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509 Beauchamp Rd..,,., _ � - .,.:�,� ,� :- :.;a, .- :; . r , . . . ,. .' . .. � '# r _ ,� .A � O J, AUTHc�Ri�ATiorr No: `� ��� DAVIE CQUNTY HEALTH DEPARTMENT . - • Environmental Health Section PROPERTY INFORMATION Permittee's PA. Box 848 Name: '�q���`��?���-" ���'�•��'`�-� Mocksville, NC 27028 Subdivision Name: Directions to property: �```��.� "�C.: �,C.>� .�j, Phone # 336-751-8760 Section:� Lot: � f , � AUTHORIZATION FOR �.. il ?�,. ~ WASTEWATER '�] �, ,�� E�,/"�', � r�� t y�� ���"� �`a' �n SYSTF,M CONSTRUCTION Tax Office PW:# ��+ �`� �3� "�`'' � =t� r"��.?'�1�.!!1 D.,3'�c.� �1 l�':1t1��1w �rt �IL Road Name �1������f �� • . �rFl r7 a i�il ``,_�c.�i� C, ►L:,.J . �t' �Z�p. �- �' ^�>, �` **NOTE** This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Sectionprior to issuance of any Building Permits. This Form/Authorization Numbershould be presented to the Davie County Building Inspections Office when applying for Building Permits. , (ln compliance with Article I 1 of G.S. Chapter 130A, Wastewatec.Systems; Section .1900 Sewage Treatmen(and Disposal Systems) � , j % i�,:'-' ,� �.� �•y ***NOTICE*** TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION � �; �..�'� f��°�.; ,�--, ' Z Cl IS VALID FOR A PERIOD OF FIVE YEARS. : ENVIRbN 3� y 1 E N T`�4THEALTH SAECI� ST� DA E IS UED �.�H;,- � b. :.���.: _ � ... , . u. . � : .. ._ v y, . .. ...., .. _ • . .v.a_,-.__-- -...:.y,.� ..... y . . , . . r. , �. . __ . 11 � J " � ,�; '� '� % � � DAVIE C UNTY HEALTH DEPARTMENT '� � ° x: "''== � � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ,, - Permittee ; ` , ' N�m���_ f ��y1`�^�d� "� �"`��'�*�-�+�. � Subdivision Name: � S, �,; Directions to property: �'� w �' �-- ��`` � Section: Lot: �- � , IlVIPROVEMENT t�� %� y-, t-.-�-, j/r��y r' � �E �,C• ,j ....� � !;•✓ `., ,� �:: r--i �... ` � 3 f �< � � _..i� �' ; ., PERMIT Tax Office PIN:# `� �a � �� - ""' , . . .�_ , ,, .; f;y 4!�... .�" . t ..- \ 1' C' t 1� r. �..� Y� y! i. i,� ��. i� f - �' y ••` n .rs i� �r,F'i, �,�,. r�,n; I+.. . ..y..t �� � �f � � �' t "'s� .�� _ �e`i t. � �c:� x � . �- Road Nam���aa�A�,:�'.,.�b''�i�:T����Zip: � � ��.'''�a�_. **NOTE** This Improvement Permit DOES NOT authorize the const�uction or installation of a septic tanlc system or any wastewater system. An � AUTHORiZATION FOR WASTEWAI'ER SYSTEM CONSTRUCTION must be obtained fi-om this Department prior to the construction/installation of a system or the issuance of a building pemut. (In compliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) w-% "�••, ***NOTICE*** THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE ;" ;�,.., � f� °,� <=- •"y ��`" PLANS OR Ti� Il�TENDED USE CHANGE. YOUR WASTEWATER �� ' ENVIRONMENTAL HEALTH SPECIALIST DA I SUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE ; , INSTALLING TI� SYSTEM. �. • RESIDENTIAL SPECIFICATION: BUILDING TYPE � ti"� # BEllROOMS Z# BATHS G # OCCUPANTS � GARBAGE DISPOSAL: Yes oc�i 'o�` COMMERCIAL SPECIF[CATION: FACILTTY 1'YPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No �%,2A,�Q�'S� -�.,/ / LOT SIZE✓• J TYPE WATER SUPPLY�N 1� DESIGN WASTEWATER FLOW (GPD) Z�C.� NEW SITE ✓ REPAIR SITE �� '.� .^7 SYSTEM SPECIFICATIONS: TANK SIZE .� L:o�GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH � LINEAR FT. G�, OTHER � .y`"1��Tk=-� ��I i C7 ,I� f�XC",�� � ! REQUIREDSITEMODIFICATIONS/CONDITIONS: If�ZU�,�.. C►�i CGr.J7Ut/� ,�_::_t_.i'� � o�� �fl. (-�l�M % _ n PERMIT LAYOUT s�pp(����� I�' G*� L��i.�T� F'Ii�ISi.ED G�A � J�( �� {z-`'� ���� �� �� "*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 - 130 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. I OPERATION PERMIT �-,�a,� A�-� SYSTEM INSTALLED BY: ��� � "" 4 ITI��� M,� ��-�t�v.,._.� , � �...� . ° . � 70' .. �An� 1� 'DAT� ja-23 i°"�'�� � �`�,�s; g�� x�"x►y" i�'-rs' � AUTHORIZATION NO. ���� OPERATION PERMIT BY: DATE: � �'��TEIE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT T S TEM DESCRIBED A VE HAS BEEN INSTALLED N COMPLIANCE WTTH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPUSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) / APPLICA710N F011 SITE EVAWAiION/IMPROVEMENT PEAIHIT dc ATC n��/ �r , Davie County He�lth Depanrnent � ��'"�►rr`� � - Envi�nmenla/KealtfiSe�cdon � P.O. Box 8�8/210 Hoapital Streat � Mockaville, NC 27026 �336)751-8760 l�l F� I 21999 I •**,TltPO�TANT*** THI3 APPLIGATION CANNOT 8E PROGTESSED UNLE33 ALL TNE REQOZRED INF.'ORMATION I3 PROVIDED. Refer to the INFORMATION BOLLETIN for instructions. =. a�� cp � Hsiiea �►�1 iC�Nfl�L �./Yl0 � K contzot n�� f.3 i I 1/� ac.1G Nax1 inq Address .50 ��EAG�C /-/�q /r►P P� eoma �one Q�1 Q� - 5 6 0 2 City��8tate/LiD I7Q✓I�►�C� ��C. � i00�o Business Phone %2%' S3�'�, Z. liame on Pe=fniL/!1?C i! Di!lerent than Above � llal'I.in� 1►ddress City/State/Lip 3. Ai;;,:!!.�.c%1�::oII SOI: L S�te EVa1118�.oA U Ia�roveio�ent Pesmit/ATC ��iqth ;. sysr�,-.m to service: CJ Honse �Mobile Home � Bnsineas U Iadustry ❑ Other s. If R�esidenae: � People Z i Bedroo�s Z ; Bathrooma � 0 Distnrasher 0 Oarbaq�e Disposal �;Nashinq Hachina 0 Sas�ment/DinmbinQ 0 Sasement/No IIivai�ing 6. I! Bnsiness/InQustiy/OEhes: Specify type � people f Sit�s � Commodea / 8hawera � Urinals i ilater Coolera IP -FOa�SERVICB: � 3eats Estimated iPater Uaaqe �Qaiions per my) 7. �.`ypa �.f.' r►ater sv�.lp: � Connty/City 0 i%11 0 Cams�nit� e. Do yo� anticipatr. �a�ddi8��ns or eapwnsions ot the facility this tyatem is intended to aervef ❑ Yes �No :�i yes, �vbati �; oe' *'"/M�'�'RTATJT'•" CLIENT� JIlUST CO�1lPLETE THE REQUIRED PROPERTY llVFORMATION REQUESTED BELOVI'. .���tLer � FLAT or S1TE PL.AN MUST BESUBbtITTED 6y We dlcnt wlth THiS AI'P1dCATlON. Property Dimenaions: �s� �/n�P WRITR Dltt�+-CtIONS (from Mocksville) to PROPLRTY: ,�-�fo Efls T rv 8a � 'ra:�tiice�PiN: #SS%0-6S3-SZ�-O Roi sa�TH To yiccSDAcERD, rPASTTA�C'HE6LBANANiI� Go, Prnperty Addreas: Itoad Namu �EA�e NqmP Ro . Cicy/Zip AD✓ANCE� ^l,C. z7oa6 if in a Subdivisian provide information, as follows: Name: Section: Block: Lot: R/bN7 a�+1 N/[tSoA« Td /�ot,e5 L'flv2�/� R� R lG /f T o�✓ /YlOCKS CHd�CH �PD , n"lo�KS CN��GH �Po� To B�AUCH�M�Ro. 'C��ss R�,�vL'N�li»� ��� Tv /�R���1TE DRIf� /�! FRoivT oF /y)oCKS Cr/v2`�-[� `�LLOGc� /{I✓AT� �'p, ?o P,QvP��2T`/ Date Property Flagged: 2 /8�9� This i� to certify t6at the ioformation pravided is ccrr�ect to the best of my knonledga I understand thst any permit(a) issued l,e�eafter are subject to au�pension or �+evocatioo,lf t6e aite pl�ns or iateaded uae cbaage, or i� t6e information �ubmitted in t6is �pplicatioa is talsitied or ch�nged I, also, uada�ta�rd tJbat I anr ryporisiblejor a// cba,ga incurred from �3s applicatso,r. I, heneby, give conaent to the Aat6orized Representative o� t6e Davie County Be�it6 Department tu eoter upoa above described property locuted in DAvie County and owned b�• DOR/S /rIoG,E! to conduct ail tating pc�ocedura as necesssry to determine t6e �ite anitabilit�. �,/� �%/ �/J DATC ?�/3r`1 �l SIGNATURE __�c�("��rrt � i�'!�/� THCS AREA MAY BE USED FOR DRAWING YOUR SI'�'L PLAN (include all o ot6e follo�ring: E�IaHng and proposed property lina aad dimen:iona, atructutYa, setbulcs, and septic lo�atlons). �_ 700 � p �5 e ` -� N _ __ _ - - j �,LL�pL�/� Q �' � �''� SGPTrG S�sf�� �' 1 �T � � �i--�4�, o �- 0 0 � � � �� � :v�'.evlaed DCHD (( � � . --__ � _EAUCI�fAMD r�: — --� DR�� �—o 0 r P�ppasEp `o� LD�R7�Odl�G� fJ�ML' Account Na lnvoice Na T / � �{/o T�; AL L�D ul �,e� u/f} T6�� f�TEc�PN�n/� Foccaw s ORI.✓E�tJA1/ . � ,�, � , . APPLICANT'S NAME _ PROPOSED FACILITY SUBDIVISION Water Supply: Evaluation By: FACTORS Slope % ' HORIZON I DEPTH Texture Qrouv - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT SoiUSite Evaluation �___----� � � G�A�=�- ��< ��!`DATE E�ALUATED �r 3I) I� � 4-IO �� PROPERTY SIZE � 3 �t�%r'-u> ROAD NAME 1 i�i �it,Il�.t,yP �/ On-Site Well Community, Auger Boring Pit structure Mineralogy � HORIZON II DEPTH ; Texture group . � Consistence Structure Mineralogy - HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Consistence . RESTRICTNE HORIZON CLASSIFICATION LONG-TERM ACCEPTANCE RATE SIT'E CLASSIFICATION: 1 2 � � i� U --r� � -� iL C L '" r5; � S i•` i �- 7�%i in� L Q �� LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) Public '" Cut 3 4 5 6 7 0 EVALUATION BY: OTHER(S) PRESENT: � Lt— � �`'G�. LEGEND � Landscaae 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 Mineralogv 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 - gaUday/ft2 ■■ ii ■■ ■■ ■■ ■■ ■■ ■ ■ ■ ■■ ■■ ■■■�■■ ■■■��■ ■�■��■ ■■��■■ ■■�■■■ ■■■�■■ ■�■�■■ ■����■ ■����■ ■■ ■ ■ ■■ ■ ■■�■ ■��■ ■■■■ ■�■■ ■��■ ■■�■ ■■■■ ■ ■�■���■�■ ■■�■■���■ ■�� ■�■ ■�■ ��■ ■�■ ■■■ ■�■�■ ■�■�■ ■■��■ ■■�■■ ■■��■ ■���■ ■�■�■ ■�■�■ ■■�■■ ■■��■ ■■■�■ ■���■ ■��■■ ■■�■■ ■���■ ■���■ ■�■�■ ■��■���■■���■ ■��■�������■■ ■����■����■■■ ■■■���■■��■�■ ■■■■�������■■ II�Z�l1�■�■■�■�\\���■�■��■/:l����■■�■■��■■�■ !J�■�I�■■�■■■�i\■�■�e���%►1■���■■�■�����■ �:::--=====�w�■�■■■■�r�■�■■�■■■■�■�t��■ ■��■�ii■■��� r�r�� ����■■■i■��■■■��■��■���■ 1l�I.n�A�■■■�i1i���l�■�■f�t■■�■�■���■�O■■■■ ��Ylr�■��■��I�■��\\����II��■�����■�■���■�■ ■���iiinsi�■��■�■\■�����■����■■�������■ ■��■��■I�!��■■����\�■/��■�■���■�■��■��■■ ■��■��■III���]�■��■��►��[I��■�■���■�■��■■■■■ \�\����11■■����■��\�t1■�■��■���■■■��■■�■ \`\■\''�!■�■���■����■►\f1■�■■�■����■■��■■�■ \■\\�ri�D?!��■��■��■�■7�■�■���■��■��■�■■■ ■���c�■�u-.•_■�■��■�■�►��■■■���■■���■�■■■ ■���.�������.�����■���■�■■��■■�■���■■■ ■■■��■���-.�■■�■�������■■�����■�������■ ■����■�■■�•������■��■►■■���■�■�■���■�■ ■■�■��■�■■■�.�.�■�r�■■��■■�����■■�■■�■■ ■■�■������■■����■��a■��a�■���■��■�����■ ■��■ ■■�■����■����■���►��■�������■���■ ■�■■ ■■���■■�■�����■�����■■�■�����■■■ ■�■■�■�■■���■����r��■■�■■►��■�■��■■��■■ ■��■�■■�■����■�■■�■�■��■■��■�■■��■■■■■ ■��■�■■���■■�■��������■�■i�■■�■■�■�■■■ ■��■���■�■����■�v�■■■�■�■■����■��■■■�■ ■�■�■�■■■���■�■��■�■■�■��■���■�������■ ■����������■���s�■■�■����■�■��■��■�■■■ iiii '�iiiiiii�iiiiiii�iiiiiii�iiiiii� ■�����■■�■�■�►�■��■■■��■�■■���■�■■��■�■ ■�■����■�t�■��■��■�■■�■��■��■�■������■ ■■���■�■■■����■����■■����■�������■■��e ■�■■�■��■�■�■■���������■���■■��■��■��■ ■������������������������������������■ ■��■��■■������■���■���■�■■�■�■���■■�■■ ■■■■ ■■���■■�■����■■�■��■�■��■■��■■�■ ■��■ ■■■���■���■■�■■��■���■■��■���t�■ ■■■■�����■■��e■�■ ■■��■■���■■■�■■�■ ■■�■�■�■■��■■���������■■�■■ ■■■��■■�■■�■����■�■■���■■■■ ■■■���■■■����■��■�■■���■■���■�■ ■�■���■�■��■�■■�■�■��■�■����■�■ ■���■�■����■■■■�■■�■�■��■■���■■ ■�■��■■�■��■�■�����■���■■■��■��■ ■��■����■■�����■���■■��■■■■��■■■ ■��■���■����■■■■�■��■�■�■■■��■■■ ■��■���■■������■���■■■■�����■�■■