114 West Chinaberry Court Lot 24J 1, b-P�i` UZATION NO: Q 9 5 Q DAVIE COUNTY HEALTH DEPARTMENT
7 `
Environmental Health Section
Soo
PROPERTY INFORMATION
Permmees� T P.O. Box 848
Name: 12{1 on1A� Or�P Mocksville, NC 27028 Subdivision Name: 55
Phone #: 704-634-8760 '
Directions to property 1"U S \ : r Section:_ Lot: .! L4
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:N, -'i g
SYSTEM CONSTRUCTION
St37� G. mar: Ckami �' '.�'1 a Road Name
**NOTE*,* This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Enviromnental 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 ivilii Article 11. of O.S.,Ctaapter 130A,Wastewater Systems Section 1900 Sewage Treatment and Disposal Systems) }„
(b ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '
IS VALID FOR A PERIOD OF FIVE YEARS "t
.. _ ENVIRONMENTAL HEALTH SPECIALIST: DATE ISSUED - -
.., 1 -�. .... .,.:...§x. �,.-.-.�vr .r.tiv i•^•..yr-m- r„tyy.,y,,, „ .. p.rvr Nr.... as ..�i �♦/' •.•,.
' ^ g DAME COUNTY HEALTH DEPARTMENTO'Q o
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
' PermtltCe”
Name:' P�4d 0i1A` kl n t (\Ps Subdivision Name: 9)AaR R"
q Directions to property: 1a Q ` �•.� crn _ _ - Section:._ Lot:
IMPROVEMEM
PERMIT Tax Office PIN:# - -2_
G�`'.--�.r,�,.. x.J�. C\s:rc..w---:;s�•5..^ �• ��.1 r,v^>�c.�^>.� 1� - * :.; ��,'�•
Road Name :�� 1 a p�� a� , Zip:
**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 from this Department prior to the
- constructiordinstallation 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 SPECIALIST DATE ISSUED _ SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE }jO1t�.. # BEDROOMS ti ' # BATHS a• # OCCUPANTS GARBAGE DISPOSAL: Yes or QUS
COMMERCIAL SPECIFICATION:.FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL. WASTE: Yes or No
LOT SIZES 'J TYPE WATER SUPPLY � , DESIGN WASTEWATER FLOW (GPD) (p NEW SITE ^ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE M GAL. PUMP TANK - GAL. TRENCH WIDTH 31 ROCK DEPTH _ j� LINEAR FT.!
OTHER
REQUIRED SITE MODIFICATIO
IMPROVEMENT PERMIT
LAYOUT '
5
FVt
**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
SYSTEM INSTALLED BY:��1•cy+
i
No U S
.� 4
AUTHORIZATION NOQ L� OPERATION PERMIT BY: (�\_ (% D - C d.9�3 - - DATE: I D _,1 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) '.,
1
**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
SYSTEM INSTALLED BY:��1•cy+
i
No U S
.� 4
AUTHORIZATION NOQ L� OPERATION PERMIT BY: (�\_ (% D - C d.9�3 - - DATE: I D _,1 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
Davie County Health Department D 2 O f2
Environmental Health Section L5 I5
P.O. Box 848
Mocksville, NC 27028 JUL — 9 199T
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS
—�-Q'� THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed /IATi 6N a - Contact Person C14 /J/' G C rO .4
Mailing Address Q` Sh.11C A00 Home Phone
City/State/Zip KY/ / Z122 52 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: 14dite Evaluation
City/State/Zip
[ ] Improvement Permit & ATC [.J/Both
4. System to Serve: [;,fHouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms --7 # Bathrooms (Dishwasher [ ] Garbage Disposal
VWashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify
# Showers # Urinals # Water Coolers
-
# People #Sinks # Commodes
If Foodservice: # Seats._Estimated Water Usage (gallons per day)
7. Type of water supply: [YjCounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes r] No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXYTfi¢4'COF THE PROPERTY MUST BE
SUBMITTED WITH 7$ APPLICATION:
[lVl_ '
Property Dimensions: //U X X11 G i WRITE DIItECTIONS (from ocksville) TO PR PERTY:
Tax Office PIN: # t{%�- �� ✓� k
Property Address: Road Name L'I+ In U
city/Zip
e >ti JQ Vhl
If in Subdivision provide inform on, as follows: R ki
Name: S'00 --(k -'4i h ok— ��tl '9
Section: Lot #: o `Y
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 t} Davie�ount��ealth Department to enter upon above described property located in Davie County and owned
by �y� . j //� PJYt S P�lo conduct all testing proc dures s necessary to determine the site suitability.
DATE — SIGNATURE
Revised DCI -ID (06-96)
THIS AREA MAY 13E USED FOR bRAWINy YOUR SITE PLAN:
4 FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
FEB 2 8 1996
1.,Application/Permit Requested By, T. Kt/Ye Swtieegood, agent AOA MA./M/[.6. Rod Woodwand
300 South Macn Sfiheet Home Phone 704-634-1010
.Mailing Address
MUCKSVILLE, N: C. 27028 Business Phone 704-634-2222
2, Name on Permit if Different than Above'
3.Application for: rA General Evaluation ❑ Septic Tank Installation Permit
4.: System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown ,241
-2 -ice
5. If house, mobile home: Subdivision SO.TH ARBeR Section Lot #
3/4
No. of People
No. of Bedrooms 3
2
No. of Bathrooms
Dwelling Dimensions -1300 Aq. Ueex +-
6.:If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes N
No. of Lavatories A
❑ Basement/Plumbing
❑ Basement/No Plumbing
91 Washing Machine
Q Dishwasher.
❑ Garbage Disposal
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 ❑+:No
If yes, what type?
❑ 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..
PROPERTY INFORMATION RE2UI=:
Tax Office PIN: # S71%7c1�
PROPERTY ADDRESS, as follows:
Road Name: SOU.th AAbbA
City: _ MCCLsv.tUe. N. C.
SUDMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
I'
-,,: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.
Feb)=Ay 26, 1996 T. Kyte Swceegood, agent Doh
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. EX 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner ttotehr ppaeeperson authorized by the owner:
I hereby give consent to the authorized represent ve of tha J e ClQadylUoodu7D aartment 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 eego d
FebtuaAy 26, 1996
DATE 61 MNATWRE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �3a�
ADDRESS At"�
PROPOSED FACIILTY V\ aVUa
Water Supply: On -Site Well
Evaluation Byit�_ Auger Boring
DATE EVALUATED
kat � a 4
PROPERTY SIZE g� �49 i( -a 881A 04
LOCATION OF SITE
Commupity Public ✓ _
Pits ✓ Cut - - -
FACTORS
1
2 3 4
Landscape position
S
Slope %
O_1%0
O-$
HORIZON I DEPTH
u
'
Texture group
Z L
Consistence
Structure
V,
Mineralogy
IA
%ki
HORIZON II DEPTH
LAU,
a.
Texture group
C�_
Consistence
Structure
INIB1
Mineralogy'V\
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
ss
RESTRICTIVE HORIZON
SAPROLITE
_
—
CLASSIFICATION
S.,S
LONG-TERM ACCEPTANCE RATEI
4
04
SITE CLASSIFICATION:
LONG -TER
REMARKS:
DCHD(01-901
01�
.4
Landscape Position
EVALUATED BY: dR�
OTHER(S) PRESENT: N 0 N Q
Z ,' Q &
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 <-lay loam- . SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR- Ve.-y friable FR -Friable FI -Firm VFI-Very fine 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
Saprolile - 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(suilable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2