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2027 Hwy 158•1 • °""�'"`�'> DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT �PI rrnnnirurur nceurT **NOTE** This'improyement 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 6.5. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) S PROPERTY ADDRESS —\A 9-%1 L DATE LOCATION J-\.Sc•?v� �� S1y,' S 1»,�1 . `"'�c.�l.• ��ic'+ ti SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE. 1. �t��c,e # BEDROOMS �jr # BATHS D� # OCCUPANTS , GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION ,FACILITY TYPE • # PEOPLE # PEOFILE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIIE t TYPE WATER,SUPPLY V•�'^ fir• DESIGN WASTEWATER FLOW (GPD) NEW SITE L,l REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE SAL. PUMP TANK GAL:' 'TRENCH WIDTH � ROCK DEPTH -----. —', LINEAR FT. OTHER` REQUIRED SITE MODIFICATIONS/CONDITIONS: •.-011 ***THIS PERMIT IS SUBJECT?0 REVOCATION IF SITE PLANS`OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. r r..+1 % r IMPRDUEMENT PERMIT BY .�,,.. **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 AUTHORIZATION NO. x SYSTEM INSTALLED BY 0 Mr M e let LO�' OPERATION PERMIT BY � DATE t **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. i DCHD 10/95 r r„i ji , nY>a°.a,yt4g1 v>.�w . yWt`i i�i r, ,w'k� r4. .. S f `F •;r . _ .. - .,.. Davie County Health Department /00-400 ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systess) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Farm/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** NAME `t� o rcc� s RU �� e'er DATE 1 ' I� � ^AMRIZATION. NUMBER 6 0— NAME ON IMPROVEMENT PERMIT 11f different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE**# THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. EMIRM"AL HEALTH SPECIALIST `.' DATE DCHD 10/95 t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Davie County Health Department Environmental Health Section P. O. Box 665 Mncksville_ NC 27028 C6C�MG 01Tz4 1. Application/Permit Requested By Mailing Address 2 V� 7 US S% Home Phone Z?oZ: Business Phone . 2. Name on Permit if Different than Above 5647d le" 3. Application for: 0 General Evaluation CVSeptic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly ❑ Business: ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 7 ❑ Basement/No Plumbing No. of Bedrooms I2(Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions `Do�u,l2 ali ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public ® Private 8. Property Dimensions 3��-`� — Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? M ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY)REQUIRED: Directions to Property: �Sg - -T,1 lc,F i- �►�� M ugly MAP � W% 64t4 C) au -,L cleat a j Tax Of f ice PIN # _57 Vq - [(o -Q4t 3'�> Road Name U5 !Sg- Box # (if available) City - - mAP a P -0 N'5l ;y.al This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. is Jy --9 DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. N?12' I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by.the owner: 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 all testing procedures as necessary to determine said site's suitaBilify for a ground absorption sewage treatment and disposal system. 1'D -el f&0�� - DATE SIGNATURE DCHD (1193) lop • t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME _:hratm i�s TI U ADDRESS S P. % V PROPOSED FACIILTY N. .Z tt\9 Water Supply: On -Site Well Evaluation By:� Auger Boring DATE EVALUATED / % Is' PROPERTY SIZE 'Q)� LOCATION OF SITE I fe Community Public Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % - ja a 13-60 HORIZON I DEPTH Jjb S 191, Texture group L 5 C L 5 e L S c. Consistence v -E Structure Mineralogy HORIZON II DEPTH L4 0 1' : 11.0 ' Texture group 0C Consistence Structure �Bk Mineralogy' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON ---- — SAPROLITE -- — CLASSIFICATION ,S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: Q'S LONG-TERM ACCEPTANCE RATE- REMARKS:� LEG DCHD(01-901 Landscape Position EVALUATED BY: `-1 t. OTHER(S) PRESENT: `AUC' A 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 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 ■ecce■■■■■■■■■■■■■■■■■■■■■■■■e■e■■■■■■M■■EeeM■M■■/MMe■■■.■ ■■M.eM■ ■■eee■■ee■■■.■■■■■■■■■■■■■■■■e■e�■■■■■■■■■M■■■■■■■.e■■M■■■■■■■■■■ iiiiiiiiiiiiiii0iiiiiiiiiiiiiiii.■iiiiiiiiii�iiiiiiii''■iiiiiiiiiiiii .....■.....................................�........�.......■.MEN . ■.■■.■■■■.■■■■■■■MMM■■■e■.■■■■■■■..■......■■..■■■■/■ ■MMM■■.■■■■.■ ■■.■■■■■■■■■■■■■■■■■■■E■■■■■■■■■�N■MEIN■■■MM■■M■.■■■■■MMMM.■■■MM■ ■■■■■■■M■■e■■■■■■■■■MM■MMMM■■■■■ ■■MEIN.■//...■■■.■..■.■■■■.■..■■■ ......................................."MEN . 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