2553 Davie Academy Road Lot 66AUTHORIZATION NO. + DAVIE COUNTY HEALTH DEPARTMENT"``
s Environmental Health Section PROPERTY INFORMATION
Permittee's `y P.O. Box 848 `
Name
Mocksville, NC 27028 Subdivision Name:
i;` Phone #: 704-634-8760 1 %,
Directions to property: s t Section: Lot:
AUTHORIZATION FOR
1 r>il c c- Ctp`i \ 1 C\•�, WASTEWATER Tax Office PIN:476o
SYSTEM CONSTRUCTION
Road Name: J1e, ip
i
**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)
�.� ..• ,..,•.r s��•,� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
- 2 DAVIE COUNTY HEALTH DEPARTMENT - t
r t IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permlttee's «a. w
1 1
Name'
Subdivision Name: U' -C",. F', 1
Directions to property:_ ; �,i - .. �y;�.,r. Section: Lot: !'
�IlVIPROVEMENT
r: t ;, , PERMIT Tax Office PIN:d,r 61
Road Name: IbAli1P ��aI., Z p:
**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 HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE��)-�
• = #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes o No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZEt�U�Ob TYPE WATER SUPPLY' DESIGN WASTEWATER FLOW (GPD)?0 NEW SITE REPAIR SITE
� j�
SYSTEM SPECIFICATIONS: TANK SIZE 0 D GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH —1-< LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT t s;j...,,
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 N l
` SYSTEM INSTALLED BY: J/ N
-7o
s
D
Feo-4,—
AUTHORIZATION NO. OPERATION PERMIT BY: —DATE:A�Lhk
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIB OVE 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
MF (- -- '-,
OCT 1 01997
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed
— (fA�a
Mailing Address
City/State/Zip �• %D D�
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [esite Evaluation
Contact Person
Home Phone / z� —
Business Phone 5`'/11
City/State/Zip
[ ] Improvement Permit & ATC [ ] Both
4. System to Serve: [ Wi ouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms .3 # Bathrooms Z [ 9'Kishwasher [ ] Garbage Disposal
[ -Washing 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: [ ] County/City [ ell [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT **NNJffOF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /d0 x 0-04 WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #6-709 - 0 2 -
Property Address: Road I`�ame 41f '- !1 ��
67
City/Zip
If in Subdivision provide information, as follows: lkt !�; 07-_ �icei,�z ex' -Z4
Name:
rr
Section: G 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
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
Represe ative of the Davie County Health Department to enter upon above described property located in Davie County and owned
r
by to conduct all testing procedures as necessary to determine the site suitability.
DATE �D —/ 0 _ ir% SIGNATURE
Revised DCHD (06-96)
THIS AREA AWy 13E USED FOR DRAWING YOUR SITE PLAN:
X0 i,
/0 0/
NO.: ADDRESS:
=00 00
LOCATION:
---
MAR I -1-1 1 PARCEL
DEED BOOK 95 PAGE: 4 7 2
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lOKK
LOT
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DWIPTIR
SO. FT. (BUILDING) ------
YEAR BUILT: - - - - - - -
e
DIREUMS:Highway 64 West turn left
on Davie Acad
on left
OMMNETI•H a r r i s
SIGN: yes
FIRMHoward Realty PR.:
POSS: closing
LSA Debbie Pennington PH:
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LOCATION:
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MAR I -1-1 1 PARCEL
DEED BOOK 95 PAGE: 4 7 2
' t
lOKK
LOT
DWIPTIR
SO. FT. (BUILDING) ------
YEAR BUILT: - - - - - - -
DIREUMS:Highway 64 West turn left
on Davie Acad
on left
OMMNETI•H a r r i s
SIGN: yes
FIRMHoward Realty PR.:
POSS: closing
LSA Debbie Pennington PH:
LK. BX. ---
t °5
LISTING WILL BE RETURNED IF NOT COMPLETELY FILLED OUT.
TYPEWRITER ONLY.
J0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION E LOT
Soil/Site Evaluation
APPLICANT'S NAME 4� DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE 1'U
SUBDIVISION ROAD NAME y�
Water Supply: On -Site Well Community Public
Evaluation By: �� Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
5
Slope %
-•Y�
O
HORIZON I DEPTH
(o
Texture group
C,I _
CL
Consistence
IV
Structure
�-
Mineralogy1
ORIZON II DEPTH
Texture group
Consistence
Structure
Q�
Mineralogy�\
.l
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:
M
LONG-TERM ACCEPTANCE RATE: •�
REMARKS: Nqa� \\
DCHD (01-90)
Landscape Position
EVALUATION BY: \ e��
OTHER(S) PRESENT: S9
LEGEND
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
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No
No
4 Davie County Heafth Department
and Home Health Agency
Environmenta[Health Section
P.O. Box 848 / 210 HOSPITAL STREET
COURIER 809-4.06
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-8760
October 13, 1997
Ronald G. Jones
185 Livengood Rd.
Advance, NC 270QIG
Re: Site Evaluation
Oakland Heights E/Lot 66
Tax FAIN: #5708-07-1547
Dear Client(s):
As requested, a representative from this office visited the
aforementioned site on October 13, 1,937. Erased upon the information
provided on the application for site' -evaluation and after the evaluation
was completed, the site was found to, be provisionally suitable for the
installation of an on—site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
C� �- ZM
Charles E. Little, R.S.
Environmental Health Specialist
CL/wd
Enclosure(s)