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4572 Hwy 158 (2) DAVIE COUNTY HEALTH DEPARTMENT + IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **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 Depart ment.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) NAME ROPERTY ADDRESS �O — S 1-1 � a 70 D(0 DATE 3 LOCATION SUBDIVISION NAME `` LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS `� GARBAGE DISPOSAL: YesQ COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE:"Yes/No ` .J� LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)..a Y0" NEW SITE V, -REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE\Oorj GAL. PUMP 'TANK GAL. TRENCH WIDTH �, ROCK DEPTH LINEAR FT. 00� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: Y ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE,SYSTEM. 1 ' t IMPROVEMENT 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 SYSTEM INSTALLED BY �fl AUTHORIZATION NO. OPERATION PERMIT BY DATE D/ **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 FICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 t V•4 J1..t ''P''tWy '1 :�.< �y�r '.t':,H'ly:-� r. .y.�.M• .{:- ^..r•.E,n^7 ...a d4,✓ t .....'F ... r w.. ... C ^ l" ,. Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 l 0 a a �-, Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S.,Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Heg1th 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.*** \ AUTHORIZATION NUMBER ^ NAME - 1a DATE 3 ), � � t1, NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COM WS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*m* THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONWAL WEALTH SPECIALIST DATE - ,DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT cr q y Davie County Health Department Environmental Health Section / - P. O. Box 665 Mocksville, NC 27028 �0 1. Application/Permit Requested By Mailing Address 4_5y !.l Sf{,c��4�/'f� ,�Df//�/trC/= Jam[' Home Phone/6 ??W4,13.2-3 3.23 Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation peptic Tank Installation Permit 4. System to Serve: 0'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms a- O'Washing Machine No. of Bathrooms 2'bishwasher Dwelling Dimensions 364110 ❑ 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: P--Fublic ❑ Private ❑ Community 8. Property Dimensions 'Z„/6 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2-ko If yes, what type? NOTE: Improvements Permits shall be valid rom date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFORMATION REQUIRED: // E7cco e008S s/K �kl ��-aJ� Tax Office PIN: # /-SZ- 9&54 Jr;_) PROPERTY ADDRESS, as follows: / Road Name: city: ALy6Lxce IA-1 SU13MIT A PLAT WITH THIS APPLICATION. Revisions effective October 1 , 1995. 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. DATE SIGN URE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: Es l. I OWN the property. ❑ 2. I DO NOT OWN the property. ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by �3. .moi-�rS WCw�'/�� all testing procedures as necessary to determine said site's suitabi' for a ground absorption sewage treatment al system. DATE SIGNATU DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED 3 ADDRESS S `th, PROPERTY SIZE Q- PROPOSED FACIILTY i'\O'V S Q, LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By?� t L- Auger Boring Pit Cut FACTORS 1 2 3 4 Landscapeposition_ Sloe % - -3" _TF, 3b� HORIZON I DEPTH Texture group Consistence \= = 1 Structure MineralogX1: HORIZON II DEPTH '' 2 Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: g ' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: `� ` OTHER(S) PJ E NT: REMARKS: _ � • ±�*��` •h AI ll LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Footslope 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-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 3C--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 ■■■■■/■■//■/■■.■/■■■■/■■■..■■■■■■■■■■■.■ ■/■■■■■IOS.N■■E■ ■■■■■■■ SON SOMME.....■.....................................�........�........■.■■. ................................■......... ........ ■■.E■E■■■EN.■ ..........................................■......... .■.■■■.■.■■■. ■■■■■■/■■■■■■■.■■.■.■■■.■■■■.■■. 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