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468-474 Hobson Drive Lot 30B, Section A. AUTHORIZATION NO: 1504 DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section PROPERTY INFORMATION Permtttee's ,�f'y P.O. Box 848 A, Name:Mocksville, NC 27028 Subdivision Name: %7 f Phone # 336-751-8760 zos Directions to property: Section: Lot: AUTHORIZATION FOR '' ,� WASTEWATER Tax Office PIN:#�c1` Ld - OCICi K SYSTEM CONSTRUCTION t - Road Name:%i. � -:5'1i7QG� **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) / " 7-;e � ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION )i %f IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 7-- 1504 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitted s Name ,t {` - Subdivision Name:tr�'� Direction's to property: f Section: Lot: zo IMPROVEMENT .,,.•^ +,� PERMIT . Tax Office PINI - Road Name ZIp: 5 l..ft� j **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 or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT / # SEATS INNDDUSTRIAL WASTE: Yes or No LOT SIZE ii"7 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)6 G NEW SITE l/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE Z,'D GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT **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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: e,. I r �a AUTHORIZATION NO. OPERATION RATION PERMIT BY: DATE: _�� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 EVALUATION/IMPROVEMENT PERMIT & AT �6 0 W R k Davie County Health Department o EnvironmeniaiHealth Section P.O. Box 848/210 Hospital Street JUL 1 5 1998 Mocksville, NC 27028 (336) 751-8760 F1JVIRnNK,IFKJTAI 14FAITII I ***IPIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 , —5,� . . 1. Name to be Billed Mailing Address City/State/ZIP .Contact Person Borne Phone (� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address beim C G S a bnJ P City/State/Zip 3. Application For: Slegite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House "obile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 _ # Bathrooms _ ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/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 ❑ Well ❑ Community e. Do you anticipate ad itions or expansions of the facility this system is intended to serve? ❑ Yes mfo� ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: )/2 t cl C' G �7CTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # s �{ �j — 5 S ' o� (n too L J Property Address: Road Name c,�SC iI S� city/Zipr�e-L- :S l � AX 19 - 31 nn r_ic1 h If in a Subdivision provide information, as follows: -13 Name: Section: 4lock: Lot: U 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 Dart Cunty Health Department to enter upon above described property located in Davie County and owned by U to conduct all testing procedures as necessary to determine the site suitability. st DATE / - 2 S-" 9 g SIGNATURE �G THIS AREA flIAY BE USED FOR DRAWING YOUR SITE PLAN: moa No. 7 Invoice No. (!� Revised DCHD (07/98) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION I_. LOT -=,B Soil/Site Evaluation APPLICANT'S NAME PY'N A-V DATE EVALUATED �T `� PROPOSED FACILITY / �/1� PROPERTY SIZE SUBDIVISION B<, 4 /yC ROAD NAME Water Supply: Evaluation By: On -Site Well Auger Boring Community, Pit v Public v Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ` Texture groupG 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 y� SITE CLASSIFICATION: EVALUATION BY: G/ LONG-TERM ACCEPTANCE RATE: f OTHER(S) PRESENT: REMARKS: 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 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) MEMO ■O■■ NONE ■■E■ ■■O■ ■■■■ NONE NONE ■■■■ NONE ■■M■ ■■■■ MEMO Moon ■ ■ ■ ■■■■"m ■■■■■E■ ■o■■■■■ ■■M■■E■ ■■■ME■■ SOMEONE ■EME■ ■ENE■ ■■■E■ MEN ONE MEN OEM ■E■NO■ ■■■NO■ ■ ■ ■■■m■■mm■■■■ ■E■momo■O■om ■E■!ill■■mmils MEMINMENEM■M■ ■■■■M■MMM■M■ ■EMEMEMEMEM■ ■E■in■■m■mm■■ ■EMB■■MEMEM■ ■E■I■MEME■■M■ ::i�CMMUMME ■EMIN■■M■ME■■ ■E■IN■E■E■■■■ ■E■IN■■ME■■■■ ■■M!MME■E■EM■ ■MME■■E■EME■ 0 ■■n■o■■ ■EMEME■ ■EMEMM■ ■■EM■■■ Monsoon ■ ■EN■■ ■EN■■ ■EN■■ ■E■E■ ■E■■M■■ MONSOON ■■■M■■■ ■■■■MM■ ■■MEMS■ ■M■■■■■ ■EMM■■■ ■E■■ moon moon OMEN MEMO ■EM■ moon ■EMEH■MM■■ ■E■EM■■MEM■ ■■M■■MEM■M■ ■■MME■ME■■■ ■■E■■EMM■■■ ■E■EM■■ME■■ ■ME■MEME■M■ ■■M■■MEEMM■ ■M■■M■■■■■■ Emmons ■E■■O■ ■■MN■■ ■M■■m■ ■■ME■■ ■mm■■■ ■E■ ■N■ ONE ENE ■E■ 5745-55-0726 5745-56-0646 x, 5745-56-0566 5745-56-0487 2a I 5745-56-1306 25 5745-55-1226 5745-55-1147 5745-56-1057 n 5745-55-1997 5745-55-2807 5745-55-2728 30 Q (2.394)' \ 5745_ 55-2663 3f I I (:o.05A, 1 5745-55-3145 1 1 I I INDEXED INDEXED ON 5745.15