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430 Deadmon Rd, •� - 7 � , � . �. .. , _ ,., {' � ' ':� � .. r- . ..�i �. , � 4 _ ., - � . . . ., . . . . �- . . . . . .. . .�I ,0 .. AUTxoRizATioN rro: O 5 8 2 DAVIE COUNTY HEALTH DEPARTMENT � ` � ' ' � '� Environmental Health Section PROPERTY INFORMATION r ermittee's /� .� y� P.O. Box 848 Name: C�, i� /i'/.�%.�' /�t� Mocksville, NC 27028 Subdivision Name: � ,;.I�> Phone #: 704-634-8760 Directions to property: ��^�'�;�r',h v'�' C7 Section: Lot: AUTHORIZATION FOR j,�tJ / WASTEWATER Tax Office PIN:# ��r` 7 L ��'' -�"' 1''� r SYSTEM CONSTRUCTION `(�� % Road Name: N�/��Ij Ir1 {I ��ip: ��� **NOT'E** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pernuts. " (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) " �� ,-- ' ***NOTICE*** THLS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �.� �. b`�f-.�'` Jrf.=G��� � %%�/; '��(.�� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ,; . , . , _ ,����� �, , .- . �� , �� - . � . � �' � = .� DAVIE COUNTY HEALTH DEPARTMENT f'�!Y�. �i�,� ,� IMPROVEMENT AND OPERATION PERMIT5 PROPERTY INFORMATION �8�"rrri tte�`'s ,.1 ,�> � � I�'ame: - ��- ,.� f,�;/��; -r >, t`" �_ _ Directions to property: y�"��F�t ,�f,11/x► �� �"�'� r Subdivision Name: Section: Lot: IMPROVEMENT ;..; ,^' �, ,/�,., _ ;> � PERNIIT Tax OffiCe PIN:# - r� �'� � f• Road Name: ,+�{ � /,�f �'. is j;' � �' � � �.ZIP: ' t r. ;,y r� **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a sep6c tank system or any wastewater system. An � AU'I'HORIZATION FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the construction/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 Treatment and Disposal Systems) ti,:;�' ,� ,- ji�- ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF STI'E ,f .1:e , i,,_.,.''' ,. i% �� a=i � �'; ,. �: PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE /I7 r'.�°� # BEDROOMS �# BATHS �-� # OCCUPANTS �� GARBAGE DISPOSAL: Yes or No � COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE � TYPE WATER SUPPLY � 0 DESIGN WASTEWATER FLOW (GPD) � NEW SITE !/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 1' '1,,:J�'—GAL. PUMP TANK GAL. TRENCH WIDTH 'c �� � ROCK DEPTH � LINEAR FT. C f�'�l%J REQUIRED STI'E MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � ��<<Q �s ���� R� � � �(,J � � **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 SYSTEM INSTALLED BY: � AUTHORIZATION NO. D.S��- OPERATION PERMIT BY: �e� DATE: �/Y/'�� **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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OSN6 (Revised) i"" �� �-. ,... .. � . , ���� D _ r I��o � �;'OV � ATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section � P. O. Box 848 II Mocksville, NC 27028 (704)634-8760 V�'"� **** P6R�'ANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed C� . p rn�z « Contact Person �-^CI..D MailingAddress ! �.� �Ulvh L(�� �� Home Pho�/��J .�q--��/Z% � City/State/Zip �f�G6t✓�' ,� G �i Z/� Business Phone %11 �' 2. Name on PermidATC if Different than Above Mailing Address 3. Application For: �Site Evaluation 4. System to Serve: ❑ House � Mobile Home 5. If Residence: # People .O� � Dishwasher 6. If Business/Other: # Commodes If Foodservice: � Garbage Disposal Specify type _ # Showers # Seats _ City/State/Zip j�S Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms �_ � Both ❑ Other # Bathrooms �L � Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # People # Sinks # Urinals # Water Coolers Estimated Water Usage (gallons per day) 7. Type of water supply: � County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: � WRITE DIRECTIONS (from � Mocksville) TO PROPERTY: Tax Office PIN: # S% � � - y Z - 9 G�� � � .Sc.c, � � fi=a Property Address: Road Name ����� � � 1 City/Zip /i�oGK 2'1D �� � 1 1 If in Subdivision provide information, as follows: t Name: Section: 1 1 1 Lot #: � 1 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter aze subject to suspension or revoca[ion, 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 L►�ClGN/l� 1L �l, �N � l�' // 1�' �- to conduct all testing procedures as necessary to deternune the site suitability. DATE il-- I-' � 6 SIGNATURE v � � � Revised DCHD (06-96) % 5� I'L�' US'.� � `�`� . !, 1 _ . ,�� ,_ �.. � � ;, ` L� Q , � � � �.` _� -� 1� � � � �, � `' ` 2 � � � v.. � � �i � `l • ``, �-` ' , O � , i �9� ' � r. 0 3 5�" E ��, �� w•L-rE� -- — — — � — � —� ' , t _ _ ` � �`�- 3 � � � _ � 5 �� � �2 _ _ -�°-�'- - �- -z ' � . ° --- --- l ` � �� � � ' �� � '� � ., . �— 1 ,'� _ Q SO �y i � � � - .�, a i �� "?���'°SErJ � �, 1 � ��aN°n'E-�` �,,g� �cQ `_ _ - � -- - - _ - " �E . . x�� 1O� _ - p � �.. — _ ` � FX�ST(HG EA,ST DR.{YEW.�y c�4°S — K 2��8� ��� w . � o��� k-S�Bq `�t N 574�-42-�J�6Z S — - - - - - � . ---_--- -r . L+ _ � � . +�- . •£� . "� � ".. r �::' N N � � -:,� � � �_ 1�... re� � N - . 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P . � : t�. �' �. ,.. _ � i a� � �, � �. 16.f��-A� � � �. � �� ��. � ' • � .� , ` � ,._ _ 3a . , c. �t 3n � 4 . . m _ �„ � � Q � � � , , - (. � � ti . - ;.. , -> • N � t �� {, �. � J �`�.' �.� � 4 3 4.87 �, � ; ��j � • .,. � � 82 � � '" � ,� x'�. :� ¢.,� � � � �,,r 3 6 � ;� , ,��� � � � �rz '� �r -,���,w � �CY� � j `� , ' � � f � � ' �,, �k er .� '8" .,��r .�. � ,. � ', ,� <� a f . . � . . � : A � � F� ' " . M . — . ���� '� .� � , , . a ' �.. �, k � • �'C -.�`'4t �, > � a • '4"� � �'�:�''�r� 2 4 9 n �t. � � � x - ''+' � -a �� ` ^'Y ,�. �`" -k �� � : '" .. � ,, �.. _ � ' __ � � . . . . - " • DAVIE COUNTY HEALTH DEPARTMENT � • . Environmental Health Section Soil/Site Evaluation NAME /�'/%,Z/`Y/ DATE EVALUATED ����l�1�� ADDRESS PROPERTY SIZE ��'z� PROPOSED FACIILTY � TC7'`� LOCATION OF SITE r�/'r.���� Water Supply: On-Site Well _ Community Public �/ Evaluation By: AugerBoring !/ Pit Cut FACTORS 1 2 3 4 Landsca e osition .L--- L� Slo e R � HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � 'v �` Texture rou Consistence � .i Structure ' / J' Mineralo ." ..� HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH rexLure group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLaSSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: y� EVALUATED BY: -�c�� i� LDNG-TERM ACCEPTANCE RATE• � i OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linearslope 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-Silt,y �:lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR- V��ry friable FR-Friable FI-Finn 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 ,iC--Single grain M-Massive CR-Crumb GR-Granular ABK-AnQular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mincralo�cy 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 wate�' 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� ■��■�����■■����■�����\�/■�����■��������■ ���■��� ■������■ �����0 ■■�����■�������■����■�N�����������n��■ ■������■����������������■ ■��■��■����■ ■������■����������■ ■���������■�����■��������������� ■■�����■■��������■�■������■����■������■ ■ ■����������■���■���■■ ■�■��■���������■����■������������■�������������A������■���������■■ ■��■�■■�����������������������������������■���■������■����������■■ ■■���■■�■�■�■����������■�����������������������������■������■■���■ ■��■■H���■��■■����■�����������■����������� �������■ ��■���������■ ..........................................C....■...�............. .................................................... ............. ■■��■��■■������������■�����������N��������������� ■����■�������■ ■�������■�������■����������■■��■ ■■■■����/■����������������■��■�■ ■�■������■������■�■���■�����■�����■■����������■�■ ■ �■������■����■ ■�����■■�����������■������■ ■■����������������■ ■■�� ■������������ ■����■�����■■■�����■���������������■■�■������■ ������H���������■ ■����■������������■■������■��■■������������■�����_��■� �����■��■ ■��■�������������■�������■����������■��■ ��� ■ � ■�� ������n �� ■�■�����■������■�����■������������������������■�� �■���■��■�■����� ■���■s������■�■����■����������■��■�■■�■�����������■������������■ ■��■■�����■�■��■����■■�■��A���� ■■�����N���■■����■��■��■��■���■ ■■■����■���■������������■����■��������■�■��N�����������N�������■ ■��■■■����■�■������■��������■����■�■�■��■■���■� ��■�■���■■�����■ ■��������������������■������■���■■��������������� ■���■���■�■���� ■■�����������■��■�����■����■�������■ ■����� ��u������� ■���■■■� .................................. .......... ...�.�..... .._.. _ ................................�.......�_.... . ........ _.. ■������n�������������������■■�■ �����Nv ■ �N/u������■��� ■�� ■\�������■■��������■■�������■■�� ����N�■ ■ N�����������■���■ ■■�■■�����������■����N��■���■�����M��■����■ �■ ���� ■���■���■� ■■�■■■■������■��■■����h��■■������■■■�������■�■■■ �����■ ■����� � .........................................��.... . ....C......� ...v......................................,�...._ � �. .........0 ■�������■����■���■���■�����\���■■������■� Ll��■�� ■ ��■■ �■����■ .........................................�.......C..C....�5....... ................................�......._............... ........ ■�H�������■����r���■�■���l����� ��\�N� ����� ��N���■��������■ ����v����NN�n����■�n����■■��H����■������� ��M��� �������■ ■��■ �����������■���■����WI/■��■�■���r�����■�■�� ■ �� ����■�■�� ■�������������������■������■���u ■ ��■� ■ ■ ��■ ■��■�� .................�...._.........��' _. ��CC��� �:: _:::� ■��■������■���■■� ���� Nn����� ■ ■�■■����������■���■■�■������������■ ■■ Nu� n�� �� ��■■���� �■■��■�������■������������■������ �u ■ ��� ��■�■� ■��■�■ �����■ ������ _����� ' ���•_�- ■ ���������■�� ■���������H������■���u�r=C:�ii����� ' ■ �■� ����■■ ■�����������������������HI������■■���� ■N��� �����■�■ ■�■�■������������������■�Iu�������N ■� ■�■����■ ■■■�����■�■�■�■■��� ���■�11������ ■ ■ �� �N�� �� ��■����■����■h����������ll������ �� �� ��■�■��� ■����■ ■�����v������ 1��� ■� ■ ■ ■ ����� ....... ..............a��.......�. .C�=.....�� ■���■■�1������I�����■��■���1���•=== ■ N��� ■ ��1� ■\�������■�■ ���Nn� {��� ��� ■ ���� ������■ ������������■■��Hu����v ���i� �■ H� �������� ■�■■■���������■��u�■�..■�������■ N �■ ■�■�■■�� ................................�. .� ...... .......................... ..... . . �...... ................................ . ....... ............. ... ........... . ............ ■��■�u� ���� ��q�����■���� �� N����N\ ..._... 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