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ON-PERMITS
� PROPERTY -FORM
ei6i ce DAVIE COUNTY HEALTH DEPARTMENT
MPROVEMENT AND OPERATIp TO'N EP
NaThe Subdivision Name: W0�
qK
�{
,.
Direetlons to property L: F 1.# •� - `t ,.,� _ Section: Lot: 106)
/ { IMPROVEMENT
f `�' C . IL `c fi: [ - " PERMIT Tax Office PIN:# =1
T —T
'�' `•� c�c. '�..c� Road Name n, c,t.t ii�'Zip:.!, ee�r
*NOTE**This Improvement Perini[ DOES NOT authorize the construction or installation of a septic tank system br anyµ.yrwastewater system. An
AUTHORIIATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constiucdonlmstallafion 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)
t ti ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IP SITE
PLANS OR THE INTENDED USE CHANGE: YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST'' DA7II SUESUED - 'SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:, BUILDING TYPE � '# BEDROOMS # BATHS # OCCUPANTS OARBAOE'DISPOSAL: es 'r No
COMMERCIAL SPECIFICATION:- FACmrTY TYPE'.,` # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
:.LOT SIZE k 3 IITYPE WATER SUPPLY \ )- DESIGN WASTEWATER FLOW (GPD) J 6� NEW STTE , `""REPABt SITE '
SYSTEM SPECIFICATIONS:: TANK SIZE C&b GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2 LINEAR FT a..L_
OTHER
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) 6348760. -
b4ox
%ouS�
N NOS , ,$ OPERATION PERMIT BY: - (� . - kATE.:
E OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
11 OF G.S. CHAPTER 130A, SECTION:1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
[AT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
.APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE
Davie County Health Department D r'
Environmental Health Section
P.O. Box 848 MAR 1 019 7
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
L Name to be Billed Ta�f/aha a—w a5' � t , Contact Person r��lt�rn 1/ d LtGI/� e
Mailing Address Rbc � e Va ller /fu Home Phone �_�� •S�7
City/State/ZipBusiness Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC [moth
4. System to Serve: V/] House [ ] Mobile Home ( ] Business [ ] Industry[ ]' Other
5. If Residence: # People # Bedrooms # Bathrooms-_ . [vl Dishwasher [ ] Garbage Disposal
[VjWashing 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: UTCounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [4No
If yes, what type?
ZIL L o c A rusa vn oklt ra iv
PROPERTY INFORMATION REQUIRED: *** IMPORTANT **.leAT OF THE PROPERTY MUST BE
i
SUBMITTED H
WITH IS APPLICATION.
Property Dimensions: ��0 X 3 WRITE DHZECTIONS (fro Mocksville) TO PROPERTY-
Tax
Q J Tk A -
Tax Office PIN: #� - �` � -n6 9 !rD l � `f0 %%��fifoec r
Property Address: Rodd N e S S. �� aV �.. 9e !? o
City/7j cru v�%�v�� {o CA, O/ S'/ 7�*A �o%t
P q L
If in Subdivision provide inform on, as follows: td l AYE /( i'4Gi 7
�+��Name: 7 �-
Section: 9 Lot#:
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 to nduct all testing pro 7.0
res ecessary to determine the site suitability.
DATE SIGNATURE LMrm.� .>
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
'y
N0 U S�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION � LQTd��
Soil/Site Evaluation
APPLICANT'S NAME
R w \��
DATE EVALUATED J r o
�q�
PROPOSED FACILITY
+d ESQ
PROPERTY SIZE )10'x 3
`E 1 1
Consistence
SUBDIVISION
FM7907LUWD
ROAD NAME
Water Supply:
On -Site Well Community
Public
Evaluation By:
Auger Boring Pite
Cut
• • �
•
SITE
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-90)
EVALUATION BY:
•
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 land 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
CONSISTENCE
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 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 sand surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable),I PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
Consistence
FM7907LUWD
• • �
•
SITE
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-90)
EVALUATION BY:
•
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 land 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
CONSISTENCE
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 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 sand surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable),I PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
>�V�o
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P V O V IS
-Olt
Davie County Health Department
J� Environmental Health Section —FEB 2 81996
P. O. Box2 —
Mocksville, NC 27028
1. Application/Permit Requested. By. T Kyte Swicegood agent AoA MA./Mhz. Kod Woodwand
300 South Matin StAeet 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: (A General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: .51 House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other El Unknown ,23
2 -W"617-
If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 3/4 ❑ Basement/No Plumbing
No. of Bedrooms 3 91 Washing Machine
No. of Bathrooms
Q Dishwasher
Dwelling Dimensions 7300 6q. fleet +- ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes N No. of Urinals
No. of Lavatories A No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: X 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
❑ Community
'NOTE: Improvements Permits shall be validfrom date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
PROPERTY INFORMATION REQUIRED': f�
Tax Office PIN: # S7L%7c�rf/��
PROPERTY ADDRESS, as follows:
Road Name: South A)tbbt
City: Mocfz.5v.iUe 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.
Febxuaxy 26, 1996 T.' Kyee S/jw��.kcegegg000d, agent box
Ro and 4gj VI'l l V
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. E 2. 1 DO NOT OWN the property..
If you checked Box #2, the rest of this form MUST be completed by the
�nttowner
��toh�r ��ae�person authorized by the owner:
I hereby give consent to the authorized representMive of�th� vie CKo4yWooda D artment 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 aground absor tion sewage treatment
and disposal system. T. ►Y cego d
Febxuaxy 26, 7996
DATE AT E '
'DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
p Soil/Site Evaluation q
NAME f DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY`LOCATION OF SITE 1t7�
Water Supply: On -Site Well Communit Public
Evaluation By:t.� Auger Boring Pil;E Cut
FACTORS
1
2 3 1 4
Landscape position
S
Slope %
O
�-
HORIZON I DEPTH
"
1'
Texture group
Consistence
IF T_
Structure
Mineralogy)t
HORIZON II DEPTH
1 '
2
Texture group
C
Consistence
- T,
Structure
K
LN K
Mineralogy1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
•5-
5
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG -TEA
REMARKS:
DCHD(01-901
LA
KMW
EVALUATED BY:
LEGEND
PRESENT: W o NQ
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 <.lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay ' C -Clay
Moist
VFR-.Vory friable - FR -Friable FI -Finn 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
3C -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 - 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