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150 Oakland Avenue Lot 31Y . ♦h § :.. t M'...15'. r .. _ --�., Y t ` T .. '+,.._) . .. r t' /( v 1134 `/-o' '' AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION __: . e'er aittee's -- ---_P.O:-Box-848----- Name:. "�, ,"�* a''� ? Mocksville, NC 27028 Subdivision Name: Directions to property: %.i ' /i� J� !T Phone #: 704-634-8760 ..F Section: Lot:' AUTHORIZATION FOR WASTEWATER Tax fid- 1r SYSTEM CONSTRUCTION Office PIN:#/ Q 11 Zip IrldA Road Name:<��lltl tL **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) X) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � / ,' -,-. � IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAL�TI- SPECIALIST DATE ISSUED'r DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION . Permlttes Name. "j ,: .;Directions to property =' IMPROVEMENT PERMIT Subdivision Name r �r,'sZz ':'��° Section: a'`� Lot: � �= Tax Office,PIN:# Road Name: ZiD: --i **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 .19(0 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 # BEDROOMS 1-? # BATHS ✓_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No r COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT �> # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) lr NEW SITE �j� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE,'C J GAL. PUMP TANK GAL. TRENCH WIDTH(ROCK DEPTH .� LINEAR Fr.�% �I 11TLIR4 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) 6348760. OPERATION PERMIT SYSTEM INSTALLED BY: j I �s i AUTHORIZATION NO. Z/V OPERATION PERMIT BY: 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) 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 PROCESSED THE REQUIRED INFORMATION IS PROVIDED -CEIVE l ► � �!. Ys� Il_ 1. Name + be Billed V t= t Contact Person Mair..- s Address d Home Phone / J�, City/State/Zip \ G� Business Phone �r�, %�% ��(�Ydbf�-rt. 2. Name o i Permit/ATC if Different than Above Mailing Address City/State/Zip I 3. Application For: Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [y} i ouse [ ] Mobile Home [ ] Business [ J Industry ![ ] Other 5. If Residence: # People # Bedrooms -3 # Bathrooms-, [ ,Dishwasher [ ] Garbage Disposal [vf Washing Machine [ J Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [►�Count /CitY Well Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [vrNo If yes, -hat type? EITHER A PLAT Olt SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***1r 1 RIT OF THE PROPERTY MUST BE ` SUBMITTEDWITHTHIS APPLICATION. Propert; Dimensions: l�d WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax O, ' ce PIN: #LM 9 K.- -C� 1)' - , .I e- _ Prop...; Address: Road ame e'4 6=n=4 A74— '� City/Zip 7 0c 1///& J If in Subdivision provide information, as.follows: Name: QA KL__�l d o' Section: % Lot #• This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are I subject to suspension 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 Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by h'c`�(�N tJ fi 1✓ � =� t F c all testin procedures as necessary to determine the site suitability. DATE. lL SIGNATURE Revised DCHD (06-96) THIS APEA AAy BE USED FOR D1tA1VINC JOUP SITE PLAN: �' 13/ ' `qCD � f 1 w n` ^¢ionppL J � ; Department of Hur- an Resou ---D7ivisbn of J r•,h ,� • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION__ LOT Soil/Site Evaluation APPLICANT'S NAME X / PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring L/ Pit DATE EVALUATED PROPERTY SIZEAle— ROAD NAME C/ I� i1 /ff rJ� %� 1/ e- - I Public Z/ Cut FACTORS 1 2 3 1 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �- I Texture groupI Consistence Structure S 10 Mineralogy ` / I HORIZON III DEPTH Texture group Consistence ! Structure I Mineralogy HORIZON IV DEPTH Texture groupI Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION I LONG-TERM ACCEPTANCE RATE , 1 SITE CLASSIFICATION: e 'z EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: I I REMARKS: LEGEND Landscaue 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 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 DCHD (O1-90) SEEN ■■M■ SOON NEON ■■M■ MOON NEON ■■M■ ■O■■ ■■M■ NEON ■■M■ MEMO MEMO ■■M■ ■■H■ ■■O■ ■■1 ■ ■ ■M■■■■■■ ENMESHES ■M■EMM■■ ■EM■■MM■ ■■E■■EM■ Monosson ■MEMEME■ ■ ■EMMU■ ■OH■ ■ ■EMME■■ ■ME■■S■ monsoon ■E■■EM■ ■EMMM■■ SOMEONE monsoon ■E■MM■■ ■E■■ME■ ■M■■M■■ ■■MEMS■ ■E■MEE■ ■■ME■■■ monsoon ■EMEMM■ monsoon ■■ME■■■ ■EM■ME■ SOMEONE ■■M■■M■ ■EMEM■■ ■■■EM■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NEON ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ME ME■NE■ ME■EM■ ■■E■■EZ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■M■■■■■■ ENMESHES ■M■EMM■■ ■EM■■MM■ ■■E■■EM■ Monosson ■MEMEME■ ■ ■EMMU■ ■OH■ ■ ■EMME■■ ■ME■■S■ monsoon ■E■■EM■ ■EMMM■■ SOMEONE monsoon ■E■MM■■ ■E■■ME■ ■M■■M■■ ■■MEMS■ ■E■MEE■ ■■ME■■■ monsoon ■EMEMM■ monsoon ■■ME■■■ ■EM■ME■ SOMEONE ■■M■■M■ ■EMEM■■ ■■■EM■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NEON