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135 Oakridge Lane Lot 77PQ • N - wtr;- :"qf `- 1:111:04 i`i.%`jc�l%J`'"Yfi,�' S :'`y ��l`y'�e�Y't"/fi �icc�11�yYij.l....Horny ry.ry4 y.,. �v,:.�ry-•=.- ,--.,. -�,r v-.. � --c -- - /f _ ✓ �` Q A _ , R4At30N.go . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P ttee's P.O. Box 848 Name: • �./iKT Mocksvill'e, NC 27028. Subdivision Phone #: 704-634-8760 ��' - Directions to.property: Section: ' , Lot AUTHORIZATION FOR-= WASTEWATER Tax Office PIN:#./_ SYSTEM CONSTRUCTION Road Name: rfd eZip: ea a� *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 Foim/Authorization Number,shouldbe 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*** THLS AUTHORIZATION FOR. WASTEWATER CONSTRUCTION IS VALiD FOR A PERIOD OF.FIVE YEARS. ENVIRONMENTAL HE TH SPECIALIST DATE ISSUED _..._ _ . _. .... ........... .nus. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pm[�ttee's f/ t Name: ' �• �sM.� �':�«+d� rtsx Subdivision Name F�'"` Directions to property: t eN �' . Section:'` Lot: IMPROVEMENT ✓ , �4:, PERMIT Tax Office PIN:# ' Road Name: i't tc E: - Zip: **NOTE** This Improvement Permit DOES NOT authorize the constriction 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 4 E 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 # BEDROOMS w ! # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY r DESIGN WASTEWATER FLOW (GPD) f NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ,&,' GAL. PUMP TANK GAL. TRENCH WIDTH J' ROCK DEPTH , /�' 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 DAYOFj[NSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT — SYSTE I LED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: " G "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) APPLICATION FOR SITE EVALUATIONAMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 NOV - 6 I997 �D ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �' r Contact Person Mailing Address Home Phone- City,'State/Zip Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [-V4ite Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System 'co Serve: [V41House [ ] Mobile Home [ ] Business [ 1 Industry [ ] Other 5. If Resid -nce: # People # Bedrooms # Bathrooms [ aZishwasher [ ] Garbage Disposal [vf Wading Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Busin.ss/Other: Specify type # People #Sinks # Commodes # Show�xs # Urinals # Water Coolers " If Foody ervice: # Seats Estimated Water Usage (gallons`per day) 7. Type o; water supply: [,J'C' ounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [t,J"No If yes. , ,hat type? EITHER A PLAT OR SITE PIAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***cE OF THE PROPERTY MUST L' SUBMITTED WITH THIS APPLICAI... Property Dimensions: 1W X `d �x �WRITE DIRECTIONS (fro4 Mocksville) TO PROPERTY: Tax Office PIN: #,061 - -0 '- Property Address: Road ) ame J� /1 •'7` `J IA J A " 1 City/Zip If in Subdivision provide information, asfollows: Name: ow klmi cl 7)e -/'014 -ham - Cr Section: Lot ' This is to (ertify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to ;uspension 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 Represent,sive of the Davie County Health Department to enterupon above described property located in Davie County and owned by C+ ,/ = ►� 1✓"rV t conduc all :testin procedures as necessary to determine the site suitability. DATE — 1P / SIGNATURE L Revised MID (06-96) . THIS AREA MAY BE USED FOR DRA WI NC YOUR SITE PLAN: �'C 0 1 .: j0G .mac, � � G f o ,' r'J• "' �j 00 I.q 4) '36i ,S.Z;tlrces V, s t �Ir 2ces ...,.ction 47" Department of Human ReSOUIC. D_ivi3F3n of Health Servic.,s J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LOT_U Soil/Site Evaluation APPLICANT'S NAME !�>�/% / DATE EVALUATED Z! PROPOSED FACILITYPROPERTY SIZE tc ,l iKe-1, —. SUBDIVISION �A p �d— `f�l'S i ROAD NAME 0�1-6 GIE— Water Supply: On -Site Well Community. Evaluation By: Auger Boring I Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 41 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH !c Texture group Consistence f Structure Mineralogyit 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 U SITE CLASSIFICATION: — 4 LONG-TERM ACCEPTANCE RATE: i REMARKS: LEGEND DCHD (01-90) Landscape Position EVALUATION BY:.. 1/'// 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 SEEM ■■M■ ■E■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■ ■E■ ■■M■ ■■■■R■ MRM■E■■■N■■■■NE■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■/■■/■■■■■■■■■■Yi/SSSS■■/■/■/■■/■/■■/■/■■■/■■ ■■/■■/■■■■■■■■■/SSSS■■/SSSS■■/■■■■■■■■■■■■■■■■ IMMEMMEMENNEN MENNENMEMMEMMEEMMEMENEM ■■■■■■■■■■■■■■■SSSS/■■■■■■■■■■■■■■■■■■■■■■■/■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■/■■■■■■■■■■■■■■/■■/■■■■■■■■■■/■■/SSSS ■■■■■■■■■■■■/■/■//■/SSSS■■■//■/■■■■■■■■/SSSS■■ ■ ■■■M■ MEMOS ■■■M■ SEMEN RENEE ■E■E■ ■ ■ ■ ■