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137 Poplar Hill LnPermittee's f, DAVIE COUNTY HEALTH DEPARTMENT Name: I1�^ ��� �''� Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: -C i= ) 1'.. ; A Mocksville, NC 27028 Subdivision Name: tc,. f f, ! p' Phone #: 336-751-8760 Section: 1 AUTHORIZATION FOR ' t WASTEWATER Lot: t• `" r �`'� Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO: a 0 2 0 414 A 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 bavie County Building Inspections Office when applying for Building Permits. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - l �.: �•�'/%r /:" "' �' ^��� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE# BE E� # BATHS # OCCUPANTS -)- GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No l a LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) " NEW SITE REPAIR SITE 1 � rte.- --� q' _ l SYSTEM SPECIFICATIONS: TANK SIZE l� GAL. PUMP TANK U�� GAL. TRENCH WIDTH s ��, ROCK DEPTH / J ( LINEAR FT. �� ^'�- tf 7 OTHER 4 JJJ .c Gff CCC t c.; ✓l ./0/1 e` L/ y ' C REQUIRED SITE MODIFICATIONS/CONDITIONS: �� I~a i' L -S i G V'i IMPROVEMENT PERMIT LAYOUT 1, c. t j 6 P' F J.AoaU 6- 1 C) t I { I, b i� fo 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. 11 OPERATION PERMIT 0" I SYSTEM INSTALLED BY: r \`er r Ir le �4 (tY �k zb ow eJ AUTHORIZATION NO. OPERATION PERMIT BY: DATE: I Dp C **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 02/02 (Revised) Pgnnittee's _ DAVIE COUNTY HEALTH DEPARTMENT Name: t"' It 4'r Environmental Health Section PROPERTY INFORMATION - P.O. Box 848 Directions to property: s r' ' Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 L Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTFM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002844 A 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 I30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) .iI .,-***NflT11-V*** THIO A I 11rt-If11717A'r1nNJ RfID WACTFWATFD d-nWCTD1if`TIfI1T ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE � # BEDROOMS t> IS VALID FOR A PERIOD OF FIVE YEARS. # BATHS .)� # OCCUPANTS �)— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ,, — . } LOT SIZE / rf' TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) _ �0 NEW SITE REPAIR SITE s J r; 7 C,r ! . , L � SYSTEM SPECIFICATIONS: TANK SIZE le C-1 GAL. PUMP TANK iJ GAL. TRENCH WIDTH �5 ( ROCK DEPTH / ` LINEAR FT. OTHER c� f Cf fY(r..+ / i? f.+ Li �� C �.I r C- t n j , REQUIRED SITE MODIFICATIONS/CONDITIONS:, IMPROVEMENT PERMIT LAYOUT tt 1 o1 iii tj k, AC'- 1 � 0 " t y 5 � 1 b� •P' '� CJ l "J It) U ft J � �. a out :gbis - 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 0 SYSTEM INSTALLED BY: ! + oQ 1� / �� � / f�u GGt 61 I (!/ �tuLl '7 C �i AUTHORIZATION NO. OPERATION PERMIT BY: �" 11 _ DATE: t "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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 02/02 (Revised) .Permitteg.'s . { Name: 1 "0 J u' Directions to property: d L DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION - P.O. Box 848 Mocksville NC 27028 Subdivision Name: �.. rr l.i;•< i. � G;p� AUTHORIZATION NO 002 440 A Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - Road Name: �' 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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) C-" ✓, ]-,e, c� f�. _ / ./ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r _ J)lu /I, �t RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS A # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE / o fiG' c TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) S NEW SITE REPAIR SITE k -f" SYSTEM SPECIFICATIONS: TANK SIZE i' GAL. PUMP TANK //ter GAL. TRENCH WIDTH % a ` ROCK DEPTH (��' LINEAR FT. + J (o k, ztatcd In 15A tJG",C 18A.1iruri5 / �i f� OTHER r`Ccrt�d Sytitems mvi talio ba ti3U [3 D7 cTl ) �(c► /`t -d Ltj Gal REQUIRED SITE MODIFICATIONS/CONDITIONS: hiC)u Q !`l{ (.a <-p d A (C `r'? ! P t�, �ie •_:1 C'r t+ �' I • r" l �) rj i -e4It I lc -'l G J,.1 IMPF OVEMENT PERMIT LAYOUT < , 0't )�a3 t- 1 to — S ` Cj 1 cl r CA `t' G? t.{ G� CL1 P 1 CJ LL, rC 1 _ t �� . JA CI .A b (C-•-1 U �j ca`i .\ ti G f J i cg 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: 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 02M (Revised) de C7 � 5030 / 1///�/ // -Permitt"'s ti : - DAVIE COUNTY HEALTH DEPARTMENT Name~-' i" 1 r �� i' ' t ` Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Directions to property: Mocksville, NC 27028 Subdivision Name: Phone i #:336-751-8760 Section: Lot: " AUTHORIZATION FOR WASTEWATER - Tax Office PIN:# - SYSTEM CONSTRUCTION AUTHORIZATION NO: 0028`0 A 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 Forn-dAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pennits. (In compliapce with Articix 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) s y L f + ) -6;0***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED S. r DW 1 RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS .) # BATHS # OCCUPANTS '" GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ►xS LOT SIZE /r i� r TYPE WATER SUPPLY ` DESIGN WASTEWATER FLOW (GPD) S NEW SITE REPAIR SITE .51 SYSTEM SPECIFICATIONS: TANK SIZE I—X' GAL. PUMP TANK i,/AGAL. TRENCH WIDTH L^ , t ROCK DEPTH t ` t ,LINEAR Fr.'r 36 OTHER [3D7'ol cttx (1 C.+7 f— C� REQUIRED SITE MODIFICATIONS/CONDITIONS: AI-Clt-t ct ��rS ca I•-' IMPR 3VEMENT PERMIT LAYOUT } + ©� , �" �3 L- I 0 14cr•`. �•rt0 1 J° 1. Y'1 � Y U r'G L't Cl c.. v(" r ,1 G{+cL Inttntu5� 9�4Jr i/Q ,e, + J / A 1 1 C 1 h o'•i %.A 1 � � s � �� 1 +�v� \' GO 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: AUTHORIZATION NO. OPERATION PERMIT BY: c t y` DATE: { 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. DCHa 0zro2 (Rev.:ea)d l .q 50 3 V / Al V • (-) 71 q IE COUNTY HEALTH DEPARTMENT `a Environmental Health Section PO Box 848/210 Hospital Street F ^ a Mocksville, NC 27028 Phone: (336)751-8760 c IVA ATER CERTIFICATION FOR DWELLING (Chec _ �nej"1zEPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑ Name: /) .5 1 1r G /1 —4 ll JJ Phone Number: (Home) Mailing Address:�,3Address:/,3;7 o A k),,I) Ln I) • .33 3 74 - 576 Lo (Work) V c C. 2-11�/7z6 Detailed Directions To Site: 1 �/'`� �l O b Property Address: 137 r Y . A�M1'I Please Fill In The Following Information About The Existing Dwelling. 7 lwl S' 1 Si S Name System Installed Under: W. . V • Sthi,'% (041j/ Type welling: — Date System Installed(Month/Day/Year): Number Of Bedrooms: umber Of People: Is The Dwelling Currently Vacant? Yes`a' No ❑ If Yes, For How Long? Any Known Problems? Yes'Q/No ❑ If Yes, Explain: Please Fill In The Following Information Abo lli Type Of Dweng: J/ W!►�� , Number Of Requested By: (Signature) ut The New Dli �j Bedrooms: umber Of People: 6 For Environmental Health Office Use Only Approved ❑ Disapproved y Comments: Requested: Environmental Health 9 --/ ?'--OF *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(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 #: Invoice #: DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary Sewage Systems Permit Number A Name` rrr i.+i Air`(%r ,✓r? •j'Li �f `Date , io i eJ nnnfinn / ` ✓ LS x l %i:,s' /��/ /i7 , a"_i !' .!°�I�`'/ .i.°r`r Vii: �' --o r — Subdivision Name VW Lot No, Sec. or Block No. Lot Size 54.X 4�-) House Mobile Home - ""� Business _— Industry No. Bedrooms � _.No. Baths _ No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO []"' Specifications for System: Auto Dish Washer YESNO Auto Wash Ma^hine YES ® E] NO ❑ Type Water Supply *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. 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: 704634-5985. Final Installation Diagram: System Installed by es° s �'� N F T' \ , A c "i"JN ,? Certificate of Completion *The signing of this certificate shall indicate that the syystem des( the standards set forth in the above regulation, but shsall46, NO wa, .. C-f—fnrihi fnr nnv nivcn ncrinrf of timA /_'�i' 2 �dryl, a eco �n �1 Date d above has been installed in compliance with taken as a guarantee that the system will functic— • , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION [ Ste- -fh 2-- tf , 68 Water Supply: On -Site Well Community Evaluation By: Auger Boring / Pit PROPERTY INFORMATION ,rrU��a zc.C'6 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % / HORIZON I DEPTH Texture group Consistence t Structure 5 12 X Mineralogy HORIZON II DEPTH 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 7 SITE CLASSIFICATION: 1 LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: �� f ' aX�Lv_e OTHER(S) 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 m St VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm fMet 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)