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3591 Hwy 601S Lot 2 y W`.�. ...:. .4- a"+ro'r r w:fYt Y.�:7+L" 'fi.' 3•=?'...1 L Y`1 �'r - � k sV �;, '• ��,:. 1 'A;.::3 ;� 9 f:. + � , ;�•. p"y:V-;:?+� 1 1 �,AUTN�itiZ N 1615 DAVIE �j` Tr� 9?UNTYNarjlettee'ti ��� Name: fEnt i H`�AL1H'DE1 EP ART t ronmental:Health S MENT , I irections to property. °bJ� P O p 4 e�t�0�] I --�.---_ .� M � k ox g4g PROP �s- S�>» ER e,�N� Phone#336 2j02g �y ** AUT �S1-876 -Subd TE HO�igr w,s n TION NO ** SYST wASTEW IONTO Name: ON This qu (jn corn Offto �e When'e f Y B for wtew FzattMCONSTRUjo Section: Phuddi ater S N ance w,� aPPly�n�'for g-ple Yste„t Cons Tax Office pjN# Got' f- Article 11 of Buildin This Ro duction G.S.ChapteglSerMits. "'vautho�latoUSTBE1ss Road Name y' NVIR MBN ` ✓"�� '' % �A' astew yste n N bersh°E Y the D Co oN W , D b rqL yEACTy s ater s ms S uld be P eSente�e unty E Zip: SPE . `;�'C' *** ection-I goose d 10 the )a,Ironmen Q t� Dg TE t NOTIC *,� wage e Coun tal Meal ISS E * ISoln RI T�atrnent d°DIs' Building oncti pli AUjNO VgL�poRA ��FOR FAST SYstems), Op OFET ER CONST RS. RUCTION:' . n DAVIE UUNTY HEALTH DEPARTMENT i ' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pernlifte 's Name: Subdivision Name: ' ` �y i Directions to property: ;r"�" Section: Lot: 'rt= r "ROVEMENT ; r PERMIT Tax Office PIN: 1- ca - �-ra Road Name: Zip r - ' **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 Ai C f' 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 PC TYPE WATER SUPPLY • DESIGN WASTEWATER FLOW(GPD) NEW SITEy REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/dw GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH LINEAR FLY10;10 0 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �w � �S **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 a. SYSTEM INSTALLED BY: 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 NOWAY BETAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF,TIME. DCHD 05/96(Revised) A• ' 1615 DAVIE COUNTY HEALTH DEPARTMENT i4ll, " - TMPRO VEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permlttee's K''�✓ "'"". Name: 6< "" . °"' Subdivision Name:" Directions to property: Section: Lot: r ,f(_1 - U81PROVEMENT PERMIT Tax Office PIN:4L Road Name: �'l 5 Zip: **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 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 isf L #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT / #SEATS IINND�USTRIAL WASTE:Yes or No LOT SIZE iTYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) ` C i�`NEW SITE L� REPAIR SITE )� SYSTEM SPECIFICATIONS: TANK SIZE/ ''�_0GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH�'� LINEAR FT OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 4t / nn 4l Ct 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: I 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) 1k, , „r APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT 6 a V Davie County Health Department Environmental Health Section P.O.Box 848 JUL 1 41998 Mocksville,NC 27028 (704)634-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Contact Person R Mailing Address r x 13q Home Phone 2 2740 City/State/Zip 000140 et kt, I T Business Phone '2011r 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit&ATC Both 4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms Z t�(Dishwasher ❑ Garbage Disposal ©(Washing Machine ❑ Basement/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 ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ElYes MuNo If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. �90 x x-93 Property Dimensions: '- 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # � � - �U - 33 5 D 1 few 001 1 Property Address: Road Name M ,r Q 1 /�„'A 'y,��l � City/Zip f 1 l cA U i "" 1709 ; t/ .�U�v V!" 0, W lay If in Subdivision provide information,as follows: 1 Name: l 1 I 1 Section: Lot #: � 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 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 Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by rs - `I to conduct all testing procedures as necessary to determine the site suitability. 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" `�}►• � Y •s;�:c.l � "�'I'.', .'`:•a '�:i-P. t• %1�.�<.`':�,•�yMM ` -1•'f�'.%.':. `JJ�yy'•,�•r,.t�-•.', - r]��[`' ; `.. �' �• 'L• '' ':' .a' •~�j•:� '••yfkv •1 P .*�•�;• ':iSrKir�p;4S�r•. ;•E�.,.,1;i'#t�•tir' w ti DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 1�! / Y� ��- DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE � `C SUBDIVISION C Y"� ROAD NAME G �� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring L — Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure <Te <TP Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 'ZC EVALUATION BY: LONG-TERM ACCEPTANCE RATE: t L 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 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(01.90) - ■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■we■■■■■■■■■■■■■��■■■■e■e■■■eee■■■■■■■■s■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■I■■■■■ ■■■■■■ ■■■■■■� ■■■■■e■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■e��■■e■e■■■■eee■■■■e■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■se■e■■■■■■■■■■■■■■■e��■■■■eee■■s■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■ewe■■■■■■ ■■e■■■■■■ee■■■■■■e■■■■■■e■■■eee■■■■■■■■■■■■■■■■■■e■■■■e■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■ee■■■eee■■■■■■■■■■■