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114 Oakridge Lane Lot 81AUTHORIZATION NO: 1 4 1 DAVIE COUNTY HEALTH DEPARTMENT ` E Environmental Health Section PROPERTY INFORMATION Perrpittee'$ � r ,.� j , P.O. Box 848 Subdivision Name: #`'t„ ?x ° rr V Name: Mocksville, NC 27028 �i-y-��3 t :,�, Phone #: 704-634-8760 Directions to property: Section: _ Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#M SYSTEM CONSTRUCTION —� Road Name:'0'9/j-'e 2'E:- n: **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. TAL HEALTH SPECIALIST DATE ISSUED /2 q7 Dv ` 1141 DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name Directions to property: A IMPROVEMENT PERMIT a. t Subdivision Name. . 724,71 Section: Lot: 4°it Tax Office PIN:# Road Name. .° d,'. Zip: U **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 14EALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE _ & # BEDROOMS -.3 # BATHS V—# OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL�SPECIFICATION: FACILITY TYPE/i # PEOPLE # PEOPLE/SHIFT ' �) # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZI31c ,0d TYPE WATER SUPPLY l 5 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH 3� /ROCK DEPTH rte LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ,1 "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 '70 O SYSTEM INSTALLED BY: T— 4`1.,' -70 (O0 t 01 AUTHORIZATION NO. 1141 OPERAT10N PERMIT BY: 10 -el! "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE'5YSTEM DESCRIBMABOVE 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) A APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department ••• Environmental Health Section', P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ****IM'' ORTANT**** THIS APPLICATION CANNOT BE PROCESSE , THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed V t= Contact Person Mailing Address Home Phone City/State/Zip U Business Phone &q/ � ti '0 f (� T� —7XZ �-- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [y]�ite Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [VKHouse [ ] Mobile Home [ ] Business [ ] Industry 5. If Residence: # People # Bedrooms #Bathrooms_ [+Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing [ ] Other [L ,Dishwasher [ ] Garbage Disposal 6. If Bus' )ass/Other: Specify type # People #Sinks # Showr:rs # Urinals # Water Coolers } ' If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type o" water supply: [vl"C' ounty/City [ ] Well [ ] Community, 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes If yes, -hat type? # Commodes [vJ"No 'A EZTHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***. XL -M OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ,/QQ X 18�� WRITE DIRECTIONS (fro4 Mocksville) TO PROPERTY: Tax Office PIN: #� 9,p - l Property Address: Road lame City/Zip If in Subdivision provide information, as follows: Name: 14,7t J �/0 A -f -5 - Q Section: Lot #: This is,to.certify that the information provided is correct to the bestof my knowledge. I understand that any permit(s) issued hereafter are subject to:�aspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representetive of the �D�avie County Health Department to enter upon above described property located in Davie County and owned byh r� / f=1J 1i W =-1 t conduc all testin procedures as necessary to determine the site suitability. DATE. "' SIGNATURE L Revised DOM (06-96) THIS A':EA MAY 13E USED FOR WaIVZNC YOUR SITE PLAN: �► a--" .. ,. � .. �.,yfir,+ IN 'l -1 j; , � `/ ./ `M � �, .. ..• ' U � � A tom• 40 io 4L-E `vSry o 1 43 r Ix / p �i(r -'"�•� __�—. � n y cry.'. ..,. �6 !! � C iV � ;� Q ~yam +tea.-_•r'x�isr�^:a2•—z�.^: Y F,xes, Approt��d by _ Department of Human Resou-c " rDtvpszon of Health Servic::s DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit -i SECTION_ LOTV DATE EVALUATED /` /u �' / PROPERTY SIZE ROAD NAME e Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position aC. Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH (- f Texture group Consistence Structure k 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: t REMARKS: DCHD (01.90) LEGEND Landscape Position EVALUATION BY: �L OTHER(S) PRESENT: 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 SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist 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 ONES ■■■■ ■N■■ ■EM■ MEMO ■EM■ ■■E■ ■■E■ ■ME■ MEMO NONE ■■E■ SEEN ■■MME■ ■■■■E■ ■MEMS■ ■■M■O■ ■E■N■■ ■ ■ ■E■■MOM■ ■E■EMME■ ■ ■ ■ ■■MEM■ ■■M■O■ iim■■■ ■E■EN■ ■EMNO■ ■■■NO■ ■■NEE■ ■E■NO■ ■E■■E■ ■■■EN■ :iiiim ■EMEM■ ■■■■E■ ■E■EM■ ■■■M■■ ■■E■M■ ■■■■■■ ■ ■ ■ ■ ■ ■OM■E■ SOMME■ ■EMN■■ ■EME■■ ■■E■■■ ■■■■■■ ■EMM■■ ■E■NO■ ■M■■M■ ■ ■