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288 Michaels Road Lot 2AUTHORkZATION NO: 15)0 DAVIE CpUNTY HEALTH DEPARTMENT 'Environmental Health Section PROPERTY INFORMATION Permittee's P.O. Box 848 Name: r Mocksville, NC 27028 Subdivision Name: ...�.�/<� !'!Cr'`�'.-5► ,rf ; Phone # 336-751-8760 Directions to property: // �- ' ✓.j. ' X�f AUTHORIZATION FOR Section: Lot: WASTEWATER Tax Office PIN:#xm- - s� SYSTEM CONSTRUCTION Road Name: i 4`Zip: A'76),�F **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental 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 with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ;fes r`IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS : PROPERTY INFORMATION rirmitiee Name:POae{r Subdivision Name:. r, f Directions to property: � %" - Section: Lot: r--- IMPROVEMENT r PERMIT Tax Office PIN:#,j-�-�`;' Road Name:.C'�3 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 construction/installation of a system or the issuance of a building permit. (In compliance with Article I I 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 # BEllROOMS #BATHS _2-- # OCCUPANTS " GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ��lX soy %% LOT SIZEI.!1 TYPE WATER SUPPLY //?17 DESIGN WASTEWATER FLOW (GPD) �'� NEW SITE_REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE D GAL. PUMP TANK GAL. TRENCH WIDTH -b ROCK DEPTH 1,- LINEAR FT.�(S OTHER "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 (336)751-8760. OPERATION PERMIT ISI SYSTEM INSTALLED BY: _ Rn AUTHORIZATION NO.. OPERATION PERMIT BY: �rC/7 DATE: / `SD "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 05/96 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE lJ Davie County Health Department Environmental Health Section 6 19% P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 PE11VIR Aiii`CEn'�TAI,HEALTH ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS /� nRALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed kO17 , �p L r�j/`AP Contact Person �'2�r Mailing Address PQ _ —1'� Home Phone City/State/Zip ,n d I J IvV � no ( Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit & ATC ❑ Both 4. System to Serve: ❑ House m' Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 19, 3/Dishwasher ❑ Garbage Disposal Washing 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: ❑County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U//No J If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE f v� SUBMITTED WITH THIS APPLICATION. Property Dimensions: ! o & �J07 1 WRITE DIRECTIONS (from —7 1 Mocksville) TO PROPERTY: Tax Office PIN: # 57# # 6 - I - 1 4� ha lm Cr� P -d -�� Property Address: Road Name 1 V IM,& 11�.A 1 p 1 City/Zip / O V 1 O 1 , If in Subdivision provide information, as follows: 1� Name: UI �X JL P rV 1 1 Section: Lot #: 1 1 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 as necessary to determine the site suitability. DATE 6 - �- / " if SIGNATURE Revised DCHD (06-96) conduct all testing procedures fic,d*' A if 6LO s APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI D r '� • �+ Davie County Health Department , 2 11995 �•�� E t I H Ith Section nvironmen a ea (/r � P. O. Box 665 I Mocksville, NC 27028 ENT HEALTH COU 1. Application/Permit Requested By r a'7 0 '_�✓��her�/� C• i' �i Mailing Address "'��. t-• ft�•f: rJ,:�` Home Phone ro ✓ o �5��,�//� Business Phone k ;Z J.5 2. Name on Permit if Different than Above 3. Application for: / General Evaluation a Septic Tank Installation Permit 4. System to Serve: ®,'House ❑ Mobile Home ❑ Place of Public Assembly/ ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision -� 'T °� d' �Q� Section Lot #_ ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher 1 DO V I, 0 0 S� Dwelling Dimensions --t--e , �B ❑ .Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ❑ Private ❑ Community 8. Property Dimensions©PSewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes "o If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: �6/ So. S ,a- -h- MrAuG �l �e ro 3000Ft This is to certify that the information provided is correct to the best of my knowledge, incurred from this plication. � �lT f' jj ✓ %%QQ� � DATE I understand I am responsible for all charges SIGNATURE` CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 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 representativ of the Dewe Co my Health D�e artment to enter upon above described property located in Davie County and owned by ii� c) &Orx, to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. is.-/'* s DATE DCHD (1 193) '. DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation NAME �/�� //•lJ�7�✓ ADDRESS PROPOSED FACIILTY 'ev4af zP Water Supply: On -Site Well rem DATE EVALUATED PROPERTY SIZE LOCATION OF SITE /�` ��► e Community Public L'___1 Evaluation By: Auger Boring Pit 6/ Cut FACTORS 1 2 3 4 Landscape position L .I— Slope Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t & r Texture group 0 - Consistence Consistence Structure /C Mineralogy-/ 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: RS EVALUATED BY:/ LONG-TERM ACCEPTAN RATE: �7 OTHER(S) PRESENT: REMARKS: DCHD(01-901 �vr LEGEND Landscape Position R -Ridge S7Shoulder 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 CONSISTENCE Moist VFR- Vf---y 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 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 ■■■■■■■■■ ■■■■■■■■■■■■■■■■■ son ■■■■■■■■■■■■■■■■■ MUMMEMEMINIMMINE ■■■■■■■ MMIM■E■MMM■M■■■MM■ ■■■■■■■■■■■■■■■■■ ■�son MIME■■■■■ MAIN MMI■A■■■E■ ■■■■ME■ ■MMM■■■■ ■/■■■■■■ ■■ ■■ ■M■■■IMM■■■ ■MMM■/IME■■ ■MIM ME�H■ ■■ ■■ MK■ENEM■■■ME■ MAIM■■ ■ ■MM■ M■M■■ME■ MEMO �M■M■MMM■E■AM■■■■ ■■■■■■IMM■ ■■■■■■■■■■■■■■■E■ ■■M2■■■■■/■■■■■■■ on, County Planning Board P\0 Tax Lot 16 Tax Map M,-5 I.1' Total 100.00' 0.696 Acres+/ - 6 3 In ;v N r- r7 r7 vt' O a to � 111Y q r` z 10D.00' TK-_ CERT -----------' to be correct. Fllln; Fee Paid This day of _-, 19 Probatefee paid. by Fenster cf Deeds by DEPUTY -ASSISTANT Control Comer N 15,1 27 0„ 9 E 309.13' Total Lo 106.00' 119.41' 106.00' i 83.72' 01 0.697 Acres+/- J 10.744 Acres+/- 5 3 4 to M t7 tet• N 0 O a01 I� C n z U N ._ W a o � I to DEPUTY-ASS:STANT Tax Lot 42 Tax Map L-5 Carol Jean A. Ev DB 114 @ PG 4 r 32.18' 67.62' SS.J4' 41.96' 106.00' 37.78' r 106.22' 23.72' I -3 4"r_IP _.� - 82.28' 25.29' 125.86' S 12"00'00"W 155.74' a� s' 22.67' S 10! 48'10"W Tota' �---- Total S 13� 16_05'W 152.34' Total T S 1'26'00"W t0ota� S 19�` 4�. W _ N 10`i 7'05"E 125.2T N 12"00'00'E 184.44' Total N 13'16'05"E Total �_�� _ 151.5!' Total N 13`26'0'0"E 107.12' i 01.00' E2.08 60.00' 3236' 5 L '�` �. "�'_•_ z�N 3 r� " �f:' i ni �I ri 70.44' 61.1 27 Er'i 7r 2G' 26.5 c 411 + i 40' Buiid no Lind E Z3 Uj .41 0 1 o 3 i _ d I o Dye o� I o!� E LO Q%j' j S c: O N O O O O i O C r �I G G CO o cj O O o O L7 C o Do In DOo, G Tax ! z n t� Z Z c C O o Tax I' (Ls Z(3)O 0.791 Acres+/- 0.700 Acres+/- 0.734 Acres+/- 0,782 Acres+ - ' 101.53' 99.46' 1'05"W 400.99' Total 3 2 3 o tj a W 30 �, � o 4.o 0� r1% N N M Do � O r � C � I O U / O t� <a.O , i p � , rrf I a q M aJ r z M co c O r` Z E 1 i° o Tax Lot 41 N Z W Tax Map L-` o a, Chares Eubie E: g a/w Carol Jean DB 86 C PG r 32.18' 67.62' SS.J4' 41.96' 106.00' 37.78' r 106.22' 23.72' I -3 4"r_IP _.� - 82.28' 25.29' 125.86' S 12"00'00"W 155.74' a� s' 22.67' S 10! 48'10"W Tota' �---- Total S 13� 16_05'W 152.34' Total T S 1'26'00"W t0ota� S 19�` 4�. W _ N 10`i 7'05"E 125.2T N 12"00'00'E 184.44' Total N 13'16'05"E Total �_�� _ 151.5!' Total N 13`26'0'0"E 107.12' i 01.00' E2.08 60.00' 3236' 5 L '�` �. "�'_•_ z�N 3 r� " �f:' i ni �I ri 70.44' 61.1 27 Er'i 7r 2G' 26.5 c 411 + i 40' Buiid no Lind E Z3 Uj .41 0 1 o 3 i _ d I o Dye o� I o!� E LO Q%j' j S c: O N O O O O i O C r �I G G CO o cj O O o O L7 C o Do In DOo, G Tax ! z n t� Z Z c C O o Tax I' 31 � �' 12) 33 Do� 3�- fn radia,, 0.7 Acres+/ -Z 0.749 Acres+/- 0 Ac•cs+/-Z K5 Acrc_-/ - E s7c 12.2.39' 106.00' 121.74' } S 14014'50"W 475.09' Total 124.96' DB 7G- Lr) 6 Lr) 1 , (Ls Z(3)O E+/'- 0.700 Acres+/- 0.709 Acres+/- ' 101.53' 99.46' 1'05"W 400.99' Total 31 � �' 12) 33 Do� 3�- fn radia,, 0.7 Acres+/ -Z 0.749 Acres+/- 0 Ac•cs+/-Z K5 Acrc_-/ - E s7c 12.2.39' 106.00' 121.74' } S 14014'50"W 475.09' Total 124.96' DB 7G- Lr) 6 Lr) 1 ,