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381 Michaels Road Lot 22:r� aco ,. AUTHORIZATION NO: '14 4 7 DAVIE COUNTY HEALTH DEPARTMENT .' *:w " 1, % Environmental Health Section PROPERTY INFORMATION Permittte's f P.O. Box 848 Name: Mocksville, NC 27028 Subdivision Name:C" Ir Phone #: 704-634-8760 Directions to property: %' f / r`' ?" Section: Lot: AUTHORIZATION FORWASTEWATER 7 ' SYSTEM CONSTRUCTION Tax Office PIN:# ,��146- ry ® r Road Name: X711 1 C'_ it Q ek Zip: ` rl o "7 Q **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 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED • 1 '•'DAME COU . s HEALTH DEPARTMENT M �'. •' PROVELWAND OPERATION PERMITS PROPERTY INFORMATION amem asSubdivision Name: Dliectl0[�S,to property, r' ,fir f W. Section: Lot: IMPROVEN[ENT �v PERMFT Tax Office PIN:# [ � . 4- - f Road Name: Zip:�,A '*NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system Ani AUTHORIZATION FOR WASTEWATER. SYSTEM CONSTRUCITON 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 13QA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) **NOTICE*** THLS PERMIT IS SUBJECT TO REVOCATION IF SITE " f IN PLANS OR THE TENDED USE CHANGE YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE dis... # BEDROOMS 1-9 # BATHS 2- # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE ' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No IAT SIZE TYPE WATER SUPPLY_ 'DESIGN WASTEWATER FLOWi(GPD) JCS NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK S GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /. LINEAR Fr. �� + OTHER. : ;REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "CONTACT A REPRESENTATIVE OF THE DAVIE BETWEEN 8:30 ,L00 A.M. OR 1:00 - 1:30 P OPERATION PERMIT s )EPA'RTMENT FOR FINAL INSPECTION OF THIS SYSTEM INSTALLATION. TELEPHONE # IS (704) 6348760. - " SYSTEM INS . •F • s: -, ..:�.mwi'�y •.s rq+�...�ku.'Wt�-%•:4z4'+q.[ . c t < AUTHORIZATION NO. OPERATION PERMIT BY:DATE: e:� ' /A *'TEE 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 SHALLYN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 03/96 (Revised) r #, DAVIE COUNTY HEALTH DEPARTMENT °' - IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �} R Perrrnttee s . Names - F Directions to property: Subdivision Name. Section: ! Lot: IMPROVEMENT PERMIT Tax Office PIN:#99 �f - Road Name t1 ` xi =' 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 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 f % /7 # BEDROOMS rP # BATHS :P # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE,/? Iit f- TYPE WATER SUPPLY ^ DESIGN WASTEWATER FLOW (GPD) '—_ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ' GAL. PUMP TANK GAL. TRENCH WIDTH- J `, �t"- %� ROCK DEPTH �• LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: 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 INST�Li.�B-BA' AUTHORIZATION NO.--,/-/ L-21 OPERATION PERMIT BY: fes. /� �.� DATE: **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) �'w •, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI O Davie County Health Department r:—i— JUL 2 I 1995 t I He Ith Section /r Lk rmen a a P. O. Box 665 Mocksville, NC 27028 EALiH 1. Application/Permit Requested By ! o'? 'U Irm .Ser -1/;e— C• e'Jr e yi cei Mailing Address t._ . t/ ! I Home Phone r / // ,, iS-usinesss hone Oy 2. Name on Permit if Different than Above 3. Application for: 90 . Evaluation E' <eptic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly) ❑ Business ❑ Industry nn. ❑ Other >Jf-gS ❑ Unknown 5. If house, mobile home: Subdivision ✓Teta— ��� Section _ Z Lot # 7 No. of People No. of Bedrooms No. of Bathrooms f�- Dwelling Dimensions ` 100 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ❑ Private 8. Property Dimensions ,�L' O �� si ,�Q ©� 14— Sewage Disposal Contractor 1-11 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine El Dishwasher ❑ .Garbage Disposal ❑ Yes "o ❑ 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: �0/ Sa.A J�,- �G 2 l 1 4 �, ,rr7 s V This is to certify that the information provided is correct to the best of my knowledge, incurred from thi a plication. 1 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 Department to enter upon above described property located in Davie County and owned by / ii s a f-0 &Z ge*6 _ �"14 . to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 11" ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE -/00 YX00) LOCATION OF SITE Water Supply: On -Site Well _ Community Public c� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L, Z_ Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group' Consistence Structure 1 i 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: LDNG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: j 6/9 /` 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 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- Vl---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 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