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376 Ben Anderson Rd < ¢- �v pFvrts :J y;T.•( :.,�� .m9>4.'.,t.•:� <:v 4"r-t -.�:,p Y:. 4 .;.:. .. , ..`...^, s r. e r .ti . ..- - ..t. - ,..'l 4b DAVIE 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 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) A��?�- �RTYADDREE'SS NAME \�Q N��N s ;q l`I�1d�r56 n``� 114A guf'"�• 9� t LOCATION U) SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION:]BUILDING TYPE # BEDROOMS L # BATHS # OCCUPANTS L GARBAGE DISPOSAL: Yes o COMMERCIAL SPECIFICATION: FILITY UK # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE: YeslNo. LOT SIZE . TYPE WATER SUPPLY, `�W 4 DESIGN WASTEWATER FLOW GPD>� `6a NEW SITE ✓ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZER! l GAL. PUMP TAM, GAL. TRENCH WIDTH � ',\ROCK DEPTH _1'-,. INEAR FT. - , OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ` s; ***THIS PERMIT IS SUBJECT,•TO REVOCATION IF SITE PLANS �R THE INTENDED USEsCHANGE. YOUR WAkERWATER SYSTEr CONTRACTOR MAST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. X33 ---------- Qs 13 IMPRAMENT PERMIT BY � **CONTACT A REPRESENTATIVE OF THE DAVIE RTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:08-1:30 P.M. ON THE Y I TALLATIDN. TELEPH01E,,# IS (704) 634-8760. •r . .j OPERATION PERMIT S STEM INSTALLED BY AUTHORIZATION NO. � � OPERATILNM PERMIT BY DATE �V_ **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. DOHD 10/95 Davie County'Health Department ENVIRONMENTAL HEALTH SECTION p''0. Box 665 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 Health Sect on prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Budding tikpections Office when applying for Building Permits.*** OffHORIZATION NIMER NAMEDATE N2, 0 3231 231 -- V NAPE ON IMPROVEMENT PERMIT (If different than above rt)v�X:�- SITE LOCATION o 0 CONKNTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WIM*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM'CON§TRUCTIDN IS VALIU,FOR A PEqOD OF-FIVE (5) YEARS. cl- ENVIRONMENTAL WATH SPECIALIST DATE DCHD 10/95 4PvV C C [ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI Davie County Health Department APR 2 41996 `1VV C� Environmental Health Section ,v►�1 (� P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL HEWN DAVIE1. Application/Permit Requested By 4 t�>= N �►> Mailing Address 5:16a, }'A Q R Aq,--7- ST Home Phone 6po i vow ` c>1z p 0c, Business Phone���y 2 e3 -6 qXl 2. Name on Permit if Different than Above �dtRL�w�, L/ 111�+�►'l 3. Application for: O General Evaluation J51 Septic 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 ❑ Basement/No Plumbing No. of Bedrooms CYWashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions u/ ��� k �r ❑ 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 Pi>Private ❑ Community 8. Property Dimensions 3_con!Et 77 P1C-A-Z<'_2 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes PNo If yes, what type? 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTI INFORMATION REQUIRED: Directions to Property: Tax Office PIN: # j>2.- 20 `F,4LQ_ 1 /4wy &of Ai t-E7 L/J)Z(ry CAVAC11i Ad PROPERTY ADDRESS, as fol lows: trsG zJtD/-+ Q 1 .670x.` Road Name: 13, )u nr1J fk"&,0 ��i( '��� C PQ- a--,Q C i f y: wit,c.k5 u n SUBMIT A PLAT WITH THIS APPLICATION. l Revisions effective October 1 , 1995. Q.,,, ►� �, Arlt �0 �1��� k � a ✓vvu.-Q2 .� 0v 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 SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY :A) MUST CHECK ONE: ❑ 1. I OWN the property. 2. 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 �N�(mow Ln c�rvt to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. ' DATE SI T DCHD(1/93) • to IN partial Ince seled in 11110 to premises aumyed: This N to tirNly that this plot was drawn from a recorded map and field Purvey:that the property Knee and location of all structurot ort seett"My*MM berm;and Matti its no ener6achmenta either way across property Nnoe,unless otharwl"noted. Thio we ON"that tete subl".I property Is not located In a spacial Mood hoard area as determined by the Department of Housing end U& M Development MAL,,�Efi C l % • 4 . B r2 c`n x o 'r�'Al-'• a sua�1.4 IV N A � V 0 � ;II "N, �39.. Ear F /v33J�d 0 Ab • N: �GG 45.. • � r : d¢ V 00 t e�3 ?sv Sc '4pa./APP m LOT NO,_._.. BLOCK_,.,_ PROPFATY OF KBE= I SECTION— MAP _ - ,p q,��E,{��- g�„E� .GA7,-4% 1 7'dyV. �YlP PLAT BOOK pa, IVIn:I'SVI-14 � ✓•C. DRAWN by: LJGC ,.�� PAGE JERRY C. CALLICUT`I' RLS f DA?E: 4-8-9e.- zX4vle COUNTY 1107 Perry Street N. C• Greensboro, NC 27403 JO1 NO.: J- -2)& tool( No.: L.L.S• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation II NAME Q�l � .0-N NS��Q'R.12q'A a �Ml 1 'WbATE EVALUATED -L - �b ADDRESS P '�1 PROPERTY SIZE PROPOSED FACIILTY C3 LOCATION OF SITE n Water Supply: On-Site Well Community Public Evaluation BySb'�-' L Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position -15 Sloe % 4 - ° -$ HORIZON I DEPTH Texture group _ Consistence "L Structure Q v'_ Mineralogy ,, I HORIZON II DEPTH " u Texture group Consistence Structure A Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S �S RESTRICTIVE HORIZON SAPROLITE -- CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: S EVALUATED BY: LONG-TERM ACCEPTANCE RATF1: ,1-A OTHER(S) PRESENT: REMARKS: A LEGEND Landscape Position R-Ridge S7Shoulder 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 3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralozy 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/f12 DCHD(01-901 ■■/■■■■/NEEM ■//././■■./■/■/■/■■ ■../MOON/.■■.....■....■......■■■ ■■..■■...■■■.■/OMEN.■./.■�/..■.■.■.///..■ ■ ■..■■■■■■■.../NOME..■ ................................ ................................ ■■■■■■■.■■..■.....■■■.■■..■.■■........■.�.■.��■�ECCCCC■■CNONE No ■.■■■■■■■■......■.■■..■.■..■..■........■ ■■O ■ ■■ ■.■■.■■.....■.....■......■■■■■■■■■.■.■.■..■■.■.No MONS■■..N■E■■N■■ ■.■.■■■EN.■■E.E■■■■.■E..■■.N■N■ ■..■■■...■■■.■..E..■■ME.NOE■■EM■ ■■■■■■■■■■■.■■■■■......■■..■..■ ■■■■■■.EMEE■■■.EM■■■■■■■■E■■■E■■ MEN MEMMEMEM ■..■■■■■.■...■..NOON.■./.■.■.■.■.■■■.■■■■■■■■■■ COMM■■■.ONE■MEMO N ■■■..■■■.■■EON■■■E■■NEE■■..■■.■■.■.■C.MM■CMM■M■■ MMN■MCEM■■■M■EC ■.■■.../....■■...//■NEEM/./../■O�■.■MEN■■�■■.■HH■EONEMEMM■ EEO ■.■■E.■■■.■EE■EE.■■■E■EO■NE■■■■■ ■.■ENE■ .. 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