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1078 Calahaln Rd
:.. .�..;; 4� , .-:, ..w_..� .:.....;, �e,.:.ni.m��...?.?iW �,;�,� ',3'q ���: - .. - . . .... r . . r . . . v�. y.°s-� _� .. , i� ' ,� , � . �pJko AUTt'!)RIZ�CTION NO: ��Y ���+' DAVIE COUNTY HEALTH DEPARTMENT • -- �'' Environmental Health Section `PROPERTY INFORMATION ;,o � Permittee'y..----�" P.O. Box 848 ���\ � � � Name: ���� ��-�'� 1''�- Mocksville, NC 27028 Subdiv�sion Name: " �."�� Phone # 336-751-8760 Directions to property: ���� 7��' ��c-�`�i�li� Section: Lot: ` AUTHORIZATION FOR �1 �' � _ r� � WASTEWATER "�� t�%� � � �C-� �''� � `�t.'�- l.. ��i r.jni �,�j� n 1-j�1C..� Tax Office PIN:# SYSTEM CONSTRUCTION f,, _ ..� {r,''t..� �L :��`o�, j� � � tG'� Road Name: `:.�; LnF+L�L...� l�,�lp. L%t_�2 !S **NOT'E** T'his Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Forni/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits: (ln compliance with Article 11 o�C`i.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) � i''�; ,..,..._...:_,� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '��,�.:_:,...--- ,f I , l(:,�- i,. � ��'9 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONM N�'AL HEALTH SPEC[AL�T / DATE 1 SUE � t_,; ; . � . .-,� �..,. __ , � „ , ,. - . _. _ _ _ _ ;�f '- � , �p �� �! p�,�o ' � � -„ . . . i� � �` DAVIE COUNTY HEALTH DEPARTMENT � ,..-:--. �,�. u-�=--`""" TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATIO Permrt�ee's .;: - _ .-- � I � � � Name �>= _ � r � �y i��� ` c..�'1 �: ��.. Subdivision Name: . ( ,� ��' Directions to property: �'�"� f^ 1 u ��` = fi 1+.: i-t� � �..t. i� Section: Lot: . ,� t IlVIPROVEMENT � • r; � � -. _.� L f C� . j ; ,- , _..�+ : r� � `� r�..i !�'i! .�: � }-"; � �,1 PERMTT Tax Office PIN:#- � _ f + � L � i �� 1 � �<�'� Road Name: `I ( <", � � n�, ..� �.�i" � Z�P, t__ J, �, . **NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATIQN FOR WASTEWATER SYSTEM CONSTRUC'TION must be obtained from this Department prior to the constcuction/installation of a system or the issuance of a building pernut (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section :1900 Sewage Treatmenf and Disposal Systems) ' r-=,., f` ***NOTTCE*** THLS PERNIIT LS SUBJECT TO REVOCAT'ION IF SITE . - : ; � ,' ` � �- � J � "`,; ; r� PLANS OR Ti� INTENDED USE CHANGE. YOUR WASTEWATER ��' ENVfRONN1ENTAL�HEALTH S�ECIALI5T DATE SSU D SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE ; �,: INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �_ # BEDROOMS '� # BATHS � # OCCUPANTS _,z._ GARBAGE DISPOSAL: Yes o N�o� COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE I}�-�' TYPE WATER SUPPLY�JN ' l DESIGN WASTEWATER FLOW (GPD}---�.v`� NEW SITE � REPAIR SITE �f �1 rl ! SYSTEM SPECIFICATIONS: TANK SIZE�QQGAL. PUMP TANK GAL. TRENCN WIDTI�—�4� ROCK DEPTH I Z- LINEAR FT. � Q n�ruFv `-� ���1�!/{ � 1' O y.� 'JCJ X1�:.� REQUIRED SITE MODIFICATIONS/CONDITIONS: � IMPROVEMENT PERMIT LAYOUT \�� J ' ,� D j \�� j�G . � � � ��. F-,n�1 �_n s A \� T � � � �� � J� � � � � � � ., e 0 rJ �t �-� � � ak�ISi E�iS1 IF .�l� � f.:�'<E.O� r�IEdIS[4f..n�, �Iii!'s��$ M . �-��n/�� -�"2�- ^�i"' �r�FGR��. f"�' .�C � **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: _ r _ _ g �'j� II AUTHORIZATION NO. OPERATION PERMIT BY. DATE: / ��� •*THE ISSUANCE OF THIS OPERATION PERMTf SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE , WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A'i GUARANTEE THAT THE SYSTEM WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) ' "- APPIJ['AiION FUR 611E EVAWAiIUN/IMPIiOVEMENT PEAMIT �_ •� Davie County Health Depardnent D � - Environmental Healdr Se+ci�ion + P.O. Box 84B/210 Hospital stzeet Moakaville, NC 27028 �336)751-8760 2: e� L� � � FEB 2 5 1999 ***II�ORTANT**• THIS APPLICATION CANNOT BE PROCESSED UNLE33 A�, INFORMATION I3 PiipVIDED. iLefer to the INEORMATIOTi BOLLETIN for iastructions. �. �� � � e���� �� �.�5 �. e i�i� ���t �� �a�� ?lailinq Addreas / 1 G�('6_ /a h4.(�v �dC . Hama phone s� �.Z—� 7�-- City/State/ZIp �dc�r�� ���c l�/�C- �?a.Z 8 su�ia�s Phone ���,�1 ?o�- 1�3n- `�G•33 Z. 11ame on Pe�it/)►tC i! DifferenE thati Above Mailit�g 1►ddres� City/8tate/Zip 3. Applicat3on For: �'3ite Evaluation 4. system to service: ❑ House �Mobile Home @�Improv�ement Petmit/ATC 9�Both U Busineaa 0 Industry ❑ Other s. If Residence: ; People � # Bedrooms �_ � Bathrooms �_ �'Dishvasher 0 Oarbaqe Diapoaal �Naahinq Nachine 0 Baaement/plus�inq 0 Saeement/No Plumbinq 6. i� Snaineas/Industry/Other: 8pecity type /��f'.�- -r� f Co�odea i 8hrn►era � Uriaala � Peaple � 9lnlce � Rater Coolers IF �'OOD3ERVICE: � 3eats Estimated iiater Usaqe (qallons per dap) 7. �pps of water supplp: J� Consity/City 0 iiell 0 Coa�aunity e. Do you anticipate Additions or e:panaions oi the tscility thia syatem ia intended to servei 0 Ye� �No If yes, w6at type! **"IMFORTANT"' CLIENTS �llUST CO�IlPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PI.AN MUST BESUBMITTED by the client wlth THIS AI'PLlCAT10N. Property Dimenaioae: Q�pw.( . 1 QC.r � o F l 2'? uG • WRITE D[ItECTIONS (trnm Mocicsville) to PROPERTY: Tai Oftice PIN: #.�'��o - 7�- z�y�' �oGOO,E�(�`� (,�J �� i, 1 c�2�1 � I�) Sh�.��c� (d Prnperty Addresa: Itoad Name �� 0.��t}n( `�� ,�va�.d , � L�.2 h1 ��..�1'.�,��� City/Zip f�1.oC,KS�:1 (z n� Z7o� �d .~�'o �v 2r.�,-�,�-;-c.,K� � rx.�- a..�- If in a Subdivi�ioa provide intormation, as tollows: Name: IU Section: Block: Lot: �c-F�' -�Tilom�zc C.�CZ.,,K'- 1.�,�L� m�-�— Rv.c� S it w� �..� �i 8,�.�. � look �.. �-1� t 27 G2c. �r-c�.'� Date Property I�lagged: ��U. � SY � ��- Thi� i� to certi�y ihat the informatioa provided is corr�ect to tbe best of my knowledga 1 underotand that nny permit(a) issued hereafter are subject to su�pen�ion or revocatioa, ii t6e aite plans or intended use change, or if the in�ormation �ubmitled in t6is application ia tnlsiQed or changed I, also, anderstend tbat I am responsible jor a/l cbargu incrirred fronr t/,is appGcation. I, 6ereby, give conaent to the Authoriztd Repre,aentative o� t6� Davie County Healt6 De artment to enter upon above described property locsted iu Davie County and owaed b�- U��,, _� 1'Yi f) O� to couduct xll te.sting procedures as neceasary to determine the eite auitabilih. �J'`qr j� �. c� �: /�_ DATE d- o� 7' �/� SIGNATURE O`- THIS AREA MAY BE USED FOR DRAWING YOUR SI1'E PLAN (Wciude all of tbe toilowing: E�sting and proposed prnperty lines and dimenaiona, atructures, eetbacks, and aeptic locations). Revised DCHD (07/98) Account No. '7��d lnvoice No. �� � ��� _ _ � —__ - —,--_- -- ----� ------ — I� ��il —� _ . _-- — , - — .� � , _ ,�� ; � � . . "-. - � . � t � : � � g � x� L� ��.5 ., + . ' � -. . � � = , �� . ..:. ��. � . . �I _ ��� � , �A�..�, � � , � ,: � �' '' _ � �� � i " �4 S � y� , �. � � � 1.i - ... t3 v� ' �` , � � � ��" . s R �' i a . "� �.r, ma. �x ' ' ,w ` � � "��.. ..) � � x � . . . � �� m;�. � � . � % � � � � ' `� e.`�' �„t �.,t � � . , �� � r.�� . .t �;� �„ ��� a' �t � ,�^ � � . „� e �, , � ,- � � � r �_,� . .�_ , . � �— a � W _ ,�� � N ,� , � � • - ° ` O � _ t0 �t �- E .. � � � � .� , ��_.� _ � R N Uj < , " . R ' " - ' � S d' s r� �. � � ; � �� a _ � ~��.� � � = ��� � 20 �34� �� � � �� � . � P '� � �," .� �` �� ��� � `, � � � AR C E L�5 W!T H �,., c� = p_ �� �� � -� � o o g � '��'. . �...__ * � NO I.D.� SEE �2O � � �' � � 4 $ E w: ., � � . �- ��-.. 5 2 , w. _ 4� ' ' e � - . � a. tt- �r ,�,..s.� � � �' tt � 3 9.6 p � � ` � r � . � a � � ,. � � a . ,� � „ P 4 , �' - � Irt �ri 3 � � r .� ` �^'�" �. 2 t A� � � � �� � `� � � � �� : ` -, � � 5 8'""�-7. 4�p"""" �� , � � � � r � � � �. 1, �A i`N . "f . , . �S �� � } � �' a Y � �.,` , v •` : i. 'v Q n " �� �� e ,, � :k "�f .o- � � � �• � � � _ l L � (�J J�/� � • �7 ���.1 i"� V � - � � , ' � 6 �� � � � p . 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DAVIE COUNTY HEALTH DEPARTMENT .•• Environmental Health Section SECTION LOT SoiUSite Evaluation lt APPLICANT'S NAME I L�o�a3 �-�� DATE EVALUATED � Z2 �j PROPOSED FACILITY �• �r"`�� PROPERTY SIZE I et-�'.Q�G �L I Z% SUBDIVISION ROAD NAME �[��a `-� � Water Supply: Evaluation By: On-Site Well Community Auger Boring ✓ Pit �� i�u�, i i v n n�iu�.�iv [� A r1T /1T rmr. I,LHJJIt'11.H 11V1V SITE CLASSIFICATION: `� v LONG-TERM ACCEPTANCE RATE: �' J REMARKS: DCHD (Ol -90) Public Cut EVALUATION BY: OTHER(S) PRESENT: �-IfiM.aS �4�i''L' LEGEND � Landsca�e 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 otes 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 � ■ ■■���■ ■����■ ■�■��■ ■�■�■■ ■■���■ ■■�■■ ■�■�■ ■���■ ■��■■ ■��■■ ■■��■ ■�■�■ ■���■ ■���■ ■■�■■ ■���■ ■���■ ■���■ ■���■ ■��■■ ■■■�■■ ■�■��■ ■■���■ ■■�■■■ ■■��■■ ■■�■■ ■���■ ■■��■ ■���■ ■���■ ■��■■ ■■�■■ ■■��■ ■�A��������������������������� ■�Ilr��■��������ii�iii��������� ■�11��■■������■�■��■�■�■��■���■ ■�[1���■��■�■�■�■■�■�■����■■�■■ ■�I1�■��■�■■���■�■��■■■�■�����■ ■�11��������������������������■ ■■■ ■�■ ■�■ ■■ � ■ r� �� ■■ ■�■��■�����■�����■G��■�/����/G�■ ■��■�■■�■■���■■ �r■■■/i��■����■■ ■�■■��■�■�����■����■�i■��lG��■■�■ ■�■�■�■■�%■���G��■�ii■■l������■■■ ■�■■■■��������■�����■�i%�■��■�■■■ ■�����I���/���/�f����ii�� �1�������■ ■��■�L.1■�/���■�%��ili�ii���iil���■���Iti� ■��■��7/i���%��b:C�iiiiiii�iii�In\Ili ■�����w]■■G%�■�'" ■�■■■���������I�■ ■�■■■�il►1L����I■ ■���■■�■■��■��I�■ ■�������►]��%%������������������I�■ ■\�■ ■�■■ ■ ■ ■■■�■���■�■��■■��■■■■�■■■■ ■ ■ ■ ■■■���■ ■I���■�■ ■�����■ ■■��■�■ ■�����■ ■�i�■ ■���■ ■��■■ ■�■■■ ■���■ ■�■■■ ■���■ ■■■■■ ■■■■■ ■��■■ ■��■ ■���I�■�■ ■■��I■■■■ ■��■i��■■ ■��■i��� ■���!�■ ■■�■I�■�■ ■■��!�■■■ ■���i■�■■ ■���i;�■�■ ■■��i■■■■ ■���'���■ ■��■���■ ■■��/��■ ■��■'���■ ■■�■���■ ■��■���■ ■������■ ■■���■�■ ■■���■�■ ■■�■���■ ■■�����■ ■■�■ ■■�■ Q , ;.�-�-=�s� , � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATE13.�CERTIFICATION FOR DWELLING (Check One) REPLACEMENT p� REMODELING ❑ RECONNECTION ❑ Name: �����i)� � t ���� ��� � Phone Number: ��/��� G�?�� (Home) Mailing Address: ��'? ;� � `i�l,�{]�ln1 �C:�% ��/ /�.�� � (Work) 6Mr����S�;� � ll�= �. �(� ,�7f � �;r--- Detailed Directions To Site: ��� �'�]'� f� �'��"� �� 5�r%'t % f�� /� j21� c'i Yv �i����i C�:� �?f���k�-! � ���.���=� _._�:� f �,;��)/�aA.I�U_ �'ci �� %-r��f f ��� ��� i��21�= ���c�!� �� `� � , % _�P-�- �t�..1 ��-�'1 �� (.,alJ9? Isv 1-i ti'lr`�rJ t`� ! r✓��f� G'� c'�'Z %}i17.1 �f'-a Lt,t� (! < r 3'G?r' �� �-.�rJi�= Property Address: ,�r'�d? 1�" �`�S ���:�✓F . Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: ��'r�t?� � �l�l���C%< Type Of Dwelling: �d�� �� Date System Installed(Month/Day/Year): /�� Number Of Bedrooms: �Number Of People: ,-�_ Is The Dwelling Currently Vacant? Yes ❑ No �1 If Yes, For How Long? 5 Any Known Problems? Yes ❑ No �7 If Yes, Explain: Please Fill In The Following Information About The New Dwelling: . . ' rti`°f „ Type Of Dwelling: t-E^��S{= Number�Of Bedrooms: � Number Of People: c� � Requested By: (Signature) For Environmental Health Office Use Only Approved��` Disapproved ❑ Requested: � ! 5'i��' � (�` !� � 1 /^ �Ci��V11%"��' b'l ��<�1f` ��'�./'� ���''•�(L 1� ik.e�`�i � i%%Yi1 tA� �-"�p���.�- ���;.���C—�,a'�%%G`i!'v Environmental Health "�The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limitedl that the on-site wastewater svstem will function properlv for anv �iven neriod of time. Payment: Cash ❑ Check ❑ Money Order ❑# Amount: $ Date: Paid By: Received By: Account #: �, a71�`�G� � Invoice #: �') �" !�i `�w