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156 Oakland Avenue Lot 32r�� •'-� � . .i tc x`�y: . N• :�r_ . .. -. _ - . - � ��hV y AUTH6RIZATION NO: 10 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's ^�a�--P.O.-Box-848 ----- — ---- Name <4j/ r: 1� :�/,y-a%r,_�% Mocksville, NC 27028 Subdivision Name:��f7`/f Phone #: 704-634-8760 Section: -Lot: Directions to property: > " i{� r f } s r; :�:: _. + �', if / o � AUTHORIZATION FOR _ WASTEWATER Tax Office PIN:# il, SYSTEM CONSTRUCTION Road Name: **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) t rj •','i 4� .�� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ��r/ -oy �s IS VALID FOR A PERIOD OF FIVE YEARS. ElMkONME14TAL HEALTH SPECIALIST DATE ISSUED r $� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION )Se�rrllttee's Name r f> r i Jr,. ,: �` Subdivision Name G2 ' z, ��^ ��J�✓ Direciions to property: •.` ' `� �' e*' d` Section: �' Lot: t IMPROVEMENT �. jPERMIT Tax Office PIN:#iia Road Name: ` r. :r f �-^Zip: 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 .1900 Sewage Treatment and Disposal Systems) r • i i ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL HErALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE - rte— # BEDROOMS--? # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZFf-'� TYPE WATER SUPPLY c > DESIGN WASTEWATER FLOW (GPV)� Y" NEW SITE REPAIR SITE '- d .1 SYSTEM SPECIFICATIONS: TANK SIZE G� �� GAL. PUMP TANK GAL. TRENCH,WIDTH � ROCK DEPTH %-ILINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT r i **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: �+►I �Cl.1L t7;��iia oosc OS I F 2u�J � ►z° ' [3-- i � n t..►,xa �JL:-I tTiW�.i-1�Ti� 4T AUTHORIZATION NO. (�Zf OPERATION PERMIT BY: J DATE: Z CT— **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESC 1BED 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 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED THE REQUIRED INFORMATION IS PROVIDED. 2. Name to be Billed v' Contact Person Mailing Address,, JJ 'v Ho ie Phone City/State/Zip �7 �� 1 4� pr )aO�OBusiness Phone Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [1?/Site Evaluation I City/State/Zip ] Improvement Permit & ATC [ ] Both 4. System to Serve: [use [ ] Mobile Home [ ] Business [ ] Industry 5. If Residence: # People # Bedrooms # Bathrooms-,)---- [ Li"Washing athrooms_[1i"Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing Other R-115ishwasher [ ] Garbage Disposal 6. If Business/Other: Specify type # People I #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) WCounty/City7. Type of water supply: [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No Ifyes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT'AT OF THE PROPERTY MUST BE r � SUBMITTED WITH THIS APPLICATION. Property Dimensions: WjjRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: l ► t g5 �'y-�t w J I e� Property Address: Road Mame <� t At c�I City/Zip �f �d _ � If in Subdivision provide 'nformation, as follows: I + Name: Section: Lot #: ' � l � 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 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 i^ C ! taxonduct all testing proc res as necessary to determine the site suitability. DATE - SIGNATURE �= ` Revised DCHD (06-96) THIS AREA MAY 13E USED FOR DRAWING YOUR SITE PLAN: 7- �'� y- y� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION SECTION_ LOT Y'Z✓ DATE EVALUATED PROPERTY SIZE - ROAD NAME I Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure ✓C 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: REMARKS: DCHD (O1-90) EVALUATION BY: OTHER(S) PRESENT: i 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 SICL - Silty clay loam SIL - Silty loam CL - Clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm Wet SI - Silt SCL - Sandy clay loam EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP f Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - SBK - Subangular blocky PL - Platy PR - Prismatic ABK - Angular blocky 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 SEEN MEMO ■■E■ ■ ■ ■ ■ ■ ■ ■ ■EN■■ ■■■E■ ■■SE■ ■ENE■ ■■■E■ ■■■M■ ■EE■■ ■o■ ■o■ ■o■ ■ENN■■ ■■■EM■ ■E■■M■ ■ENNE■ ■■E■ES■ ■MEN■M■ ■M■■MS■ ■E■MEM■ ■ENEH■ ■ ■EE■■ ■■NE■ ■ENE■ ■■M■■ ■ENE■ ■ENE■ ■ ■ ■■■MM■■ ■■■mono ■MENME■ ■E■■M■■ ■EMMEM■ ■■MME■■ ■EENE■■ ■N■■■E■ ■■■■■■■ ■■M■MEM■ ■MEMENN■ ■E■E■ME■ ■N■■NEE■ ■■MMEME■ ■EM■■ME■ ■M■mm"■ ■■■mm■■■■■■ ■EEME■■E■E■ ■EE■■MEMME■ ■M■M■M■■MM■ ■E■■N■E■■M■ ■■E■■M■MM■■ ■EMME■■M■S■ ■EMM■NMEME■ ■■N■MEM■EN■ ■MEM■EME■■■ ■E■■M■EMEM■ ■■M■MEM■E■■ ■EMEMEMEME■ ■EMEM■M■NM■