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172 Oakland Avenue Lot 34AUTHORIZATION NO: 0749 DAVIE COUNTY HEALTH DEPARTMENT s ' Environmental Health Section PROPERTY INFORMATION PerixutL e's ' P.O.: Box 848 _ r^.�-:-GE's.+ } Name: :�, �? Mocksville,NC 27028 Subdivision Name:o�°.��•-rte+a Phone #: 704-634-8760°� Directions to property , s.�:?`1`+°' Section: Lot:" AUTHORIZATION FOR � WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION j Road Name: �fi/{!!��'�1,j1l� Zip: �i r �Y **NOTE** This Authorization for Wastewater System Construction MUST BEISSUED 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) '` j + f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTOVECIALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT wd"x-- IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION - y Peri tte6, S f/ t 3 Names'<'r F.�.:,?'I ';.' I Subdivision Name C�'_J" 'Directions -to property:;, a" tR`t s -,iY ISE;' j Section: Lot: IMPROVEMENT e PERMIT. Tax Office PIN:#/ Road Name: u';f' % %t f: A) IL Zip: 2r i',1 **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' st 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 HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �= # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No J COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE l/REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE d i GAL. PUMP TANK GAL. TRENCH REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ROCK DEPTH ,�LL LINEAR **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. i OPERATION PERMIT SYSTEM INSTALLED BY: 0— I D AUTHORIZATION NO. 101 YA OPERATION PERMIT BY: ,4) f lrie"'DJ� 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 PER]a _ Davie County Health Department D Environmental Health Section P.O. Box 848 EMAR E-7 1997 Mocksville, NC 27028 M (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be BilledpYvi Contact Person S AYNN� Mailing Address LOU Homel Phone City/State/Zip lM/ U J O ir—AJ-(-- a— l -01t Business) Phone l T40 — 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [ate Evaluation City/State/Zip [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [v}'House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: #People #Bedrooms # Bathrooms _[�shwasher [ ] Garbage Disposal [ gashing Machine [ ] 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: [ ounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes H'go If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***. ;AT OF THE PROPERTY MUST BE SUBMITTED WITHH]�S APPLICATION. 6 0 Property Dimensions: : WRITE DIRECTIONS (from1Vlocksville) TO PROPERTY: Tax Office PIN: Property Address: Road Name / City/Zip �'� k OLJG If in Subdivision provide information, as follows: Name: Section: ��Lot #: 5 I 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 thi application. I, hereby, give consent to the Authorized Represent ive of the Davie County Health Department to enter upon above de cribed property located in Davie County and owned to co uct all testing procedures as necessary to determine the site suitability. I � DATE — --G SIGNATURE Revised DCHD (06-96) THIS AREA AlAy BE USED FOR DRAIVINC7 YOUR SITE PLAN: v1 M ` I l� 7' %;�;: a �: .• � '�� .• 0 0 ria J � t V zoo. 0 ' w 4 33 i Ry tiC2. 40 `fit. ,)• .'a4 '' . ' ♦7 � r; y, rye) } i oo•o oa. o . sir .s,{. .�•\'� DAME CCONTY jP ,,• i `��, -_ .— -Sairman d4 County r`cortify that %oilI ward duly approved the final plat iiion em i . ®r. day of 1 _Z.__ t ti, I n Choirn►an of s „ 4fY that SOW 3oord duly approved tho final plat �: � ,'It�riniavt wttltls�i Ty,E V >a 0 'O®•• �l d � r h ° 68 Ty,E DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_/ LOTtt` Soil/Site Evaluation APPLICANT'S NAME x �DTE EVALUATED PROPOSED FACILITY PROPERTY SIZE /� G SUBDIVISION�,��1[� >i/r •�r��i� ROAD NAME./�� Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS 1 2 3 1 4 5 6 7 Landscape position I Slope % I HORIZON I DEPTH Texture groupI Consistence 1 Structure I MineralogyI HORIZON II DEPTH izc " ' C ►' Texture groupC C 1 Consistence r - Structure Mineralogyl I HORIZON III DEPTH Texture groupI Consistence Structure I MineralogyI HORIZON IV DEPTH Texture group Consistence 1 Structure I MineralogyI SOIL WETNESS I RESTRICTIVE HORIZON SAPROLITE I CLASSIFICATION LONG-TERM ACCEPTANCE RATE , I SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: , C_ REMARKS: LEGEND EVIALUATION BY: I OTHER(S) PRESENT: 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 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 (01-90) ■ ■ ■ NOME NOME MEMO mono NONE ■ ■ OMEN ■ ■■■EM■ ■■■N■■ ■O■MEME■ ■■mm■m■■ ■EMEMME■ ■m■■mm■■ ■E■■■OM■ ■M■EM■■■ ■EMEMME■ ■EMEM■E■ ■E■MEME■ ■EMEMN■■ ■OMEMME■ ■O■■■M■■ ■E■■EMM■ ■■EMEME■ ■EMMEME■ ■E■■EME■ ■■■MEM■■ ■ME■MO■■ ■EMMEME■ ■E■■E■M■ ■E■MEME■ ■■mm■m■■ ■E■EMME■ ■E■■E■E■ ■■ME■ME■ ■OM■■EM■ ■■■EMEM■ ■O■■EME■ ■■M■■ME■ ■■■Non■■ ■EMM\l1■■ ■■■■■illorA ■■■■■■■■ ■■■mono■ ■■■■■n■■ ■■■■■■■■ ■■■■■■■■ ■ ■ ■EM■■■■UM■E■■■■■■■■■ ■■■■■E■ ■■■■■■■■■■■■ ■■■■■rim■■■■■■■■■■■■■■ ■■■NEE.■■■■■■■■■■■■■. ■■N■■■■ ■NEEM■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■EO■■SME■■Om■E■■■■ 00 ■ ■EM■EME■■ME■ ■EMEMEMEME■■ ■E■■ME■E■EM■ ■■M■■M■■■■M■ ■■MOM■E■EME■ ■EMMEME■EMM■ ■EME■EMMEMM■ ■■MMEME■■ME■ ■EM■MEM■■EM■ ■EMEMEMEMEM■ ■■■■■■mom■■■ ■MM■NME■■MM■ ■EO■MEM■EME■ ■EME■EMEMEM■ ■MMEMMEME■■■ ■■MME■n■■MM■ ■ME■M■■■MME■ ■EM■M■MEMEM■ ■OE■ NEON OMEN NEON ■EM■ NONE NEON ■E■■ mono ■■N■ ■E■■ NONE