117 East Chinaberry Court Lot 27.wn�r �,_ .ry nY .'"'✓' FI �. y.�- � M1ny Y'Y vJx �1i: i,er ...'('j:. . ,+,V:.r.^ �. ,1 ��-"�C... ,�,.
rQ .A��j �yjOR ATIbN No ' � � �>g DAMECOUNTY HEALTH DEPARTMENT
T l
;.'
..Environmental Health Section PROPERTY INFORMATION
P O: Box' 848,
. Na ne .ff rg9t j�1 Dii "%l/�,34'�,i� ;. . Mocksville,'NC 27028 Su6diVision Name.'rJf7J
Phone #:704-634-8760
Directions to property: h Section Lot: a
AUTHORIZATION FOR
WASTEWATER:, I SYSTEM CONSTRUCTION' Tax Office PIN:it�.�
qi
Road Name' Zip:- •�
*.*NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
i 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, Secuon .1900 Sewage Treatment and Disposal ,Systems)
1/� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION : /
IS VALID FOR A PERIOD OF FIVE YEARS ///
ENVIRONMENTAL HEALTH ECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT,
IMPROVEMENT PeRXTION PERMITS PROPERTY 11��ORMATIOJ!i
_. AsanteAA
ADirections: to prog6rty: Az&bfd Section: 12 A: z
IMPROVEMENT
0
PERMIT Tax Office PINA W10-
Road Name:dhhlabey-77
==Agn zalplllw
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any s
wastewater ystem. An
" system.
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation 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
SYSTEM CONTRACTOR MUST SEE THIS ]PERMIT BEFORE
ENVIRONMENTAL. HEALTH WECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL I SPECIFICATION: BUILDING TYPE —.H-- # BEDROOMS �? # BATHS -27 # OCCUPANTS — GARBAGE DISPOSAL: Yes or No.
COMMERCIAL SPECIFICATION: FACILITY TYPE — # PEOPLE — # PEOPLE/SHIFT # SEATS _1
INDUSTRIAL WASTE: Yes or No
LOT SIZE J46 TYPE WATER SUPPLYA DESIGN WASTEWATER FLOW (GPD) NEWSITE --L,�' REPAIR SITE _
SYSTEM SPECIFICATIONS: TANKSM&—," GAL. PUMP TANK ----QAL. TRENCH 'WIDTH yVROCK DEPTH LINEAR Fr.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACTA REPRESENTATIVE OF THE DAVIE COUNTY TF,51�9ARU�� INSPECTION OF THIS SYSTEM
I L
An
BETWEEN 6:30.9:30 . AM.'OR 1:00 - 1:30 P.M. 01*ND FINS TIC N. FINAL
# IS (704) 6348760.
OPERATION PERMIT
M INSTALLED BY:
K.
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF.THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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)
c APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department D [E
y' Environmental Health Section
P.O. Box 848 _ 2
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PRO ED.
1. Name to be Billed 1 YS Contact Person L
Mailing Address �e Home Phone q
City/State/Zip U tAl- 1> _ 1 ka Business Phone ci
2. Name on Permit/ATC if Different than Above
Mailing Address !
3. Application For: [KSite Evaluation [improvement Permit & ATC
4. System to Serve: [/] douse [ ] Mobile Home [ ] Business [ ] Industry
5. If Residence: # People # Bedrooms_ # Bathrooms
VWashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
City/State/Zip
[ 1 Other
[ 1 Both
[gDishwasher [ ] Garbage Disposal
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 [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes M Ro
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** %k1LT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: AM" X .1
Tax Office PIN: # 69112 - I 2/ - L
Property Address: Road Dame e h n(W.
City/Zip Z P
If in Subdivision provide information, as follows:
Name: S r7,0 O !�
Section: c� Lot#: D=7
WRITE DIRECTIONS (from Mocksv�ille) TO PROPERTY:
1A/i�i _ 1 ///2-01ld �/l
l
f. fill d/ i,/.i
N
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 C t onduFt all testing
DATE --L / SIGNATURE
Revised DCHD (06-96)
THIS AREA AtAY BE USED FOR DRAWING YOUR SITE PLAN:
as ge�sary to determine the site suitability.
r
i
o p' -
V
�yo s19�
LICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
=C�C�OML�
FEB 2 8 1996
1.plication/Permit Requested By T. Kyte Swicegood agent AoA Mh./Mhd. Rod WoodwaAd
300 South Ma cn S.tAee-t Home Phone 704-634-7010
Mailing Address
MUCKSVILLE. N. C. 27028 Business Phone 704-634-2222
2: Name on Permit if. Different than Above
3. Application for: General Evaluation ❑ Septic Tank Installation Permit
4:.' System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown 27
.5.
SOUTI2 If house, mobile home: Subdivision - Section Lot #
3/4
No. of People
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions "1300 dry. Aee-t
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes Nq
No. of Sinks _
No. of Urinals
No. of Lavatories A No, of Water Coolers _
No. of Showers Water Usage Figures _
7. Type of water supply: p Public ❑ Private
8. Property DimensiensSee attached map Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
91 Washing Machine
Q Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑CNo
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.
Directions to Property:
PROPERTY INFORMATION REQUIRED:
Tax Office PIN: #
PROPERTY ADDRESS, as foi lows:
Road Name: South AAbbx
Gity: Moekyitte, N. C.
SU13MIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
iThis 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.
7-ebxuahy 26, 1996 T. Kyte Swceegood, agent 40x
Rod -and 11" WoodwaAd
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. Ot 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 represent ive of thvie Chun y Heal D artment to enter upon above described
VJa
property located in Davie County and owned by Ko lVao�
-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 Cego d
f•ebuuahy 'L6, 7996 - �
DATE �� ATOE
DDHD (1193) -
DAVIE COUNTY HEALTH DEPARTMENT r
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED e7
ADDRESS S \`= PROPERTY SIZE 90 X 21
PROPOSED FACIILTY V't CW -I's LOCATION OF SITE ' g) �r?�
Water Supply: On -Site Well _ Community Public L,'
Evaluation By:tU- Auger Boring Pig V/ Cut
FACTORS
1 2 3 4
Landscape position
Slope b
Q -Ku
HORIZON I DEPTH
Texture group
Q L Z L
Consistence
Structure
2
Mineralogy
HORIZON II DEPTH
t' a
Texture group
C
Consistence
F
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
SITE CLASSIFICATION: W r� EVALUATED BY:
LONG-TERM
(�ACpCEP,NCE RATE`: OTHER(S) PRESENT:
��
DDMID YC. ROPr V \
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 e.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
SC -Single grain M -Massive CR -Crumb CR -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 - 1n 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