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1241 Main Church RdAtITHOR14A TION NO:DAVIECOUNTY HEALTH DEPARTMENT 1648 Environmental Health Section PROPERTY INFORMATION Permittee's P.O. Box 848 Na'me: Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to property: 1-I U)", U01 -j -I v Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: I -11t �Dzip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health 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. (In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ILL, 4IS VALID FOR A PERIOD OF FIVE YEARS. C 11zxh? DA ..j ,•,-v: ,� ;. y.; .w, .,, .�-V" •: , , 'fir ... .. .. _. f x 16 � � DAVIE OUNTY HEALTH DEPARTMENT �.� r IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION P'imifte 's Name "" r ��y L:' 0 r Subdivision Name: Dlrections to property: s,_ t.: y_ 1 , i , Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# 1t rtRoad Name f =31 fr,,.r 1<) + Zip: c 7 **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) r` + ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONM TAL HEALTH SPECIALIST DATE ISS(JED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPESt-# BEDROOMS _ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes orS) COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE CPG' PE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE ✓ REPAIR SITE 11 �) SYSTEM SPECIFICATIONS: TANK SIZE (t2?4GAL. PUMP TANK GAL. TRENCH WIDTH'S ROCK DEPTH Z LINEAR FT. F -' OTHER��J"ftB•.J REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT,.,—r � jG-- "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 Qp �3 STEM INSTALLED BY: ' 1W tV kc 1--,--), Vz --q AUTHORIZATION NO. JtA OPERATION PERMIT BY: DATE: & 122_ 7 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE�SDESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION.1900 "SEWAGE TREATMISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 0996 (Revised) `� APPUC4110N FOR SITE EVALUATION/IMPROVEMENT PERMIT & A 6 O Davie County Health Department Q Environmental Health Section P.O. Box 848/210 Hospital Street AUG Mocksville, NC 27028 (336) 751-8760 AW NT— HEALTH I ***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to�the INFORMATION BULLETIN for ijxstructions. 1. Name to be Billed 01 fA4111 Contact Person Mailing Address c Home Phone City/State/ZIP / �/�n (�� J(l / / �j �2 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ,❑ Site Evaluation improvement Permit/ATC TI -froth 4. system to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 2 ;3# Bedrooms # Bathrooms -2 IJIfDishwasher ❑ Garbage Disposal Q/Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/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 Frwell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 4No If yes, what type?' ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY 11010VMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SURA11TTED by the client with THIS' APPLICATION. Property Dimensions: Ila O AI- WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 6$-,)0 t — a /) 7 2 (. o- 6o1� —t Property Address: Road Name d/L�<. �2 %/ �� Q.nt � City/Zip m [A If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date PropeWedge. gged: This is to certify that the information provided is correct to the best of m knoun erstand that an ermitsP yat-any O 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 to conduct all testing procedures as necessary to determine the site suit#%ility. DATE Y- A-/ — V Y SIGNATURE / 1 L//,lino THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includefall of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). I Irm b' ��2, �/ 11 �0 V. P. Revised DCHD (07/98) Account No. Invoice No. 0 I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME COW L'AVAUJ DATE EVALUATED PROPOSED FACILITY &r PROPERTY SIZE W �� SUBDIVISION ROAD NAME !' LVA I N ur eo Water Supply: Evaluation By: On -Site Well Community, Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope % 6,Zv 12. HORIZON I DEPTH Texture groupGt_ Consistence Structure Ae Mineralogy HORIZON II DEPTH Z4 —Z Texture group G Consistence Structure Mineralogy l: HORIZON III DEPTH Texture group C k Sc Consistence SS Structure Mineralogy HORIZON IV DEPTH �-3 Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE (7. SITE CLASSIFICATION: -5 LONG-TERM ACCEPTANCE RATE: V REMARKS: DCHD (01-90) EVALUATION OTHER(S) PRESENT: ( _ W."D j 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 ■■■E■ ■■NE■ OMENS ■EN■■ ■E■E■ ■■NE■ ■MEM■ ■E■■E■■■E■■■■■■ ■■■E■■E■■E■■E■■ ■■EEE■■■■E■EE■■ ■■■■E■■■■■E■■■■ ■■Eon■■O■■M■■E■ ■■■■EOE■■■■■■■■ ■E■■■■■■■■■O■■■ ■■■E■■E■■■EME■■ ■■M■M■■■■E■EM■■ ■■o■S■■E■■■■ES■ ■EE■EE■■■■■■■■■ ■E■O■■■■E■■E■■■ ■■■■E■EE■■EE■E■ ■E■■EM■E■E■E■■■ ■■■MMMMMN■O■■■■ ■■■EN■E■E■E■■■■ ■E■■E■■■■■■■■■■ ■■■■E■EE■■■■■E■ ■■■■E■■■■■■E■E■ ■E■■n■EE■E■■■■■ ■■EME■■E■E■■■E■ ■■■■■■ ■mono ■■■■■■ SENSE ■■■■■■■■EOM■■■■ ■■■■o■■■■■■■■■■ ■■E■E■■■E■■E■■■ ■■■■E■■■■E■E■■■ ■■ No ■■ ■■ ■ on MEMO ■■E■ OMEN NONE ■E■EMM■■EMM■ ■E■■ moon SOME NONE ■■M■ MEMO ■■■■ NONE NOON MEMO MEMO MEMO ■o■■ MEMO OMEN OMEN ■■■M ■■■N ■■FA■ ■ MEN ■E■ so NO ONE ■ENNE■ ►■EOE■ ■EON■■ MENNE■ ■■■■E■ ■E■■■■ ■■■■��■■■■■■■Mie■■ ■■■M■MM■■MHAW ■E■M■MEM■M■■■ ■MMMM■MMNMAMM Eo\■■■ ■■m.'■ ■E■ELIN ■■■EOE ■E■■E■ ■■ENE■ ■■ on No PE no ■■ ■■E■ ■■E■ OMEN ■■■■ NONE ■E■■ OMEN ■■E■ NONE no ME ■ on