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155 Jones RdDAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR OPERATION PERMIT Account #:.990005851 Tax PIN/EH #: J20000006502 Billed To: Valerie Bostick Subdivision Info:: Reference Name: REPAIR PERMIT LocalionrAddebsg:: ;155 Jones Road -27028 Proposed Facility: Residential Repair Propeft.y Size;; 1.621 Acres ATC plumber: 5908 . **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type:__ S.T. Manufacturer Tank Date Tank Size Pump Tank Size Bedrooms System Installed By: JDE Rq Inspector#: Date:_&Z d1Z GPS Coordinate: -a ptJ2a�r L`W e 0u\,1In1be �o deed eXM(j Environmental Health Specialist: A Ad Date: DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) r) S► ('_ PHONE NUMBER 75 l -05 5 ADDRESS 5 �-e >K Cx SUBDIVISION NAME 0c �S c� c \ G �, r C-1 D. LOT # I � 6Z / ACiC5 DIRECTIONS TO SITE J:4 00000O 6lS0Z DATE SYSTEM INSTALLED 3 NAME SYSTEM INSTALLED UNDER�nrl i TYPE FACILITYS �' NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY W 2 k —(SPECIFY PROBLEM OCCURRING - DATE REQU NFORMATION TAKEN BY K Q (Q` JJCYc(HY11- This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005851 Tax PINIEH #: J20000006502 Billed To: Valerie Bostick Subdivision Info: Reference Nanie: REPAIR PERMIT LocationiAddress"' ,155 Jones Road -27028 Proposed Facility: Residential Repair > Properly Size- 1.621 A res Site Type: ❑New Mepair ❑Expansion AT*C*IWy�*rThis9A0uqhorization to Construct (ATC) MUST BtISSUED by the Davie County Environmental Health Section prior to.issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms_ # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ,tot Cf Type of Water Supply: ❑County/City [)Jell ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size SLP' AL. Pump Tank I--- GAL. u c� Trench Width Max. Trench DepthRock Depth Linear Ft.—_200 2.-S%, Site Modifications/Conditions/Other: ���U7m h Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. �P feu C %L D bon �6 EXU T_ a Environmental Health Specialist Dater20, DCHD 11/06 (Revised) N j: A•4'ihr ,.: to '�."`�.r?ai: iP" sr ,,,.. ., +a .'ai- ,s 1�'. ,k+t W `'1 '$s `�` ;,P",:.:,,t +. i, -¢'' s` . ♦s-... -c.'�r; `.• OF_'; � I•' r�.Y, '� �. Subdivision Name Lot No. Sec. or Block No. Lot Size 3 House — Mobile Home _ Lr Business _ Speculation No. Bedrooms —.No., Baths No. in Family Garbage Disposal YES NO S ecifcatioris�for-Syster _ Auto Dish Washer YES �r NO E)"� Auto Wash Ma^hine YES N� Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. 10) Q,9 to —�l �:_103 Improvements 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 day of completion. Telephone Number 704-634-5985. Final Installation Diagram: r-v�-N System Installed by��"�� 1 F �SeJ�- Certificate of Completion \�` Date ! j 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. &D. p V DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIOP *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a nitary Sewag Syste s .� q -� Permit r Name ate N- e ` �y , Location L V J to try C l Subdivision Name Lot No. Sec. or Block No. Lot Size 3 House — Mobile Home _ Lr Business _ Speculation No. Bedrooms —.No., Baths No. in Family Garbage Disposal YES NO S ecifcatioris�for-Syster _ Auto Dish Washer YES �r NO E)"� Auto Wash Ma^hine YES N� Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. 10) Q,9 to —�l �:_103 Improvements 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 day of completion. Telephone Number 704-634-5985. Final Installation Diagram: r-v�-N System Installed by��"�� 1 F �SeJ�- Certificate of Completion \�` Date ! j 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Re uest d By Mailing Address HomePhone I27 / Business Phone (�� Jy 4 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: .House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No. of People No. of Bedrooms No. of Bathrooms ❑ General Evaluation ❑ Mobile Home ❑ Other kseptic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing Washing Machine kDishwasher Dwelling Dimensions / I J U u ❑ 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 ` kPrivate ❑ Community c� 8. Property Dimensions I ac > Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ��No If yes, what type? *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. Directions to Property: !' / 0 a TtrnQ-`41,c) 1'1 �Ur Ora- This is to certify that the information provided is correct to the best of my incurred from th's application DATE and I understand I am responsible for all charges It /7 SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. 1 OWN the property. ❑ 2. 1 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 suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation NAME f Y�� 6 `1 CA'-_ DATE EVALUATED g- 6 I- I s ADDRESS PROPERTY SIZE PROPOSED FACIILTYLOCATION OF SITE Water Supply: On -Site Well V Community Public Evaluation ByV�(-- Auger Boring V Pit ity t_ Cut FACTORS 1 2 3 4 Landscape position .5 .5 --S' Sloe Z - - - S HORIZON I DEPTH '' �� It � Texture group Consistence Structure MineralogX V� `. HORIZON II DEPTH -a Texture groupC Consistence �- Structure - D Mineralogy ', I' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S S -S RESTRICTIVE HORIZON SAPROLITE --- — CLASSIFICATION - LASSIFICATIONLONG-TERMACCEPTANCE LONG -TERM ACCEPTANCERATE ,to SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHERS) PRESENT: N O 'N 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 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 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 ■■■■■!■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■!■■■■/.■■■./■■■■Elea■ ■..■■...■..■....■..a.aEEEa...a■ ■...■■.....■■..■.■■■■.■..■i■MEMO ■E■MMM.■MMM.■MM■■.■...■■■■.■■■■■.a■..■M.■■■■■..■MM■■....■■■M■.EM.a ..............................................■...■M REMONE ■//.....■...a.....EE■N..■■.■■.■E■..a....■■■e..NM.E■�....■..■.ME■ MOEN ..................................O..MM...■MM■ME■■�IN■■■MMM■...._■ .................................................................. ::C::C:000:C:C::C::CC:::::::C::: .................................................... .... ....... 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