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309 Pino RdPen-yt%ee's 1 _ DAVIE COUNTY HEALTH DEPARTMENT Name: j(`'►a� I+� �� i�- Environmental Health Section PROPERTY INFORMATION ! 1+ti (ir•it;� P.O. Box 848 Directions to property: - Mocksviile, NC 27028 Subdivision Name: y f rj; Phone#: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER Lot: SYSTEM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002633 A Road Name:.7 % 111 ' Zip . J **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 Aif� l I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �7 ti***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .5 ,6' r--i'!x{%; A - UP IS VALID FOR A PERIOD OF FIVE YEARS. 3NVIRONM NTAh-HEALTH-SPECIA1dST DAT IS D RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS —7, # OCCUPANTS, GARBAGE DISPOSAL: Yes or No COMMERCCIIAL SPECIFIC�AjTION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 7' G�}r�YPE WATER SUPPLY DESIGN DESIGN WASTEWATER FLOW (GPDk NEW SITE REPAIR SITE r' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH- ROCK DEPTH "' LINEAR FT. � '.�-� oo '""?„ As stated in 15A NCAC 18A.1969(5) OTHER -� accented Systems may also be used REQUIRED SITE MODIFICATIONS/CONDITIONS: ' �--+"' ' •l i k.._� L, . IMPROVEMENT PERMIT LAYOUT f t� U -- OPERATION PERMIT t� T N-' _10 l�"j U �P -'cR rt�N ,,- Pn4 . y �t OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. rrpT4 L 2.00 r- . WZ,, ISYSTEM INSTALLED BY: jk__­1 ��I� "14 Ne w 1-1-o^Z: por Dej s AUTHORIZATION NO. OPERATION PERMIT BY: DATE: z "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYST ESCRIBED ABOVE H S 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) . f DAVIE COUNTY HEALTH DEPARTMENT p� Environmental Health Section PROPERTY INFORMATION �.,.- P.O. Box 848 -ir•�I �,i -� )1 t Directiong to property: 1 '°' Mocksville, NC 27028 Subdivision Name: M�f ;Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# 002633 �� +� r� SYSTEM CONSTRUCTION - - AUTHORIZATION NO: A Road Name:.,~'( 1 t iaa,1{Zi � P� **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. (1n compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f • � fi r f ! ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. --ENVIRONML/NTAL-HEALTH SPECIALIST DATE ISS01113 r RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS .. # OCCUPANTS ---7-_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE�YPE WATER SUPPLY 1 ,hDESIGN WASTEWATER FLOW (GPD -.J.-(-) ^() NEW SITE REPAIR SITE .. 1 (► I J SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ,. ROCK DEPTH LINEAR FT. tt t.... OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT tm LJ rAE V 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. OPERATION PERMIT SYSTEM INSTALLED BY: 111'1 t �r-7(I S`r1� ro 'J T Np W �"� t'7.1r1/lJC Nor o. -j 5I - 14 t r2 A,J Sc:' AUTHORIZATION NO. OPERATION PERMIT BY: DATE: 1� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS ESCRIBED ABOVE IQS 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 M102 (Revised) C_' .- -,.s Mailing DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 W&fl wHeyl ON-SITE WASTEWATE ERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ Detailed Directions To Property Address: c q aAJO r Number: '76S-- W W (Home) 1 Ve_ (Work) Ylfe Please Fill In The Following Information About The Existing Dwelling: Of L/ rNe� � Name System Installed Under: ILV 1,1 r fC Type Of Dwelling: CcSG Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People:_ Is The Dwelling Currently Vacant? Yes V/No ❑ If Yes, For How Long? Known Problems? Yes ❑ Nc1,2--' If Yes, Please Fill In The Following Information About The New Dwelling. Type Of Dwelling: bw ni Number Of Bedrooms:_ Number Of People: 3 C/ 04C Requested By: - Date Requested: (Signature) For Environmental Health Office Use Only Approved ❑ Disa Environmental Health *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a Quarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: 3356 Invoice #: x,. 4� g" MJ - § y.: 4 4 a i � S mJ A +Ew..�u.. +•+'��,..A' yM2,Mg ,= ,' i;'6- A -^ srrts watr�.wJi, •w+.^ea,a`- w: *f'� ,: V � i 70 r ,S� 3 7 a ., VII S c 'sit INice• s i *'�.px'n��. �K JK 4 04 r x d �X �, � , �`' � � ,n � to ° � • s i� s �" t � -' DAVIE COUNTY HEALTH DEPARTMENT y, _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION - "Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 130. - �� Permit Number Name I fC3-% l.t Vl / -° Date n•1 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ' ' F' House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES [D NO [– Specifications for System: Auto Dish Washer YES ❑- NO C] Auto Wash Machine YES ❑ NO E]-- 1 �, C i{ Type Water Supply !, J r s -- I---- _— *This permit Void if sewage system described be ow is not installed within 36 months from'date of issue. l J i Qi leo i N 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. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by�U/i.1G (�C� i Certificate of Completion Date *The signing of this certificate shall indicate that the system described above had been installed in 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. J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION Account #: Billed To: iVOY, 0I+1Tt, Reference Name: Proposed Facility: PROPERTY INFORMATION Tax PIN/EH #: Subdivision Info: Location/Address: _'3001 RJO Property Size: Date Evaluated: �J 2q I oce Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position I_ Slope % 320 HORIZON I DEPTH .- Texture groupG� Consistence Fr Structure S� Mineralogy HORIZON II DEPTH Q - Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: 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 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 Fl. - 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 -4. WIM DAVIE COUNTY HEALTH DEPARTMENT' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article .13c Sewage Treatment and Disposal Rules-(10 NCAC 10A .1934-.1968) Permit Number Name LuImAe— Date 12- s-�s N2 4128 Location 901 AcT I 0. Set�:p - � gnu 2.Q� `-[. 2 . It P-i- Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ a✓ Auto Wash Machine YES ❑ NO ❑, Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. • �Pr goy Improvements permit byl::)rmv-�� *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. Telephone Number: 704-634-5985. - Final Installation Diagram: System Installed by $n iL t .Certificate of Completion Date /2 The signing of this certificate shall indicate that the system describe 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. o-. :. t, .. - ..w ..n ,":. r_ .,. •. `i. .... -, -•1..3..:i1+'., ..-Vsw..vw: Y' -...-.- k. '.� i .,._ ` - .. fi' DAVIE COUNTY HEALTH DEPARTMENT J IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ;,NOTE:Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c - "- Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date �.�- s -8s^ �. 120 Location qnl Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business __ Speculation No. Bedrooms _ No. Baths _ No. in Family _ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑- Auto Wash Machine YES E]NO C] 3"v Type Water Supply 'This permit Void if sewage system described below is not installed -within '-36 months from date of issue. '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. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by L) [I_ 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. DAVIE COUNTY HEALTH DEPARTMENT 1' y IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name., L ' Date Location 0- LA — Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business Speculation No. Bedrooms'- No. Baths No. in Family — Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Ir'O P�L-_-- Auto Wash Machine YES ❑ NO ❑ Type Water Supply ___ "This permit Void if sewage system described below is not installed -within 36 months from date of issue. 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. Telephone Number: 704-634-5985. Final Installation Diagram: 4/y System Installed by 4,6- Y 1 Certificate of Completion �� • i'�-'1 r'lt.,l� 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. i �4 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. Telephone Number: 704-634-5985. Final Installation Diagram: 4/y System Installed by 4,6- Y 1 Certificate of Completion �� • i'�-'1 r'lt.,l� 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. ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name t y t ;, t i t t`.t_.• ,R• Date i s (, _. 7 �.... P0•1 Location 'r1 ' l _1 Subdivision Name Lot No. Sec. or Block No. Lot Size " ''' House Mobile Home _ Business Speculation No. Bedrooms Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply No. Baths No. in Family YES ❑ NO S - YES p' NO ❑ YES ❑ NO D-' Specifications for System: *This permit Void if sewage system described below is not installed within 36 months from date of issue. 1 t.fC�J f ii r , I ; �. (..-( t .............. LSI Improvements permit by r � "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. Telephone Number: 704-634-5985. Final Installation Diagram: j. u System Installed by Certificate of Completion i ` L 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.