355 Michaels Road Lot 25AUTHORIZATION NO: 1200 DAVIE COUNTY. HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permide's P.O. Box 848 .
Name: I=t C"�;'''.. ''�lLL,Mocksville, NC 27028 Subdivision Name —'AL -tv
Phone #: 704-634-8760 z
Directions to property: ��1 }'� lrt) `� —J0 Section: Lot: G
hh ,Y AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
(`, lis i Road Name: {Y,IC i ��ei=L� ZhZip: Z?'3
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
�ENVIROgp�E�' AL HEALTH S ECI�ILIST DAiFISTUED
or
,} 12:00 DAME COUNTY HEALTH DEPARTMENT t .�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
None• 1-r° Subdivision Name: `&I. I 99
Du do to property: �E��: trl;'1' ' ► Section: Lot:
n '
L.? 9 s'"�1. �R�IIT _
Tax Office PIN:# S?q& _ Z o
Z c, i C; Lim Road Name: 14AsL. &zip:
**NOTE** This Improvement Permit DOES NOT�authoriw the construction tion or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained f om this Department prior to the
constcuctionlinstallation 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)
r ^�'~�^°� v • , / ***NOTICE*** THIS PIItMIT IS SUBJECT TO REVOCATION 1F SITE
r lj PLANS OR THE IN71MED USE CHANGE YOUR WASTEWATER
ENVIIt(1'AL HEAD HSYSTEM CONTRACTOR SPECI�►L IST DA IS UED BALLING THE SYSTEM. ST SEE THIS PERMIT BEFORE
RESIDENTIAL SPECIFICATION: BUILDING TYPE ri► # BEDROOMS # BATHS # OCCUPANTS 21 GARBAGE DISPOSAL: Yes or No
---COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIM. TYPE WATER SUPPLY' co
DESIGN WASTEWATER FLOW (GPD) NEW SITEREPAIR SITE
�l i r
SYSTEM SPECIFICATIONS: TANK SIZE l�/l.! GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I LINEAR FT.
OTHER ` I1ST04M1 o a
REQUIRED SITE MODIFICATIONSICONDMONS: IaTAL , orj 6"TQJ1(z r IF- :-I g � O'lFwAie, gazto ltd !
�F . �°QoPEe►'/
IMPROVEMENT PERMIT LAYOUT;,
'04,
F&AT Pe on't' 0-A
"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.
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"*TILE 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.
TY`Lirl MbG ID._ -_r
7 jr
_ DAVIE COUNTY HEALTH DEPARTMENT
Y y
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
'Peimittte''s
Name: Subdivision Name:
Directions to property: f a ? Section: Lot: �—
IMPROVEMENT
> ' n PERMIT Tax Office PIN:#
Road Name. t r ? .°w t ` Zip: ; L
**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 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 1 # BEDROOMS .3 # BATHS # OCCUPANTS :` GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
V
LOT SIZE �� C.'.�C (f �' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �FZt] NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZAW GAL. PUMP TANK GAL. TRENCH WIDTH ^ ROCK DEPTH LINEAR FT. '
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: I T l �'� �= C� U'., �`I t (J / Y�-�- �- ` (-.-y-
AFF
IMPROVEMENT PERMIT LAYOUT
**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:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAI
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)
4 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT r; l
Davie County Health Department
Environmental Health Section
P. O. Box 848 �.
Mocksville, NC 27028
(704) 634-8760
JAN 2 8 1998
ENVIRO"""'"- L HE Z' J
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U ESS --� -�
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed `ep—j Contact Person
r7383� — 17 1
Mailing Address 0 G�731 /n n Home Phone
City/State/Zip No' e � eel �V V � l 0 l Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address _
3. Application For:
4. System to Serve:
5. If Residence:
®'Dishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
❑ Site Evaluation
f M
❑ House obile Home
# People
❑ Garbage Disposal
Specify type _
# Showers
7. Type of water supply:
# Seats /
9' County/City
Cit /State/Zip
1,� �S �Ap
Il Improvement Permit & ATC
❑ Business ❑ Industry
# Bedrooms 6
"Both
❑ Other
# Bathrooms
Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
a SUBMITTED WITH THIS APPLICATION.
Property Dimensions: d d x ®� I WRITE DIRECTIONS (from
2 I
`C"� I Mocksville) TO PROPERTY:
Tax Office PIN: # - - 1 0 0 s
�a 1
Property Address: Road Name �
�/� � p � /
City/Zip 1 1 I Z' IiCJ�/ 02 / 0,26
1 0 a cert,
1
If in Subdivision provide information, as follows:
• C j � Q, 1
Name:
I
1
Section: Lot #: 1
I
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 l `" '* "� C/ SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI u 5
Davie County Health Department
Environmental Health Section JJL 2 1 1995
P. O. Box 665
Mocksville, NC 27028 EM�H
1. Application/Permit Requested By lca'7 'v'_��)''i Ser'/iCe— C• r ti
Mailing Address __f � �r_ ? � ��1'` �'�� / Home Phone 6 �`7� *Ig .33
A 45 1/ %tom Business Phone . u 7 ;Z
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
5. If house, mobile home: Subdivision Section _�� Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms T �- / CQ 51� ❑ Dishwasher
Dwelling Dimensions ❑ .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
8. Property Dimensions ,/d O 4C7y X3"- ,�040F Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes 940
❑ Community
'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: 7
z5 ✓`�
S
1A
g � �
This is to certify that the information provided is correct to the best of my knowledge,
incurred from thi application.
We-
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 De�wwe Co my Health Department to enter upon above described
property located in Davie County and owned by .'45 c, Fodr, esv;iOP1
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �1^�
ADDRESS
PROPOSED FACIILTY�'
DATE EVALUATED/
PROPERTY SIZE
LOCATION OF SITE �('�ll�..f •��
Water Supply:
On -Site Well
_ Community
Public t/
Evaluation By:
Auger Boring
Pit (�
Cut
FACTORS
1 2 3 4
Landscape position
Sloe Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence IEEE✓
Structure
l
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY: 11 ' //
OTHER(S) PRESENT:
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave s1oDe 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- V -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
5C --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/ft2