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191 Northbrook Dr Lot 18 .r, +r ra.yf�rE'�'"'dT':..i�"y}y1^`� � �±1i�ge0'�.T�f'fg'g4iL�jL'9"^t,�' "Za ii�,i'P':t'+�ffa5;1 i,',ri. .- L" y, u:t- 4., •�'.'%E`s1+.� Vii- 13 j AUTHi RIZATI0.14 NO: DAVIE COUNTY HEALTH DEPARTMENT 4 •bo J �,, „`' s . : 1 Environmental Health Section PROPERTY INFORMATION 1 ertiutfee'S P.O.Box 848 A\ e N o c. .'C��n `✓ X10 �1�b goo : Name. a Mocksville,NC 27028 Subdivision Name: Phone#: 7047634-8760 Directions to property: ��n ` fir. Section: Lot; AUTHORIZATION FOR . WASTEWATER Tax Office PIN:#5r6 1 d - J to b SYSTEM CONSTRUCTION- " G Road Name. ` •.zip: **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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTIopi IS VALID FOR A PERIOD OF FIVE YEARS: ENVIRONMENTAL HEALTH SPECIALIST. DATE ISSUED' T4 r 0 �h� ,� �•sr d• � � 4.,;k. �,•r7r . 'e Tk 'i � a5c.a� , -'°.,�Tg-S i`Z'� e,',s' a '-j �' ] .^, i DAME COUNTY HEALTH DEPARTMENT *�9�, ROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION , Permll"tee , Name:-_ Subdivision Name: Dlrections to property ;t3 �') .Section: a -NOR Lot: IMPROVEMENT ;,r. `"' PERMIT Tax Office PIN:# S> - ~5,.�:- '^'L... :•_.s+.�: " �=�?`* ^:.Sr.. ``+r ..<• - Road Name: ,;'+±.:t Qy,' :,•S.zip, *I%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 f om this Department prior to thew consItcuction /installation of a system or the issuance of a building permit. ari comphance 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,,: W *`a. �: 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 A&Q5-0 !#BEDROOMS_N#BATHS #OCCUPANTS_�GARBAGE DISPOSAL_:Yes O ;y, COMMERCIAL SPECIFICATION: FACILITY TYPE `` #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or Noy y 35p' w LOT SIZE 1)(31DTYPE WATER SUPPLY +-'• DESIGN WASTEWATER FLOW(GPD) GO NEW SITE REPAIR SITE 1� L.LINEAR FT. 1 SYSTEM SPECIFICATIONS: TANK SIZE OOD GAL. PUMP TANK' GAL. TRENCH WIDTH. 3 ROCK DEPTH 3Uo OTHER t t REQUIRED SITE MODIFICATIONS/CONDMONS: IMPROVEMENT PERMIT LAYOUT s 7. j ~ ©A x j} , s vr a **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)6348760. OPERATION EERMIT 17 ?'O : � SYSTEM INSTALLED BY: d'1 MwIJ"� K� 1 Y M� s� { y - AUTHORIZATION NO. I J� OPERATION PERMIT BY: DATE: O **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 BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. o DCHD 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC Davie County Health Department ` Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �e'�'r CD �''`'e"� Contact Person MailingAddress /7-6 S ter.s e t" be, Apl'• 3) Home Phone &3 City/State/Zip N2 o-gsV i lie "C' z-7 o i8 Business Phone 43-V— q t 95 2. Name on Permit/ATC if Different than Above Mailing Address City/State&ip 3. Application For: [ ]Site Evaluation [improvement Permit&ATC - 4. System to Serve: [douse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms 3 #Bathrooms Z [vil5ishwasher[ ]Garbage Disposal [✓]'Washing Machine [ ]Basement/Plumbing [I.-}'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?[ ]Yes [v]'1\io If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT**' CC OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: #VIZ)- _ 3-Z _ -7(,3 o //L'V (Vol A)o.t. fb Ck to Property Address: Road blame Nor , aro o K ; fd ��r.. ��f'F - �9 0 -tb, l Sf jmvej 5:6 City/Zip a-7 Da$ or. ri 91,x' - /✓orf�►b�oK S..6divisi a-� fsul�e If in Subdivision provide information,as follows: o-6 C-11-dt -S tc - (of 13 leff Name: ��r��ooK o� of C,,l-de-Sac Section: -L Lot#• �8 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 qq County Health Department to enter upon above described property located in Davie County and owned byto conduct all testing procedures as necessary to determine the site suitability. DATE- 11SIGNATURE6444--, Revised DCHD(06-96) THIS AREA AtAJ BE USED FOR DRAWINC7 YOUR SITE PLAN: i IIIIIIIIIIIIIII ..... ...... iIIItlIIIIIIIIItIIIIIIIIIIIIIIItVIZ.IIII W IiItiVj 174 ITA IIiA I IIIju IIM III .ou",IIII4-'4j­-.l IIIiII14 I14, IIIlIIIIIIIIII • + M , APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department l Environmental Health Section SEP 1 8 19% P. O. Box 665 Mocksville, NC 27028 I' ENVIMENTAL VI L 1. Application/Permit Requested By ✓y�A 1 Mailing Address Home Phone !29,9#717 Busingss Phone' 2. Name on Permit if Different than Above I Applidation/Permit for: VGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: (R/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ In Other ❑ Unknown 1 is 5. If house, mobile home: Subdivision wo �Rap�Seton Lot#, ❑ Basement/Plumbing No.of People ❑ Basement/No Plufibing No.of Bedrooms ❑ Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ 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: L-Public T. ❑ Private ❑ Community 8 Property Dimensions ) g& 4! G G2e=•L Sewage Disposal Contractor 7 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? "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. Directions to Property: JI ', L✓fL (� �✓ � �J V �Gru�L�- G%�/ / , 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. DAT ff ��•yam � SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 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 by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment If disposal system. 4 DATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation qL NAME �3$c�;rQ N� DATE EVALUATED t ADDRESS PROPERTY SIZE PROPOSED FACIILTY �'�' LOCATION OF SITE Cha Water Supply: On-Site Well _ Community Public Evaluation B ,L Auger Boring tJ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe X Sk IGQ HORIZON I DEPTH Texture group Consistence Structure Mineralogy ` 1 HORIZON II DEPTH ` Texture group Consistence Structure Rr, MineralogyV� HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: n ' LONG-TERM,ACCEPTANCE RATE: �� OTHER(S) PRESENT: No rviz 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 :lay 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 plarstic 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/ftz DCHD(01-901 ■■■■■■■.■..■■■■■■.■..■■.■.■■■■■■■■■..■■■■■■■■■.■■_■.■■■■■■ ■■■■�E■ SSSSSii555555555a55555iii55'SSSi..S5555i55555ii SSiS'SiSi SSSSSSSS ...........................C...................5....5....5........ 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