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482 McClamrock Rd 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME TAY ADDRESS DATE DATE LOCATION S SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE —mo=o- # BEDROOMS # BATHS # OCCUPANTS GARBAGE DIMSAL Ye No COMMERCIAL. SPECIFICATION`WILITY 11YPE,� Viz. # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE:;,.Yes/Np k LOT SIZE X3 �r :TYPE'NATER SUPPLY '°' DESIGN WASTEWATER FLOW (GPD) NEW SITE ►" ;REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE,ADO 6AL. PMR TANK W. TRENCH WIDTH .3 ROCK DEPTH LINEAR FT. 3 Ob OTHER ,. REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUOEOP TO REVOCATION IF SITE PL.Ak OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ► r� ly ,r y. r u , i 1 OVSo I , l 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:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. AERATION PERMIT u ED BYng.Tc�o,�.. \D xa,.� Fv�N AUTHORIZATION NO. QQOPERATION 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 13OA, 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 10/95 '. :rr `3yy +tt1-"Ll$a t.sR_..v',l� r. . ,. �0..':•,••ti.t. .. . `.r � '!' vj:-. r 1- lc ..,.ry.:..• - n. a << :;. Davie County Health Department �y f ENVIRONMENTAL HEALTH SECTION r New - P.O. Box 665 Lor). o b Mocksville, N.C. 27029 , O AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) t. . ** 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.*** , " ��• ' 9,Ij AUTHORIZATION NUMBER NAME (��\ ` Afc..1Z a C �TE N® 8 0 NATE ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION �C C A 'tcc� R 0 C- COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM r l r.� t*#NOTICES THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION'IS VALID FOR PERIOD OF FIVE (5) YEARS. k; . ENVIRONIENTAL HEALTH SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PEI IQ . Davie County Health Department t. Environmental Health Section P. O. Box 665 Mocksville, NC 27028 ...r�.�, 1. Application/Permit Requested By e5o�l Mailing Address 1?6 Gg?� 1X44 Home Phone ra34^�O (,(,E (V L Business Phone 2. Name on Permit if Different than Above :. 3. Application for: ❑General Evaluation MISeptic Tank Installation Permit 4. System to Serve: *&'Fiouse ❑ 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 3 {'Washing Machine No. of Bathrooms Z Dishwasher Dwelling Dimensions 2 $ arbage Disposal t' 6. If business, industry, place of public assembly, other: Specify type f. No. of People Served No. of Sinks 1, No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers s. No. of Showers Water Usage Figures �7.1 Type of water supply: ublic ❑ Private ❑ Community ' 8. Property Dimensions Sewage Disposal Contractor : 4: 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 25�N-o c: If yes, what type? S l '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. - PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Office PIN �� (S Z6 M c C- GAMW-.eUC- -CT}�� Road Name /#XC.CLAM"cr-- 'j-D k(p q ( Co /%t(,E Q"ft-v T,1( G)J VP-(6(4T - Box # (if available) E5 me +4 o L-'T Av,Eye-- (70''J � City MO Ck:sU i L-C.Er N C— H tLf1G�C)) — PST S4 S-T'F'-fN LFzv Ec -tto J SE 's c2—� ° c OKI- As s 1•D`� 3�� 12,2 1 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. (-Z. D -9S i DATE NATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. %a-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 byLFS7L� .D o w L-ts to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE f P. DCHD(1/93) S DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �oo Soil/Site Evaluation I q NAME \� e A���/ _ C �-\��'` \� DATE EVALUATED r l r ADDRESS PROPERTY SIZE PROPOSED FACIILTYd�S2 LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By:(��r_L Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position S " Slope z HORIZON I DEPTH VZ ` Texture group S ct- Consistence li Structure Mineralogy 1 ', + 711- HORIZON 11HORIZON II DEPTH u i�`' 6`' 3 6� ' Texture group Consistence Structure Mineralogy 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 .S, ._S S - LONG-TERM ACCEPTANCE RATEI 4 SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: N�g- REMARKS: 141y. S 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V}s.ry 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/ft2 DCHD(01-901 .....■.■........................�........CCC..................... ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■s■■■■■■MM■■MMM/E■E■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■ ■■■■■■■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCC�CCCCs■CCCCCCCCCCCCC=CGCG= CCCCCCCCC MEMO ■■■O ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ M■■■■O■■ ■■E■MEEEEE■■■E■■■M■■MMEEEMMO■MEM■■■EM■■EE■O■E■ E■■■■■HC■■■■■E■■■■ ■■■■■■■■■■■■■MM■■■■■■■M■M■■E■■■■MO■E■■■M■ ■■■ ■ ■ ■■■ ■■EEE■ ■■ ■■■■E■■■■■E■■■■E■■■■■EOM■MEE■EEME■OE■EM■�■■■C ■CCC■E■CE■■E■■E ■■ ■EEE■EEE■■■■■E■■M■■■■OM■■M■EE■EMEE■■■EME■E■O■■■■■ ■■■■■E■■■■■■■■■■ ■■O■■■M■■■■■MEE■■■■■■■■■■■■■■■■■■■■■■■EEEMEE■■■ ■■EEEE■E■■EEE■EEE■ ■■■■■EOOMEO■■M■■■■EEEO■M■M■MOO■■■■■■E■■■.■■■■■■C■■C■■■■■■■■■OE■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCECCMUMMUMCC MMUMMECCCCCC■CCCCC■C ■■■■■■■■■■■■■■■EO■■OEM■■■■■/■■■■■■■EE■OM■EE■■■■H■■■ ■■■EEE■■ ■■ CCCCCCC■ ■CCCCCCCCCCCC�EICCi'■CCCCC�CCCCCCC�■CCE�■MMMUMMUMMOMMOR CC ■■■■■■■M■EE■■EEOMEEEEH■■■■EMEMEE■ENMOEE■■■E■CCCO■E■CE■■■■■■■■■ C ....................................■........... 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