191 Bridle Lane Lot 1AUTHORIZATION NO: 0 5 3 3 DAVIE COUNTY HEALTH DEPARTMENT d
` Environmental Health Section PROPERTY INFORMATION
I'ermittee's .. P.O. Box 848 �
Name: f �� Mocksville, NC 27028 Subdivision Name: d I j'jC�
�/ Phone #: 704-634-8760
Directions to property: %Sf. �'I / _ .%'.v�= Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#� /rte- _
SYSTEM CONSTRUCTION
�'��/��CK n '� •t�csf i" �r.�l Ck` - .i i l��'���r 'fl, Road Name: .?PA"
✓ Zip:
**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
a 1�AIi •}"y'�s l� Ian t%, } !(} (� IS VALID FOR A PERIOD OF FIVE YEARS. i
ENVIRONMENTAL HEAffff SPECIALIST DATE ISSUED
-- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
-Permif�ts�'s
4; Name: /;rt; Subdivision Name 4,
Directions to property: �r'; �l� '�✓� ? Section: Lot: _
IIVIPROVEMENT
PERMIT Tax Ofice PIN:#. ' '
'Road Name �', �%�� ✓ 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
constructiontinstallation 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
jf� tr; 7 �;' j� PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
.ONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE Z-1 _ # BEDROOMS �_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE f TYPE WATER SUPPLY
DESIGN WASTEWATER FLOW (GPD) :t:rZ1 Cl) NEW SITE—L1--**-'
REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE .,-GSA/L. PUMP TANK GAL. TRENCH WIDTH S ROCK DEPTH LINEAR FT. T!}
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 INSTALLED BY:
Z O
O AZj
t'
AUTHORIZATION NO. v5 :5� OPERATION PERMIT BY: DATE: �� 1
**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)
I
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE T� IE OWE W 2
Davie County Health Department V L5
Environmental Health Section
Ae, 'ed s i � MocP. 0'� . B x 27028 h �� , O )996
Application/Permit Requested By /� p
Mailing Address a' L/ K. A � '�� d Home Phone 7 57O S L 5`
11 C_ a- 2 a �P Business Phone
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve: W140use
56eneral Evaluation
❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision $ La � ---7k1^ m Section S Lot #
No. of People
No. of Bedrooms
I
No. of Bathrooms a -;--
Dwelling Dimensions
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: ❑ Public �� 7 Gi!/t�.o rivate
8. Property Dimensions ��L �a� Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
D,E asement/Plumbing
❑ �BasemenUNo Plumbing
d Washing Machine
Dishwasher
Garbage Disposal
❑ Yes 9-110
❑ Community
'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: Tax Office PIN: #_5 8'70-6 a- ;)%?q
(A `1
PROPERTY AbbRE641-c—
(S�S , Ia s fr oi t ows :
1 +urA R; �vv� Road Name: 64l� L6A'�
V �
6 1` " rvA e.VL __ r b,Pew City: 6 �
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 thisapplication.
DATE A SIG TIRE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. n-2. I 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 representable gf the D' avi ou ty Hylth epartment to enter upon above described
property located in Davie County and owned by D /t/ /t� �_S ei
to conduct all testing procedures as necessary to determine said site's suita ' 'ty for a ground absorption sewage treatment
and disposal system. /f
DATE /1 SIGNATURE
DCHD (1/93)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED .;E � ��
PROPERTY SIZE d AAC
LOCATION OF SITE
Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH A
Texture group
Consistence
Structure
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: r� EVALUATED BY: `4
LONG-TERM ACCEPTANCE RATE: P 7 OTHER(S) PRESENT:
REMARKS:
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- Ve-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
Mineraloey
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
DCHD(01-901
Davie County 71ealK rDepaitment
and .dome Nealt§ ffyency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
July 22, 1996
Chris Angell
124 Canton Rd.
Advance, N.C. 27006
Re: Site Evaluation
Bridle Lane/Rabbit Farm Lot 1
Tax PIN: #5870-62-2779
Dear Mr. Anqell:
As requested, a representative from this office visited the aforementioned
site on July 18, 1996. Based upon the information provided on the application
for site evaluation and after the evaluation was completed, the site was found
to be provisionally suitable for the installation of an on-site sewage disposal
system.
If you have any questions, please feel free to contact this office.
RBH/wd
Enclosure(s)
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section