville, NC 27028 Subdivision Name: Sof ��p o2 Phone #:704-634-8760 D¢echons to property I, Section: Lot: Nt \ AUTHORIZATION FOR ^t SYSTEM CONSTRUCTION Tax ;Office PIN:#J 1\� -:_aiL Q 4 1 Road Name: i P ci SMON ip::Z 0115 *,*NOTE** Tlfis Authoriiation for Wastewater System Construction MUST.$E 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 s 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 i APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 NOV 2 1 1996 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS -� / ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed / Y BG/i'L//r.L9 a/ / a4d Y S �G Contact Person � Mailing Address RnJ%. /Va�/eV 4411 S7. /00 Home Phone City/State/Zip �'/ytKsVi17� 4/�r t%6`�� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 9K -Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: Ur'�'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms -3 # Bathrooms _ ®'Dishwasher ❑ Garbage Disposal Gashing 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: 2/ County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O No If yes, what type? *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: -Fee � Tax Office PIN:# / Property Address: Road Name '446ox--- City/ZipOLCsi�i//� a/0a If in Subdivision provide information, as follows: Name: a' - Section: -Section: 77 rX Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY: ,5 / S- - Ae.44n R4' er -ee{- ( u� S'/ 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 DRvie County Health Department to 9ter upon above described property located in Davie County and owned by as necessary to determine the /site suitability. DATE �I / ,� SIGNATURE Revised DCHD (06-96) conduct all testing procedures APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P R@ `odt �y/J G Davie County Health Department �a Environmental Health Section P. O. Box 665 FEB 2 8 1996 �Y 1 Mocksville, NO 27028 1. Application/Permit Requested By T. Kgte Swicegood, agent fiart MA./Mltd. Rod WoodwaAct 3U0 •South•Ma.tin StAeez Home Phone 704-634-1010 Mailing Address MOCKSVILLE, N. C. 27028 Business Phone 704-634-2222 2:Name on Permit if Different than Above 3: Application for: IA General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: {X7 House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown a/o 5. If house, mobile home: Subdivision S(jUI IHSection 2 Lot # ❑ Basement/Plumbing No. of People 3/4 ❑ Basement/No Plumbing No. of Bedrooms 3 ® Washing Machine No. of Bathrooms Q Dishwasher Dwelling Dimensions73UU sq. feet +- ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes N No. of Lavatories A No. of Sinks No. of Urinals_ No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ® Public ❑ Private 8., Property Dimensions See attached map Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? aeNo ❑ Community 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFORMATION REQUIRED: Tdx Office PIN: PROPERTY AbbRESS, as follows: Road Name: South AAbbh City: Mocksv."e. N. C. 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. Febnuahy 26, 7996 T.'Kyte Swccegood, agent gon wid DATE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1, I OWN the property. [J 2. 1 DO NOT OWN the property.. If you checked Box #2, the rest of this form MUST be completed by the tthe�towHner toter �aeperson authorized by the owner: I hereby give consent to the authorized representee oL 7� r,6 KodyUlood W1aartment 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 absor tion sewage treatment and disposal system. T. y sego d Pebhuaky 26, 7996 DATE - AT E '�^ •"� DAVIE COUNTY HEALTH DEPARTMENT S�. Environmental Health Section p Soil/Site Evaluation NAME DATE EVALUATED ADDRESS 5 Oa -9 PROPERTY SIZE )0" >I -)J L4 PROPOSED FACULTY LOCATION OF SITE �s N Ri Water Supply: e� On -Site Well _ Community Public L11 Evaluation By:r�, `,L Auger Boring Pits Cut FACTORS 1 2 3 4 Landscape position Slope S HORIZON I DEPTH Texture group Q_L_L Consistence _� Structure 4tL1. Mineralogy '- HORIZON II DEPTH V Texture groupC Consistence Structure Mineralogy\' 1 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 1 r SITE CLASSIFICATION: S• EVALUATED BY: 36, LONG-TERM ACCEPTANCE RATE: ry OTHER(S) PRESENT: 10 0 V 2 REMARKS:n.%- �LEGENp Landscape Position-` �a� - 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 •.lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay Moist VFR-•Vc.-y 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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralo¢.y 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 chroma '2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901