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179 Dusty Hill Rdya...j..,F.t �ti •ni....b"�-.:wyz'an ..i "a+'xa:rbw.�?i�;-.`d) ,4 rs,'�_:Y i,'.ii+-. �i` Y P• .. < yE .+-. :"yl< ••tn''t 1.)uM1'�S it � t1 •} r f � �i�' �X� ij AUTHORIZATION NO: 0537 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee'S ; P.O. Box 848 _ Name: '" dG/ PlIrY1 Mocksville, NC 27028 'Subdivision Name: Phone #: 704-634-8760 Directions to property: v Section: Lot: / AUTHORIZATION FOR ! WASTEWATER. SYSTEM CONSTRUCTION Tax.Offiee PIN:#D Road Nae2!$T� **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*** TI -IIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST:. DATE ISSUED i r'r'^�I ti'"�._�', r vv.'.."t}. `t"{.;r tS i n.I.y. .r.�. .>nrlc, y'p,- l•,t.v4.y3: � >. s.�`�h. ^t�ia .;: � ...y: ,rst.. t 'i'.i;.•-`t:>;:MK:Y� v :�. DAVIE COUNTY HEALTH, H.DEPARTMENT �.r IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION "Permittie`.►�' Name:• Subdivision Name: Directions to property:Section: Lot: / V IMPROVEMENT PERMIT Tax OfficeLiPIN:#`` - r� Road Name: 1.� .r .s'7•%� �ip: 1�li **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 _u t.L.l� �?1'/1 — ff •' 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 INDUSTRIAL WASTE: Yes or No LOT SIZE 00 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) "' E' NEW SITEy REPAIR SITE SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH _� ROCK DEPTH LINEAR FT- OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS:' IMPROVEMENT PERMIT �AYO If 501 (�'✓r� �� �, aft r/5 1��.�. _ F **C PRESENTATI 0 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 STEM INSTALL 0� F AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **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) APPLI ATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department �B Environmental Health Section P.O. Box 848 Dp 1 ****IMPORTANT**** Mocksville, NC 27028 (704) 634-8760 SEP - 3 1996 D THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed --R0 V vlQ1w- Bea Mailing Address ,/�1 �2 1 T� N'-11 IRA City/State/Zip I V\ o ckS V i ,1 e, _ NC_ o, 7 b A,9 2. Name on Permit/ATC if Different than Above Contact Person qUU_,-A N o C lcx-m rod',�- Home Phone Business Phone Mailing Address City/State/Zip 3. Application For: Site Evaluation [ ] Improvement Permit & ATC 4. System to Serve: [ ] House [tl] obile Home [ ] Business [ ] Industry [ ] ( [/Both 5. If Residence: # People__3 # Bedrooms # Bathrooms [, shwasher [ ] Garbage Disposal [tashing Machine [;,.]'11iasement/Plumbing [ ] Basement/No Plumbing 6. If Business/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 U10rell [ ] 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:r f i C3'L 0� % `T Ct CILQ-0 'WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #$DG�c�►— • ` e Property Address: Road Name <Y- .l City/Zip 6�4 7, C. d 76 9V C . r If in Subdivision provide information, as follows: d1'` Name: Section: 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 of the Davie County Health by_, UU +cel Ail DATE $ ^ a� Revised DCHD (06-96) to enter upon above described property located in Davie County and owned conduct all testing procedures as necessary to determine the site suitability. g -u. I -iFM PZIA� ��v Mr. F- lip -T-7-7 o tel. o c9q, 4. OW O Ln m r r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section y Soil/Site Evaluation NAME DATE DATE EVALUATED ADDRESS PROPERTY SIZE / PROPOSED FACIILTY LOCATION OF SITEltSyN Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH C70 Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure ---- Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: EVALUATED BY: ,j` t'a, / LONG-TERM ACCEPTANCE RATE: 11-3 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 <;lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V=:. -y 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 5C --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(01-901 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■OOOEM■ ■■■E■NEE■■■■■■■■ ■EMEMM■ ■■■■EEE■■■■■nn■E■n■n■■n■■■■■NE■EE■■HME■ ■■■E■M■■■NONE e■■■■i➢■■■M■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■Mee■■■■■E■E■■Ennn■■■■E■ MEMO■■N■■■lK■K■■■■■■■■■■■■■■■■■■ ■■e��e■■■■■■■■■■■eE■■■■■■EEM■■■■■■■■■■EEE■MEn■■nMEne■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■MM■■■O■M■■OSO■■■■■■■OMEEEEEE■■EE■eE■■■■■■■■■■■■■■■ ■■■■MMM■■E■■■■E■■M■■■E■■EEESMMEEE■EEE■E■EEE■■sesnE■ ■SE■E■E■EEEE■ ■e��e■■E■■■■■E■■■EEE■■EEEEE■E■EEEEEon■■n■sM■■■■■■■■_ ■E■E■■En■MME■ ■■■■■■■■■■MMOO■O■■■■■■■■■■■■■■■■ E■EMEMEENE■■■■E■E ■■■■■■■■■■■■■■ ■■O■■■■■■eee■EM000MMO■O■■■MN■■■■ MEMO■M■■■■■■ENEKE■■OEEE■■■E■■■■■ ..................■........ ............NONE N■�■...�.....■..■■■■O ••••••••••••••............. ■■MOMMME■E■■■■■■■■■ ON ■■■■■■■..OMEN ■■■E■■■■■■■■■■■■■■■E■■■■■■■■■■EN■E■■■■■■■■■EEnIN ■■■■■■n ■■■M■ME■■■ I■■■��MEeO■■!�N■ ■■■ ■■■■EON ■■ ■■■■■■■■■■■■■■■E■■■se■■E■■■■■■■■■■■■■soe■■eaee■ee�iO■■■■■■Me■Emmons ■eee■■■Mee■■MM■■M■■■■■■■Mee■■■■1H■■■■■■■NE■■■EMEEEEEEEEEEE■■Es■■ ■■■■■■EE■■■■■n■■En■■■■■■■■■n■■■■■■■■E■eeEO■Oe■■�■�■N■■■eee■e■eE■■■ ■■■■■■■■EEE■■■E■■aEE■■MM■E■M■ME■sE■■E■E■■s■■■S■ ■ =n■■M■se■e■■■■E■ ■■EEEEE■E■E■E■■■E■■■EE■E■■■ENMEEEEE■�EHM■■=■■■■M■ ■■sa■min =■■■■■■■■■I ■■EO■■■■■EEEE■EEE■■ENE■Ee■■■■■■■■E�■ ■■E■■■ MEMO MmomEN n�eeE■MINE ■■■■MMM■M■■■■eM■eMM■■■■MM■■■■■■■�■MM■■NN� oom ■■■■N■M■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■Mee■Mee■■■■■■■■EE ■EE■U■■ ■■ n■E■■■■■MM■E■MOEN OMNI M ■■■■■■■■N■■■■■■■EM■■MO■■■■■■■■■■■■MeeEM■■■■N■■■ MEMO ■EMNON ......■■......................................... 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E■■=. .............. ■■ ■s■ ■■ M■■E■■E■EE■E■Ee■ ■OMEN no MMMMMMMMMMM■MM■MMMM■ , NIMMMMMMMON M IIEMMOMM -- NEMME■ ■■EEEEEN■■■EEEHE■■E.tIMM■■■EEE■E�MEMErm■■■EE■I■nEl/■■■E■EEM■■EMO■■■■ ■Es■EKMOMMMN■■MONMGYI�■■■O■■NOOOO■O■ "fr.■KO■■I■MMI■■■■■■M■■■■■■■■■■■ ■EE■EEEEEMN■■■ENE■■■■■■EOEENEEE■■■■EE■N■EE■IIEM�IEN■H■■ENMn■E■EEE■ ■■EE■■EEEEE■EN■■■sMMKOO■M■■=M■■■■EEE■MESE■EE►11■■r/EE■ME■■wMM■EEEM■E■ Room Z■■■■■■N■■■■■■■■■■■■■M■■■■■ ■■■■mmM■■■ /, .■■ ■N■■■E■■■■■■■NO■ ■ �S■■■■■■■NN■■■■M■■■MM■■■■■■MM■M■�■■MEKE■■MEME /■EES■■■M■■■■M■■EEE■ ■■MM■■■N■■KM■MMMM■■■■■...........wNMI�N■�■��rrM��MMMNM■■■■...�■MM■■■ Davie County Heafth Department and .dome Heafth Agency Environmenta[Health Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 September 17, 1996 Roy Martin Beam 181 Dusty Hill Rd. Mocksville, NC 27028 Re: Site Evaluation/179 Dusty Hill Rd. Tax PIN: #5840-38-5784 Dear Mr. Beam: As requested, a representative from this office visited the aforementioned site on September 13, 1996. Based upon the information provided on the application for site evaluation and after the ,evaluation was completed, the site was found t,o be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, A 4 dy-1 e; I? �0_ - f 4 - Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure(s)