125 East Chinaberry Court Lot 12"
A QRx?,ATION NO: p 8 9 6 DAVIE
COUNTY HEALTH DEPARTMENT
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Petiruttee
Environmental Health Section
PROPERTY INFORMATION
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lName ;�g@ CAAN�Jt�ic�4
P,O: Boz 848
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Mocicsville, NC 27028
Subdivision Name: 6�'(� .�
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Directions to property: ` w\ S 1.1
Phone #: 704-634-8760
Section: Cot:
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AUTHORIZATION FOR
WASTEWATER
TaxOfficaPIN:#>1�Ji' 4blg
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SYSTEM CONSTRUCTION
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Road Name: ��u)tabtJUttw`iip:' O�
**NOTE** This Authoriiadon.for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorizatidn 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, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
_ ' Lo' S -� IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEALTH"SPECIALIST'; :., DATE ISSUED
.... . .,,:.
DAVM COUNTY HEALTH DEPARTMENT �Ot�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
,Na e• ,• ,a 0 E�ti` N�c1 a c v , ,-,..Subdivision Name:' t.�l t,.; \,\
Directions to`property:` �` !rf� (. Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# 11, . 31
Road Name:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constluctionfmstallation of a system or the issuance of a building permit.
(In compliance with Article I1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems]
(( i� i•.
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE,
PIANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMITBEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL. SPECIFICATION: BUILDING TYPE�Csc # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes o 1Jlo
COMMERCIAL SPECIFICATION: FACILITY TYPE
�' - - # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE: Yes or No .
LOT SIZE126-011 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) /30 NEWSITE _V REPAIRSITE 2Y,
SYSTEM SPECIFICATIONS: •TANK SIZ 009 GAL. PUMP TANK - GAL. TRENCH WIDTH 3%
ROCK DEPTH I K ' LINEAR F 3—D
REQUIRED SITE MODIFICATIOI,IS/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) 634.8760. .
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OPERATIONPERMITBY:�'� DATE: v
**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 EVALUATIONAM PROVEMENT
!� Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704)634-8760
I
****IMPORTANT****
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Joe iy-"E rC oe, Contact Person Joe— Cr . ,
Mailing Address 431 I (-vo, Home Phone 110 - 7 (0 [ N C-
City/State/Lip SA -k< n OC- 27104 Business Phone
2. Name on Permit/ATC if Different than Above D,.: 1 c}t_r'C- L C
Mailing Address S✓iwt City/State/Zip T.A
3. Application For: Site Evaluation RAJ Improvement Permit & ATC [ ] Both
4. System to Serve:[ ouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms # Bathroomsshwasher [ ] Garbage Disposal
[ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type i # 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
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** X=A`C•OF THE PROPERTY MUST BE
y t/ SUBMITTED WITH APPLICATION.
Property Dimensions:l qj?R� a aGt2 i WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: # v -r7`1,1 _ 31 V6 r7 % SDP ra AC�-9
Citymp
i
If in Subdivision provide information, as follows:
Name 56U`Hn (7"2k ,
Section: Z Lot#: %02
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 offf he Davie County Health Department to enter upon above described property locates to luavte county ana owned
by all %7�E/t�A��Sd to conduct all testing procedures as necessary to determine the site suitability.
DATE 3 % SIGNATURE
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
I
2 �,i o • 1d
_
c — ____ `270.65'
�rcaSouth Ah
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` ° -- - 272.03' -.-_
o S 03° 5'0017W— 10' Utility Easement
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_224.96' — � C
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wo1
o o 0 0 — N 03 45 00"E
L — S 03 5'00"W.__
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S 84°5504511E o
52.0 I
2E .96' Total
4S. w r� �"8 .ss' �I rS 03" 15'00110VS7 45511E
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I 54.20'
'4635"E--�
212.61 co
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CA
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V / N o I tTl
--219,75.
___ UtSiify Easement _._
m t�
—151:70' m_
S 04°10'35"W 371.45' Total
----------- ....... Walt Wils l ,g n h'c
n n DB 112 4
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{+� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PrLFEB2:8
Davie County Health Department
Environmental Health Section
P. O. Box 665
02� Mocksville, NC 27028
1. Application/Permit Requested By T. Kt7Xe Swicegaod; agent Aon MK. Mts. Rod Woodwand
Mailing Address 300 South Main St teet Home Phone 704-634-1010
MOCKSVILLE N. C. 27028 Business Phone 704-634-2222
2: Name on Permit if Different than Above
3: rApplication for:
0 General Evaluation
4. System to Serve: • IR House
❑ Business ❑ Industry
❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Other
❑ Unknown
2
5. If house, mobile home: Subdivision ARBOR -Section
No. of People 3/4
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions 73UO dq. Aeet +-
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes N
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
J12
-1E+fiZ
Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
91 Washing Machine
Q Dishwasher
❑ Garbage Disposal
7. Type of water supply: p Public ❑ Private ❑ Community
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 ❑XNo
If yes, what type?
'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': r�
Tax Office PIN: # S77�o+r�Yf�v
PROPERTY ADDRESS, as follows:
Road Name: South Ahbbt
City: - Moekzy4,Ue. N. C.
81113MIT 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.
temcua4y 26, 1996 T.':Kyte SWAde-good, agent bon
DATE Rod and §MMM110oodwatd
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. q 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 we of. th J&vieC� un Heal D rtment to enter upon above described
property located in Davie County and owned by RoclCoouta��
to conduct all testing procedures as necessary to determine said site's suitability for a ground abs tion sewage treatment
and disposal system. T. y cego d
I-ebhuaky 26, 7996 d
DATE tl r giGNATAE
DCHD W93)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS S;tarct,Q PROPERTY SIZE 1Z ` ?o %D, C1
PROPOSED FACIILTY i O uSQ LOCATION OF SITE JSU trc� tom;,
Water Supply: On -Site Well _ Community Public ✓ .
Evaluation By:�Q_ Auger Boring Pits Cut
FACTORS
1
2 3 4
Landscape position
S
Slope S
HORIZON I DEPTH
v
Texture groupC
L
Consistence
l
Structure
Mineralogy
°,
',l
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
%k
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
MT
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
g,
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Q ,S EVALUATED BY: ��ti�s�
LONG-TERM ACCEPTANCE RATE: • i OTHER(S) PRESENT'�:-�"',NONm
REMARKS: gn�. lzz a- " X G��A, � '5:z A J�j �
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
3C -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
Ilorizon 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/ftz
DCHD(01-901