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176 Pardue Loop .,,:.. , . , . , _, . . . � , . : . , , ,.. . . . ; .. . I('i:� • Permit:ge's . � � '�� DAVIE COUNTY HEALTH DEPARTMENT ,r'1:..� l � ". r' Name: �9�"' t '� r4Y��-z'.��=�z iJf '�'--+'� �'-»� Environmental Health Section PROPERTY INFORMATION ' + P.O. Box 848 �irections to ro ert : � �''�r+ ��t �� 4=.y�j'���'�� �,_, P P Y . 1�1ocksville,NC 27028 Subdivision Name: ��; - �� '^;.,� Phone#: 336-751-8760 �",t'�.,f..,¢.��'��-�..; i�..� .• Section: Lot: � ' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTF,M CONSTRUCTION - � q r � AUTHORIZATION NO: �'�'�;`��. A Road Name:����.° E 1 . ;i`;;} �_,Zip _ ;� �c.�:C�• **NOT'E**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 Pennits. (In compliance with Article 11 of G.S.Chapter 130f1,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � ✓. � " �r� / ,r,. ***NOTICE***THIS AUTHORI7,ATION FOR WASTEWATER CONSTRUCTION � ..�` �',�, ( �-��_ �� �r�J I r;�r�".%"� IS VALID FOR A PERIOD OF FIVE YEARS. �ENVIRONIy1ENTA4l-�EAL-TH SPECIALIST D�TE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE {' #BEllROOMS #BATHS ti OCCUPANTS GARBAGE DISPOSAL:Yes or No i i G��1�I f�X COMMERCIAL SPECIFICATION: FACILITY TYPE 5�'�t"7�#PEOPLE � #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No � � � (� �� [.OT SIZE TYPE WATER SUPPLY �?�"r��•f� DESIGN WASTEWATER FLOW(GPD) � ''-�-�I� NEW SITE REPAIR SITE •�.,!'`_ t f� r SYSTEM SPECIFICATIONS: TANK SIZE (.r��GAL. PUMP TANK GAL. TRENCH WIDTH �--'t'�� ROCK DEPTH �-= LINEAR FT. ��4"� � .—., OTHER � �jt��F'_,�t^� (/J-1�i.� I:�.%;�,''�.. � REQUIRED SITE MODIFICATIONS/CONDITIONS: �a�'?��f��.-�" �✓r'`� a��l'�!l�,�� � 1 �� `' � 'r'� �� p �� '� � �'�� ``' �� � (ra;S,�.r ,..�t f�� �� i;���l,.,F�l�» .7' Y�-�t'_T.,y I� C,9 , � ��r,,^ ���wSV IMPROVEMENT PERMIT LAYOUT `� � ��y� `�� � _,�` � � , �.il, � --� i i� �.�.-...� .�� � �T� . � ;� � � c;� 2,�� .�� wy�� � r,,-_ � � G..,...., ._. � �.� '''+ _l.. , �� fS �J { -�---. �! e%i�"_,l,._ ',T� G--.�.--- IC�):.�t���sf.t;', a� � � ' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-930 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT n � (�� �� P�IJI.. L-- EM INSTALLED BY: �-�'1�� S "r"��I'� O�;17 , 7 � �c,,1 t� � � � �, ; � �I � ' � �' � ,. ( .�, _ ; I i�' �� I i_n,.�k��V 9-� , AUTHORIZATION NO. ���'"� OPERATION PERMIT B � DATE: � � •+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS SCRIBED ABOVE HA E 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. nct►n ozioz pte�;s�a� ���---� ��� � _ �� �' �s� �- , . . . -- , . _ . . . .: , . . ,, . . ::. . , - .� ,- . � . . ... ' _ ...�� ' '..... ........... . .. �.. . .- s., _ . .. . . . t'`- „ . -- . -. , , - ,. .. . _ . .. .. . . . . .. . .. .... ... _ . .., . .�. �• � • , ' 1 ��� . . f! �Rer�nitte�s :; �, �� , ' `DAVIE COUNTY HEALTH DEPARTMENT M Naine; ~ � �` � n �~���l •� ' ;�:-s t' ,� Environmental Health Section PROPERTY II�iFORMATION �:� ;,, � t P.O. Box 848 �Directions to ro ert : E�''�� i� ; �,-ts`\i�,�F , , P P Y , hlocksville,NC 27028 Subdivision Name: � �9 f.��'.; ��^,n S� '��;�.,� Phone#: 336-751-8760 Section: Lot: ! AUTHORI7.ATION FOR , R'ASTEWATER � Tax Office PIN:# SYSTF.M CONSTRUCTION - - AUTHORIZATION NO: ���'�`�• p Road Name � �`t.� ; �'�`,i',t� �.Zip' <- 1 �":��,' **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmentai Health Section prior to issuance of any Building Pemiits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Artide 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) -' '` " �' ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION :y ,„„.�...�, 6 �. ," i / e y '''� 1 1'<^''�° �-'� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONIytENTAL HEAL•TH SPECfALIST DQ`I'E ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No ��C�'�j;�.' COMMERCIAL SPECIFICATION: FACILITY TYPE �f'��;#PEOPLE � #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY ���}�f�7�+ DESIGN WASTEWATER FLOW(GPD) � �L� NEW SITE REPAIR SITE , l ^� ,� ` � I SYSTEM SPECIFICATIONS: TANK SIZE �3G�J GAL. PUMP TANK GAL. TRENCH WIDTH •���-'? ROCK DEPTH t r-- LINEAR FI'. ��''�� OTHER � I,I^��k' �f^, _�!li';.� f 7*✓ + ^ I ..._� n i REQUIREDSITEMODIFICATIONS/CONDITIONS: f r:7��'it�+�..� C�l�� ;�'z:;'r,�t�?,,.1 t o���i,��� _`', tl���' €�i,tjt�..±�!�a�^, t �.Y�.�'�l� E�' :'-'1'�}�� � . �. � � � � . (..�_-f.�'r'.��. �.�'`i . IMPROVEMENT PERMIT LAYOUT � ,� ..�.____ �� v ry.,; . { /�`�\ � ' `D# . � -.� /!�, � � �f._ . ! �l �"1 y �� . a r, � �, � � �j. �� S,.'!. :i.., .....+ ...,_,_... _..... �� '� t;�Fr#/ ,�.,. � � .. ( : —.-.,r......��. -� �.��� �� _. � � _ .� r�'""""" j tc,�x�:t, ��2" �ta ► **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. .,,,,___._.::._._..._.-......_ _ OPERATION PERMIT � n � r� � '��' S � � � ��/�Q,j�IIL�.1�,�$S�TEM INSTALLED BY: t--1'��:—t% �..�'n� .��— � �� ( � �t�`f Ut�7 � p�2�.�� -� i r,�,z.� c�: � � 1 _,� �� i � ` ,�, �� ____ f �� s�� � ! `i '-`,.�k �,�a,�� �-S ,,_�� ..------- � � l � / r % AUTHORIZATION NO. '���`��� OPERATION PERMIT BY: � DATE: � a �..------""` ;.. - **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS E�y.bESCffIBED ABOVE HA BE INSTALL D IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAP'TER 130A.SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",B SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA�,TORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02(Revised) 1 �C.-�� �f �-�-� ��� .�— , a c - �_�� J ..{-� %is'� � � `���� _ ll��0 . �- � � DA�IE COUNTY HEALTH DEPARTMENT ����� , r�-� • , . 1 �IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION / ;f;�v— —____ �� *NOTE:Issued in Comp�iance With Article I I of G.S.Chapter 130a � Sanitary Sewage Sys.t�ems � � Permit Number Name J o `? ��� �-L�� �.�.��- _ Date ���- 1 �` N� 7 4 G �+ � ��� �ti -, ' Location �ti`��� � �`_;c�-���� �� �v +��a c � � ���1.�. �.��(,�> _ k � ` �= - � �� ` - ' -�-� �_J �, .�!' � . , — " J.� �,m1�..1��,,Z��-�, , _ �. .�. ' ��; ,.` �,�, _.�, / �� Subdivisian Name ���7Y� � Lot No. Sec. or Block No. Lot Size � .-�v��� L �� House — Mobile Home _ � Business --. Industry No. Bedrooms �—.No. Baths _�_ No. in Family � _ PublicAssembly Other Garbage Disposal YES ❑ NO [� Specifications for System: Auto Dish Washer YES p� NO ❑ ���� � �,� �._ ��,� Auto Wash Ma^hine YES p/ NO ❑ - �,t�d � Type Water Supply _—����c L�.-� ------ � � �' �U 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. �G/�xY,•'�"_-e' � 0 uP� �� I - ` . Q ' , �� � 6 ��--- I �� � � � � ,' ;, .�'. . ; ` � r y� 1 t-° � � ' � � 1��a �� , � �'� �, � . �.:e:�- "i f ' ' �'�p��, % . , , � . ,� � , �� Improvements permit by � ����^'�����— '--�,_;�'� *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installatio Diagram: �``"'�.�o System Installed by �C��� �`' �`�''����^- �.."„',,,,-,... �' 2 �!li '7u -� 76 N • � .. � r � - - � V� �Y �� � � . � � . Certificate of Completion �-- � �° Date ���� �� 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. . „� —,� ` � � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI --j-�--..a_,., , � Davie Counry Health Department �' ���..�,.,,. �Q ,�.��� Environmental Health Section P. O. Box 665 �Q�� � 7 i�t�j� Mocksville, NC 27028 __��____ — 1. Application/Permit Requested By �1�� �/ �r�k Mailing Address R-�� � •l�flx )i����c�n1 C.� ,IJ�, �7,d� Home Phone �9�O� °I`1�"�6�.� Business Phone �-� ���;�� 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation I.�J'Septic Tank Installation 4. System to Serve: ❑ House �Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other 0 Unknown 5. If house, mobile home: Subdivision 9 `� �� Section Lot# ❑ BasemenUPlumbing No. of People � ❑ BasemenUNo Plumbing No. of Bedrooms .� dWashing Machine No. of Bathrooms a dDishwasher . Dwelling Dimensions �'� x 7� ❑ 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: C�Public ❑ Private ❑ Community 8. Property Dimensions la b x �0 5 Sewage Disposal Contractor �A�n J W h��-/�I��� 9. Do you anticipate additions/expansion of the facility this sytem is ntended to serve? [�Yes ❑ No i� If yes, what type? -3 ���bJ�r� ��� �Ct, er '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: �����W G � '�� G(�c�.� �Ypv11 �DC1''�51/���� '�O J U y�� U � �! /- � �u�1u��1 �oac�. — � m, �� 0 K �e� �" f���o� (�oc� ,�-e�U U,C�10y�1� , P �.� �� .�-c�r��, � � 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. l- � �- � � /,�.� �...�•_n DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: C�1. I OWN the property. _, � 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. -�1_I D S� DATE SIGNATURE DCHD(12-90) rt � �'r ,,, • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section • Soil/Site Evaluation NAME � \ C9�s�— `� DATE EVALUATED �� �" � L� ADDRESS S �' �`2 PROPERTY SIZE 1��'� � 7 b� PROPOSED FACIILTY � ' ���� LOCATION OF SITE \�`��.�,����*{��`t, Water Supply: On-Site Well Community Public Evaluation By:�,��AugerBoring �,� Pit Cut �� FACTORS 1 2 3 4 Landsca e osition � s S10 e 7. _ I � _is� �r-c - J�-�� HORIZON I DEPTH � � �, u Texture rou C L t- �-L, Consistence � 1-`T � �� Structure � C C C Mineralo ' \ ;� I�1 � � HORIZON II DEPTH �� L12.` `I� " �-1 `' Texture rou C C �' Consistence -� f'� Structure k. � � Mineralo �� � 1 :� ' 1 HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS S,S � s <s s S--S RESTRICTIVE HORIZON — —' " SAPROLITE — -� �- — CL�SSIFICATION S S LOyG-TERM ACCEPTANCE RATE � ,y �y , SITE CLASSIFICATION: � � > EVALUATED BY: \o�z� �_^�� LDNG-TERM ACCEPTANCE RATE: � v\ OTHER(S) PRESENT: �� �-� REMARKS: �� , •� �� 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 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Iriineralo6ty 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 w etness - Inches from land surface to free wate�' 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 ■���������������������������������■��������������������■�■ ■■�ae�■ ■�����■■����������■■■��������������n������■�������■�����������■�■ ■�����■�������■����������������� ■���������������■�����■���■����� ■��■����������������■���■��������������������������■������������■ ■�����������■�����������������■����������������������������������� ■���������������s���������������������������������■����■���������■ ■�������■��■��������������������������■�����������■���■����������■ ■����������■������■��������■��������������� ■������■�������������■ ..........................................C.....■...........■.... ..........................................■....................... ■������■����■������������������■ ��a���■��■���■��■�����■��■�����■ ■���■���������■�■���������������������■���������������■��■■�����■ ■�■�■■���■��■�������■�����■ ��■■��������������■ ■���■������■■����� ■�����■�������������■���������■�����■��������������■�������������� iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�iiii�i i�iiii�iiii�ii��ii ■��■�������■��■����■������������■��■�������������_■����������i��■ ■���■����������■�����������■���■������■�����������������������■��■ ■�����������■��������������■■��� ■����■���������������■������■��■ ■���������������������������■�■���■����������■������������i���■■ ■���������■��������■�����/��������■�����■���������■���■�H�������■ ■����������■■�����■■���e■����������■���■�������■��_■���������/■��� ■■������������■�■��������������������������������■ ������������■� iiiiiiiiiiiiiiiiiiiiiiisiiiiiiiiii=iiiiiiiiiiiiiiiii�iiiiiiiiiii=i ■����������■������■■���������������■���■���������������������� ��� iiiiiii�iiiiiiiiiii�■iiiiiiiiiiii�iiiiiiiii=iiiiiii��iiiiii��i=iii ■�������■��■����■����N������������N����������n����=��t���t�t��� ■�����■�����■�����■���n����������������������������■ ����������� ■�������N�������������������■■�������■��■�������■ ■�����������■ ■ .....■...........................................■C..............■ ................................................. ................ .................................................C................ 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