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546 Pine Ridge RdPermittee's -- }} `-x DAVIE COUNTY HEALTH DEPARTMENT Name: �N "tiL�c1 `� � Environmental Health Section PROPERTY INFORMATION >0d P.O. Box 848 dZ407 Directions to property: —L ` %E..� Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: 002740 A Road Name: ""`���'' ���- i��� ; , .�.?r,•=., **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 f.Qt 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPT IALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE 110 0 # BEDROOMS —3 # BATHS I # OCCUPANTS --:5 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ..at .d. � LOT SIZE TYPE WATER SUPPLY`-�c::U?j' DESIGN WASTEWATER FLOW (GPD)`` "� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH.! " ROCK DEPTH 1+ LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS:" �►' U+"�-1 ^�� ' IMPROVEMENT PERMIT LAYOUT Ut,�.f. Iii 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. R OPERATION PERMIT SYSTEM INSTALLED BY: +\ r A.e (J� � Q � cv Q,P R 7 P-'- Pe 1 y.e AUTHORIZATION NO. OPERATION 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 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. DCHD 02102 (Revised) ` / 1 ^' --- / Z -7,-9 .tel-. p I c). 46t 5q7' t i 1 'Permittee's', l �' � D 1VIE COUNTY HEALTH DEPARTMENT Name:��� Environmental Health Section PROPERTY INFORMATION t" r:.._ z =:• d P.O. Box 848 s/z�0 7 .Directions t6 ve perty: - {C'' Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 t ! ,►i• - 6.f Section: AUTHORIZATION FOR ` WASTEWATER f SYSTEM CONSTRUCTION Lot: Tax Office PIN:# - AUTHORIZATION NO: Q U Z %' `J A Road Name: **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..yilding Permits. (In compliance with"Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ..t ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE /100 # BEDROOMS •--3 # BATHS # OCCUPANTS --5 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( DESIGN WASTEWATER FLOW (GPD) `- NEW SITE REPAIR SITE ,I )J `� UU SYSTEM SPECIFICATIONS: TANK SIZE GAL. ,PUMP T�A'NK GAL. TRENCH WIDTH ROCK DEPTH / LINEAR FT. E='".3 1�GrI[`! it.�i.i\../ OTHER't •C!�'7i"%!/ r jr,/'f. REQUIRED SITE MODIFICATIONS/CONDITIONS:II IMPROVEMENT PERMIT LAYOUT t � L t) -- =L-. V c AILL� OLvit � L' UT �=.. - 4 I 1 --••�� t _ FOR FINAL INSPE91. 7ION OF THIS SYSTEM PLEASE CA BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT �� SYSTEM INSTALLED BY: \k G� � I n,+ V\ AA it 0 01 J. AUTHORIZATION NO. OPERATION PERMIT BY: tr` B llA I E:�� �I _ t j "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. DCHUo2/02(Revised) ���; -r(- A9 `"!uv• _ -�` ZI APPLICANT INFORMATION Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation On -Site Well Community Auger Boring Pit PROPERTY INFORMATION Z,Ifij -2 Public / Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r7_ -,Z0 Texture group 5 Consistence Structure Mineralogy HORIZON III DEPTH 20 . Texture group Consistence Structure r Mineralogy HORIZON IV DEPTH Texture group Consistence EAWT Structure {. Mineralogy SOIL WETNESS RESTRICTIVE HORIZON 37, SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE:. REMARKS: LEGEND EVALUATION BY: OTHERS) PRESENT: 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 1!' dq VFR - Very friable FR = Friable FI - Firm VFI - Very firm EFI - Extremely firm 3ya 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 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Biiiiiiiiiiiiiiiiiiiiimom mommosmMEMMIMM mmiiiiiMENNENl� MEN MEN ■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■G'�■■■■■■■III■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION • APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME_ �e%h cher)bs PHONE NUMBER ADDRESS 67 � `i fiC % OAl e- I=(�t � �Q k ✓/l � 1 "� ZSUBDIVISION NAME Ike, l"11940 l /N � DIRECTIONS TO )T # �ass�oac�s GD/ ��D l <17nrx?,e ArIv 4 JV % lm;le div 1-1sib I Fd W/1 ATE SYSTEM INS&LED 7Z NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED i TYPE WATER SUPPLY n(,tllk- SPECIFY PROBLEM OCCURRING (Niftier Corning 41/1 /J1 DATE REQUESTED INFORMATION TAKEN B This is to certify that the information provided is correct to the best of my knowledge, and that 1 understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 �y�,�,—,� -._-._... �STZ-43,7`�"SY�i.�'s:�P�+ sa�'"`�^`:°Aµ/"�' o,'�C.�"'� ' '�'�°'�a+v}.r7.''�,'RLC3�:9•yf:�'��C$3 +rie7T. .t'72T�Cx�-,ii'"� F�1�.-+S�`�?9"r"s n',"."'f';""N'w'."x."4 "4yr2' ',]`j,i.',� . "�� �, :R �� �.1���. .ty 1 J If`i^'.'1[?,A'" 1 i� . , ��, ' �'� � :�' �"r�, � �'��� � � '�'�`�"" � � . DAVIE COUNTY HEALTH ;DEPARTMENT .; . , ``' � �,�;�, ° � ,; , . , , , ,, , � x�� 1 IMPROVEMENTS PERMIT: AND �CERTIFICATE OF -COMPLETION �,_ _ . , . , }' `NOT�� Issiied in:Gompl.iance with G.S:�of North Carolina�Chapte�r 130 Article 13c tl } Sewage Treatment and Disposal.Rules (10 NCAC 10A .1934-.1968) �Permit Number ` i � =�,� ���"3 � t� r� '?:� �"� `�;.`�Z � No :�.��-�;� � Name -`- �� w Date -=-- �.1���.�� � � , Location �n `��,;�y�.�fd'-x� C i, �'���- � '�'� �.��.��.�'• �..5 �,��-�. .` ��`y� �'_ _ l r"'�� � \' t�i"C:v 'i"'�'�` ��"'"'�. 'ti'..'w '`�:=, � ��� �: .�.�,. � `,., �,.. :.,,, �' ,.�'.''Y•,,'y"" , �'� C ' `�� 1,,, � ,�� C� ; �j d, �» G? �a `.r� ��t� Sy �� �..„,.•!� ; ' � ��..).. ;,�'�l 6 r . t , . �� Subdivision:Name .� '. . �. � � ' . L"ot�No: . ^': - -�Sec: or Block�No. --� ` ; ' � .�; " � � i `�:� .� �., . ., , .: : - . , ,. . • :. �. .,. � , � � , ��.. .� .«. .��^ ` .� �. .':. . ... . , .,.. . � ' Lot;Size��«� House �.�,..�.�—�Mobile Home �Business ` Speculation ' ; .t� . .., . . ° No.,Be,drooms {�_ No ,Baths � No in Family�._ S � � �., �, .a.� :_ , i. „, fl.•, ... � ° -�� - . ' Garbage.Disposal , YES ❑ . NO [� SpecificaUons for,System. ,, Ir `,Auto Dish Washer -YEST [�',� NO '� � �' ,��:�c;'�,� `�;{� ,�, � �� � Auto Wash Machi e YES �.��. NO �. ���; '�. � . , � . � ` , 0 � � �� ��. � � + �� l :� ��,� I} TYPe Wate�r,::Supply .�:�n � _ F� ,.�`. � '� '�� , . , . , ; ` This; ermit Void,if sewa e.s stem.describ d',below..is.not installed' within 36.months from date of issue. � " P 9 Y ��,GA �d �r; � ,1„ 1. r .�*«:;;�," � C ,i �r t}e �l. i.��o . .. .,�s . „� ,� � , „. ,� _, .. , r .. r...,� . , . . .�,: . . . .. :� . � .., . . , ,, t ... . .....M1.�, , , i . �.'. . . _ , ,r: _ � ;�. ' � '� , } - r. ,�'t , I j , �M1"� , � ,�� a. ,� p t ' r r'� � ; �. � � � � ��. � � '� � +� f',' ,�: � ' � �} — � M , + , ,. . . _.... . ...,..r.. . . � _a ; . , ..� �_,� , , ,; , , ,..__,�__...._._.. ._,____.._..,_.,.. .} , .: I � a �• q � •� •,� , 7, :I _ � i..i . . i - � tt � .. . . � �` .�.� _' � � i .� ��1 r ��� � �� r��� � �� , .� _ . � Y {{ � ' yy f L � �1 3 '1-� � . . J. t`: ._� �'• y . ._. — � � 1'� h aF � :�a "' '. 9k",r�, a ,;9 ' � ',� � ��` �. ., , , , . . _ . ,... �,�,, . ... . :. � . ,. .. � . ,, ,. �.� .:.zu. � � _ �, ; ._ , �: r; ,r: _.,�. : , . �: ...: „ , �.._ , . - 1 , .� ! �9 iZ '1 , tL ,i'� . _ , .. . . . .. . . .- . } .l�, n� f J }�k ���4 1 4 I� 1 ��i :i , . _ � � � � � y�t. � _ i i.., r �,�.t ".' ' .':. .� C t� � 4t t.»� ��� `\ `"^-.,,��.���„��^�..�'.a._ , , , , , '�Improvements permit by��: �. , , , . . _-. .. , , , , , _ ���:*Contact a representati,ve:�of,the�,',Davie�,County,Heal,th DepaFtment'�� for�fi�rial inspection� of�this system between���-8:30- '�' : 9:30 `A.M. 'or 1:00=1:30 P.M. on ,day of completion. Telephone Number: 704-634-5985. . , , - . ' .�, :. . � _ , - � ,..�i . , , �-- ;> . ' . Installation Diagram,;. _. . � _ . � .: . ... _ �,,.._.�System I�stalled.by_�`�-� �-M--�- Final `� � ., .....""r°.m: �� . . � . . � � � . - .�� r ���' • Z ,. .- . ... ti ..� , ,� . ' � � i . � x. �� �� . � r ,; , , ,,'. ,� .,,,, � . , �. . � ,%,� �.. ' .. . �� w...,_ �...'� .�" i .r�. . � ,�� ., ;.. '_ . �., , .. �.. �'�, � , �� .� : , . � ; , .ti . -, �. , ��•' � `, , � • - -,r .. • , � . 'r , ,. r � '��� v S � . . � �� � ' , . � � �'�4 '�✓ � . ''�"" ryr i ��` �' � ,� ,, � , � , � _ .. --------I��.�--------''�' d F N � ,, , "��,"_"'—� � .''-l�'� , .�'V�►� N , _.________ .`. _3 � ��� �.. . - Certific�te of Completion. � cDate . . .: > . . Y,�.µ , . �— . . . . "The signing of this certificate.shall indicate that the system described above has been imstalled `in compliance with ; the standards set forth in.the above regu�ation, but shall in.NO way tie taken.�as a guarante�,that the systerri will function_ �. satisf.actorily for any given,peri;od of 3ime._ _.j, " / 1,'.' �—� � ��, � G i!n - _ " _ '__ .. ` �i � ��'�� �1�';�� � '�� DAVIE°�COUN,TY. HEALTH: DEPAR.T.MENT.,;: � � ' � a � � *4 �1 � . , . ° . � ' . ,-..--- ----�r , � ; -� . � �,�� , � � ' ' 1MPROVEMENTS PERMIT'.AND CERTIFICATE OF COMPLETION `'"; � ' �-,� ..�. .� . . ,� ��, � .. . . .;,, � , ��� � *NOTE:Issued in Compliance With Article I I of G S:Chapter 130a� ` � � ���n,itary.;Se�g�System���, �r`., �� �,�... >...����'��,..'� Permi���er �yt•• .��r>'r!�' 1��" °�f /�/�:a2''�' �i �,.�k,�" t Y �' '+'� Name � �_,t Date: NO �� C✓T.G' �+ '�.,�j �� .r�r t� '„ �� t'� C,-,v o✓��� .�`l�!`�' /_f. i'..�,'i�G `,,,,,,,�i+��U!'`+'� ,�^�i",�� •+R, . . �.Location �� _ --�--- . , , : . .. . , ., , n � . , . . .. . :, ' , . �,.. . ' ., ,.. , ,,, � � . , . . .,, .,, ,; . , ,. , . . , . � . Subdivision N me' � � " � " � '" Lot:No. Sec. or Block No. � � --',rfC��, .. �� - ° ,:�..-..---'., _ _ Lot Size " House r Mobile Home._.�_ Business _- � Speculation � , , � �7� . Na Bedrooms � --.No. ,Baths — „— No. in Family - _,, � � : � Garbage.Disposal� �YES 0 NO '�]� �� � � � ,. Spe�ificalions for Sy�tem: �Auto� Dish VNasher�� �YES�� [�j� -NO `�.O ����;��;�� "r ;U�� �'r_ � ����� �� ,, . , . . . � Auto.Wash Ma;hine YES ❑ NO,.❑ � . , ;;yj��vr,�=� `� � r. �'�� �,tJ , ��:,,,- ; Type Water Supply ��' --- " 'This permrt Void if sewage system described below is not installed within 5 years from date of iss�ue. { This permit is subject to revocation if site plans or the intended'use change., , . . ` . `.. �.�� ���� � : . ' ' . ` . : `. � „ `�-�,.. �-.-,,,�,�� -�.�_.:......-,�.,..,.:�„ ' � � � , . , -�--..... . , , �,_:,,,. � � , . :. , . . . ' <: , , � , . � , . . ��„_._.--. ,. � � � � � ,r' �_,;_,,.:,....---�-�.,� � , . . , _ . I ._ . , �. , �� �. � , �,; . < . , 4 . , � , . , _. . �.,. . . .. . , . . � . .., :. � �,..: .� , . ; �: � "�; _ : �; .. . . �.. -: �, . . e . F ... , , : . ._ . . . , .. . . � r Y ��. _ - �� �,,;, � : :: . ' . • : ;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. or 1:00-1:30�P.M. on day of, completion;; Telep,hone Number'.704-634-5985. fl _ , — --= ' ,�-�:\'F.�,U G�?�hn'b �� ��� ' . . , .„ . � , Final lnstallation Diagram: �i � System Installed by _ , � , . ., , , ;�. � : , ., . , r� �-��a,� ,.� .� , - .� A ,. . _ : ''� .. ..^ , „ � o� ; . ;� � ,_�,� /---�"�`�r �' � . f , �`�`----_--�� ;' � ..r,� n.� ""'�"'�-�,.�. ,� " � � , � , . . ' ' 4 . . _ . � , .,:. -, � .. ��. ... �. .... � \��� ��t„� .. . _ � � i . . . . � . _ .. , . . . . . �"`�....�-' � . . , ;. .. _.: :�Certificate;of Completion- �"'� bate � � � r� ' •The signing of this certificate shall incJicate ihat.the system described above has been installed in compliance with the standards set`forth in the.above regulation, but shall in N0 way be taken as a guarantee that the system will function , __.:.....:....::�:.....,;....,.:. ....:::.a ....:....:... � � � n ���� � m� , � � � ,� ,�",� � _ 'a �sw � ��� 2P"{' �1 il :i � h�.,� '� �� t'+Y � �r d - t�3'; v � �. �'� • � � € ; V q� �..' �• p � A� EN. .p �, �"% "�' x����� 8fli�i�a(� a (� b � �f � s�"a � i� � �-�i��i �� �(��3 � .,'�� "'� "s. � � � ��^`� o� 1 fi'���'�' a° �y i � p ,�,�s s'��� ���.�'�"'�.�,'"� ss� ... � � � � „�. ` � ,�. w ,• '� � �`+ �i r"�y '. I � '°u a .� �'� '� c �'s s � � ���� ��, �.'�` i�e� . � �� iti � � s..�� �,�i�. �,�.,� � � ������,������ �'�'^'�� a "�� �,� yitt�r. 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