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353 Hobson Drive Lot 7AUTHQ ZATION NO: 0,8 8 0 DAVIE COUNTY HEALTH DEPARTMENT % 60 • a b .r, �•W r_' '.�';, Environmental Health Section PROPERTY INFORMATION Perimttee's ► - :� P.O. Box 848 Name: Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to property: �Jl -,lS+�- Section: Lot: 1 AUTHORIZATION FOR _ WASTEWATER Tax Office PIN:# -jl 5 - SYSTEM CONSTRUCTION t, SL Road Name: \A A' S o w �� Zip: �� (S **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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED .: DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Nau)e: °� .,' >.-. . ..� fi: : ': titea•, Directions to property: w4 IMPROVEMENT -.c-•� :� a. PERMIT Subdivision Name: �� ^ f . ,►�. `' `'� Section: Lot: 1 4 Tax Office PIIN:# l Road Name: �. �: t, ',_ h Zin: F ;! **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 PERM BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE\�, -r # BEDROOMS > # BATHS—,—' # OCCUPANTS 4 GARBAGE DISPOSAL: Yes or. COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFf # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE -5 )C STYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) Uy NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �tJC) GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1 C) LINEAR FT. OOI ' a 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 (704) 634-8760. OPERATION PERMIT YSTEM TALLER BT: s�%l � /lG 1 LCh�✓'� AUTHORIZATION NO. DO 26 OPERATION PERMIT BY: DATE: 41 ` < 7 "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) Y L APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC r < < Davie County Health Department �j?? Environmental Health Section D P.O. Box 848 -- 1 Mocksville, NC 27028 ��1�1Y _ 9,1997'.; (704) 634-8760{ r ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE SALL___ THE REQUIRED INFORMATION IS PROVIDED. i� • 1 ' 1. Name to be Billed 1)1&11 11 Contact Person Mailing Address hcan Home Phone y goo g City/State/Zip �� Q Business Phone 2. Name on Permit/ATC if Different than Above y Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit &.AfC ' [ ] Both 4: System to Serve: [ ] House [r1 Mobile Home [ J Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms # Bathrooms_ [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Businefs/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodse vice: # Seats Estimated ater Usage (gallons per day) 7. Type of water supply: [ ] County/City ]Well [ ]Community i 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No t Tf vec_ whit tvne7 _ 10 EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AMMOF THE PROPERTY MUST BE SUBMITTED WITH T APPLICATIO ��. Z. Property Dimensions: WRITE DIRECTION S (from ocksville) TO PROPERTY: Tax Office PIN: #� -f— - �_�� i Uje4�7t B /1 Property Address: Road Name60il Ar, oA If City/Zip C/1GSj/ tf� �7y r If in Subdivision provide information, as follows: Name, V)'/;"A"/�.� Section*— Lot #: ,2 , 3 , 7 '9 , 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 to conduct 11 testi proced s as necessary to determine -the site suitability. DATE --S— , 27 SIGNATURE n� Revised DCHD (06-96) _ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: ,J.. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME 5 �\ S , �=� PROPOSED FACILITY V\ A\ SUBDIVISION�\� C\� DATE EVALUATED SECTION LOTT7 ('C'-2-91 PROPERTY SIZE ROAD NAME`S Water Supply: On -Site Well VI/ Community Public Evaluation By:'�_' � Auger Boring Ll� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % -', HORIZON I DEPTH 1) Texture group Consistence Structure Mineralogy 1',� HORIZON II DEPTH Texture groupt Consistence Structure >� Mineralogy1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON — SAPROLITE— CLASSIFICATION V'S LONG-TERM ACCEPTANCE RATE %'—\ SITE CLASSIFICATION: Q. `5' EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 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) on mom ■E■ ■E■ ■ ■■EM■E■■■MOMM■ ■■E■■MM■MO■■E■ ■■M■■M■■EMEME■ ■MEMEME■M■MME■ ■M■■E■■■■■MEM■ ■EM■EM■E■■ME■■ ■■■MEMMEMM■■■■ ■■■E■■■■■MO■■■ ■E■E■■ME■■E■■■ ■■MOMME■■■■■■■ ■EM■■M■■M■M■E■ Dr. .\II■■ I■\:IM■ ScIRuE■ RNWIMM ■■■R1■■ ■■■RIME ■■■ ■M■■■■■ ONE ■EM■ME■ ■ME■MSM■■■E■ ■■■■■EM■■■■■ ■E■EME■■■■■■ ■■■E■■ME■■■■ ■■■M■■■MEM■■ ■■■■EMM■■SE ■E■ME■■■■■■ ■E■■■■E■■M■ ■■■ME■■■■E■ ■■EMME■EME■ ■■M■■M■ME■■ ■■■■MME■■■■ ■ ■■■E■■U ■ ■E■M■■� ■■MEMS■■ME■ ■ME■■EMME■■ ■EM■MEME■■■ ■■M■E■E■■■■ S■BI■■11 ■■11■■■ ■Ori■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■M■MEN■ ■MEMME■E■■■■ ■■■■EM■E■M■■ ■■■■■■ME■EM■ ■■■M■■ME■■E■ ■■MM■■ME■ME■ ■■■E■MEM■EM■ ■■M■ME■■M■■■ ■EM■EME■E■■■ ■■■■ME■ME■M■ ■E■■■EMMEMM■ ■■MM■■■■■ME■ ■■■E■■M■■EM■ ■■M■■■■MME■■ ■■EM■E■■ME■■ ■■ ME ON ■ 0 ME no ON ■E■ME■ ■■■■■■ ■■MONS ■M■■M■ MEMO NONE MEMO ■■■■ MOON NONE NONE ■■ ME ■■ No ■o