244-274 Swicegood Street Lots 1A & 1BPermltte
Name.
_.
Directi�
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
t P.O. Box 848
Isloproperty �/�z�"��'��� Mocksville NC27028 Subdivision Name:
AUTHORIZATION NO:
/► Y Phone #: 336-751-8760. '
' Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# t
SYSTEM CONSTRUCTION —
002568 A Road Name: ZiD:
**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 I 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMSI # BATHS # OCCUPANTS7 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT _.\ry_/ # SEATS T INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY —za_ DESIGN WASTEWATER FLOW ,(GPD) NEW SITE - REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL.. TRENCH WIDTH �"' ROCK DEPTH 0LINEAR FTAL/ !,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUZ— -
lpw
w k
FOR FINAL INSPECTION OF TIES SYSTEM PLEASE CALL BETWEEN 6:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760 ; t: ' ).
q
OPERATION PERMIT F
SYSTEM INSTALLED BY:
N
o
' AUTHORIZATION NOe���OPERATION PERMIT BY: - DATE:..
++THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S. CHAPTER I30A, 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. '
ocxDovae(RvsM) �nJ L -/'F-7-7 !,, . .
'k. �6+� �. .irJ 'l.:.µ"'V✓rr✓r. pA `. 'L 3'si`h1 �"e� 5 YYi::I � ✓I b17 'V %.�e...k4r`�./,J .r f - b.. •. ;y;�'
`a Pe�tee's� f , !./I f DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
A
}mk
/-
Direec/ho� s to props ,;f� F /� �'�r' Mocksville,C 27028 Subdivision Name: �'i:; .NPhone #: 336-751-8760
Section: Lot:
o - ` AUTHORIZATION FOR
- WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# -
iAUTHORIZATIONNO: 002568 A Road Name: 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 Forin/Authorization Number should,be.presented to the Davie County Building Inspections
Office when applying for Building Permits.
11 .�6mpliance wih Article I I 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE #BEDROOMS f #BATHS # OCCUPANTS GARBAGE DISPOSAL: Ys or No�...
\
COMMERCIAL SPECIFICATION: FACILITY TYPE It PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)ANEW SITE REPAIR SITE �7/'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH " ,ROCK DEPTH alLINEAR Fr. v 1 ),
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOU&,, t ,
4d
� l
orf -
t
�y,
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL' BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE It IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: D /
r*
AUTHORIZATION NO.ay�-moi—OPERATION PERMIT BY: - DATE:
*4HE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE it OF G.S. CHAPTER 130A, SECTION r 1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILLFUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 6112 (R*viR4 r % .. r / -;+- ' L-/ q'/ -7 `% W 7P 7
,w DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
lliN Ar) PHONE NUMBER
( �/A* U SUBDIVISION NAME
6 O _ -B t �� LOT #
DIRECTIONS TO
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITYM-O-- NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED ZS INFORMATION TAKEN BY MV
This Is to certify that the Information provided is correct to the beat of my knowled ,end U7 I understand I ern respygeible for all chargee Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED
Rev. 1193
... nuo r/,mrnuvtnlrlyl PEBMII & AIC
Davie County Health Department
Env/ronmenb/Ne,710 SMWO,7
P.O. Boz 848/210 Hospital Street
MCCkBville, NC 27028
13361751-8760
***IIHpORTANT*** THIS APPLICATIOH CANNOT BIF::O 95M UMM*99 ALL Tt
INFORMATION IS PROVIDED, Refer to the INFORMATION M"TIN for it
1. Name to be Billed
Contact Person
Mailing Address
Home Phone
City/state/LIP C
Buslness Phone .7 %
2. Nam° on Permit/ASC it Different than AbM,
Mailing Address
3. Application For: U Site Evaluation
4- system to service: 0 House W19bile Home
s. If Residence: / People
:] Dishwasher D Garbage Disposal
— a..,n, vfl —
�-u
NOV 2 5 Iggg
itQRI i NTAL HEALTI
IE COUNTY
me o
I I6 �nO � 1nii�.
city/state/zip _ f -
U Improvement Permit/ATC th
D Business 11 Industry 0 Other
i Bedrooms - gBathrooms _
D Washing Machine
6. If Business/Industry/Other: Specify type
CO00Od°° a showers
IF FOODSERVICE:
g
D Basement/Plumbing D Basement/No Plenbing
x People a sinks
/ Urinals a Water Coolers
Seats Estimated Nater Usage q (gallon per day)
7. Type of Mater supply:nn/ e>aAell
D Conmunity
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve! p yes
l] No
If yes, what type!
***IMPORTANT%*• CLIENTS AlUSTCOAtPLE7E THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN
NAIUST BESUBM/TIED b the clleot with THIS APPLICATION.
Property Dimensions: .S2L" — WRITE DIRECTIONS (from Mocluvllle) to PROPERTY:
Tai Office PIN: #-,J 5-46 tIoI.S-�� FD IS
Properly Address: Road Name i S'f _%a5 �e � oo ,Si.✓1cr'4v�
City/Zip P.Q 7n 6 C
If In a Subdivision provide information, as follows:
Name: Duh 1 A r
• Let: Section Block: R �^
—�— 98ak Property )'lagged: Z 67�
This is to certify that the Information provided Is correct try the bee'. 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 tf the information
submitted In this application b falsified or ehaoged I, also, unde stand Kiat L am rmponsfble jor all ift he l o located hoar
this appMeadmi, 1, hereby, give consent to the Authorized Representative of the DaVIpCounty Health DeparlmeDf, i
10 enter upon above described property located in Davie County and owned by _ I o 4 Qy- — f Mm i r. i dcl 5
to conduct all testing procedures as necessary to determine the site mitali In
DATE =�r� 5 9.6 SIGNATURE �Ign
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ I of the folio1dr. Existing and proposed
IMorr,•eerty lines and dimensions, structures, setbacks, and septic locations).
Account Na
Revised DCHD (o7/98)
Invoice Na
HORIZON• I DEPTHS®®®®A®
Consistence
®®---o—
HORIZON III DEPTH
rcn0 r xx, r r v n nUMLIJIN -
SAPROLrrE
CLASSIFICATION ..
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM
ACCEPTANCE RATE: 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 clay loam SII. - Silty loam CL - Clay loam SCL Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
ist
VFR - Very friable FR - Friable FI Finn VFI Very' firm EFI - Extremely firm
Wet
NS - Non sticky SS Slightly sticky S .StickyVS -Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
tructure
SC - 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
DcxD(01-90)
This � m
_-'AUTHORIZATION
co S u
*'�7,�r
[,n compjj6cwith Article 1,1 of G.S': Chapter 130A Wastewater Systems $echon 1900 Sewage Treatment ani
f I
y y.�.,:'?O**NOTICEII**THIS PERMIT ISSUBJ
1 N PLANS OR TI]KENITENDED USE'CHA
or any wastewater' system .An
Department'
pnor to the
Disposal systems)
f TO REVOCATION IF SITE',;'
:,SYSTEM SO
RE
TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITEREPAIR SITE��
P120r. Q,,A�
07VEMENT PERMIT LAYOUT
1-)Zprl 4; A
nes
SYSTEM.-',
M H
#BEDROOMS-
#BATHS' 2
# OCCUPANTS
GARBAGE DISPOSAL: Yes 6
RESIDENTIAL SPECIFICATION: BUILDING TYPE
0
COMMERCIALSPECIFICATION: FACILITY TYPE*
# PEOPLE
h
# PEOPLE/SHIFT
4 SEATS
INDUSTRIAL WASTE: Yes'or No.
:,SYSTEM SO
RE
TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITEREPAIR SITE��
P120r. Q,,A�
07VEMENT PERMIT LAYOUT
1-)Zprl 4; A
Davie County Healih Department
r - ✓ " �' Envlmnmenfa/HealthSeWon r7
-� P.O. Box 868/210 Hospital Street
Moetcsville, NO 27028
(336)781-8760
*i*�ORq.AZM*** THIS APPLICATION CtMW BE PROCESSED UNLESS ALL THE
IMMM ATION IS PROVIDED. Refer to the INr0RHATION BULLETIN for ins
gam lobe -Willed 7 t
Contact Persue ��
Milling AddressUS A
Some Pham
city/state/LIP
Uses on Pe=at/ATC It Dlefereat than Above
Mailing Address
Applioation Por: U Site Evaluation
system to service: D House 9 -196 -bile Home
If Residence: I People
0 Dishwasher D Garbage Disposal
1
NOV 2 5 1998
0 Xuprovement Permit/ATC Jsaga-
D Business O Industry D Other
6 Bedrooms_ f Bathrooms _
0 Washing Machine
0 Sasemeet/Plmbing
Ie Business/Industry/other: gpeciep type
Commodes i showers
IP FOODSERVICE: F Seats
2nWJ of water supply:
f People
i Urinals
0 Saseeent/Wo Plunbing
/ sinks
i water Coolers
Estimated Water `O"saagge igallons per day)
9 onnty/City rf'teli D Conmunity
Do you anticipate additions or elpandons of the facility this system is intended to serve? D Yes
0 No
if Yes, What type?
"""IMPORTANT"•" CLIENTS fitunca"PLE'rETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either 2PLATor Mira ell ANAfUSTBESUBuirizibythedlent With THISAPPLIVATenN
Property Dimensions: _ $; WRM DIRECiIONS (from MockWIle) to PROPERTY:
faI Office PIN: %0gs i7a'-0®
Properly Address: Road Name / f St l s
�e C,
i,Vx e404
Clty/Zip QQYn60 L
if in a Subdivision provide lorormallon, a follows: "�
Name: 7.(11 I D t -
a
lection: Block: Lot: 8 Date Property Flagged: - /%67
ils is to certify that The isformalion provided is correct to the best of my knowledge. I understand that any permit(s)
ued hereafter are subject to suspension or revocation, If the site plans or intended use change, or if the loformalion
bmilted in this application is falsi0ed or changed. 1, aloe, anderstmrd that 1 am rrsponsihlefor all charges incurred fro,W
s aWfirfi dos. 1, hereby, give consent to the Authorized Representative of the Davjg Counh Heallb�epartmeDf,
toter upon above described properly located In Davie County and owned by _ F p ey- — J� � m t , L ye� S
moduct all testing procedures as necessary to determine the site "ItsIif 0 ` J
LTE SIGNATURE_ �'/l fitjl/!!
IIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Incinddfd( of the fol lag: Eststing and proposed
)Perty lines and dimensions, structures, setbacks, sod septic locations).
Account No.
deed DCHD (07198)
Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section. sECTloly LOT I_L;
Soil/Site Evaluation'
APPLICANT'S NAME DATE EVALUATED lJ2�iry�J
PROPOSED FACILITY r r l h�f1/� PROPERTY SIZE ' S Z to S R L
SUBDIVISION ROAD NAME • - dWlCf(t47�I S
Water Supply: On -Site Well Community Public
Evaluation B /
y Aue' g r Boring t .: Pit Cut .
FACTORS, 1 2 3 ., 4 5 6 7.
Ua—
ndscape position L L
Slope % .
HORIZON I DEPTH p - top -
Texture group Cc_
Consistence'
StructureCr4 C2
Mineralogy1: 1
HORIZON II DEPTH -3
Texture groupG
Consistence " S
Structure
Mineralogy1: ( I
.
HORIZON III DEPTH - L
Texture groupCtS E
Consistence
Structure
Mineralogy
r _
HORIZON IV DEPTH -
Texture group
Consistence .
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE O,
SITE CLASSIFICATION: yam' EVALUATION BY:
LONG-TERM ACCEPTANCE RATE CJ • OTHER(S) PRESENT:
REMARKS -
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose'slope
Concaveslope CV - Convex slope T - Terrace FP - Flood plain H.- Head slope
CTC -ext re
S Sand LS - Loamy sand SL -Sandy loam L - Loam SI - Silt .
SICL - Silty'clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE .
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
SC - 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
DCHD(01-90) - .
No