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370 Stroud Mill Rd oxo N DAVIE COUNTY HEALTH DEPARTMENT 'q-/d-94 t, IMPROVEMENT PERMIT and OPERATION PERMIT uf�p IMPROVEMENT PERMIT **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 from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 5 0 -IPA1 NAME ( »,' pi— PROPERTY ADDRESS _.�-s, DATE o LOCATION <�;r��LP �/� - ��IST �Pics�.i✓ �'YIZZ Cy .l°t/ n.�r P /1�Q___�1�e�4 SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS - _ # BATHS # OCCUPANTS _cZ GARBAGE DISPOSAL: Yes to COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE __624dC TYPE WATER SUPPLY 1.t/�/,� DESIGN WASTEWATER FLOW (GPD) I-�lb NEW SITE __,ZREPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE,lain GAL. PUMP TANK GAL. TRENCH WIDTH _Z- _ ROCK DEPTH ,;.,2 LINEAR FT.—,11,,- OTHER T. 7OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. p� IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY 00 AUTHORIZATION NO. OPERATION PERMIT BY A&W 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 136A, 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. DOHD 10/95 Davie County Health Department H ENVIRONMENTAL HEALTH SECTIDMI P.D. Box 665 Gv Mocksville, N.C. 27028 is AIITMORIZRTIOM FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) e �fWhis 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.+ + NAME 4�Ui� (� /�°r" DATE �F,��-�� AUTHORIZATION NI�IBER N2 'J1 ?0 NAME ON IMPROVEMENT P,,E��RMMIT (If different than above) SITE LOCATION S✓��u. ///,�� � CONKNTS/COMIDITICNS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION FD TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRCNIENTAL HEALTH SPECIALIST DATE DCHD 10/95 C�t, rcw APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P t1 ,Ir7o Davie County Health Department U 1l I Environmental Health Section DECj P. O. Box 665 D 18 efp Mocksville, NC 27028 i 1. Application/Permit Requested By �_ \ Mailing Address 11418- Home Phone�7G`{� X 73- 33 3 t Z vi le- n. . I. �. �SCoVI Business Phone 7ny� �7S'-_30a1 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown # 5. If house, motnle home: Subdivision Section Lot # ' ❑ Basement/Plumbing ` No.of People nc ❑ Basement/No Plumbing y: No. of Bedrooms ' ' Washing Machine No. of Bathrooms ( '❑\Dishwasher i. Dwelling Dimensions 1XX 66 ❑ Garbage Disposal i. 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals r No. of Lavatories No. of Water Coolers i No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public61v1private ❑ Community 8. Property Dimensions 2` AC • Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes P<No If yes, what type? t l '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. PROPERTY INrOR11ATION REQUIRED: I t Directions to Property: q Tax Office PIN # p� t!pY �}Dl�x l rn� le S Road Name �OI � r�X ( � �,'� Box �` (if available) / I Tot Ong P City 3' Sero rn) I ( Rck O,,3 © t Iro R� 5� 1 ST w A �. CJS{ �e aY 0►� k. i , This is to certify that the information provided is correct to the best of my knowledge, and I understand I am res i e r all charges r incurred fro thi application. of q _ EEc DATE UR 4 S CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. -3d-e 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 Dep ment to enter upon above described property located in Davie County and owned by f:,-\ v to conduct all testing procedures as necessary to determine said site's suitability for a ground ab ption s ag treatment and di posal system. DATE SIGNATURE �lo�li T - Z' DCHD(1193) t p .y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE ,,1�//� l PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring LPit Cut /_1__1 FACTORS 1 1 2 3 4 Landscape position .L Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH 4- d��r Texture group C Consistence i 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: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Footslope 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-Vc.-y friable FR-Friable F.I-Finn 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 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(01-901 ■.....■■.■■■tom.■■.■■■■■....t....tt■■■■.■tttt■■■■ ■■tE■■■■ ■o■ No ■.......t.toot/■■tot■tt....t.Mt.�t.t..m.ttNM/.o...t.t.t.t.ttmtt.. ■■.....t■■■■tttttot■■t.■■.■■■tot ■■■■t■■■/tCt■■.■Ott■■■■■■■.OMEM■ ■..■.t■■■■■O■■.t■■.■M..■■.■ot.t..t.tO.t/■■/t M■■tMMEME■■MMME■■■EO■ ■.■■M■■■M■■■■MO■■■■■■■t■■■■t■OtoMmotM■■■■■■■■■■■■■■■■■■■■■OM■■■Oto ■....■■tt.ttt.t..t.tt....■.ttt....tt■tttttt■..■■.t■t■■■■■t■■■t■■/■ ■..■..■■■tt■■■.t■t..tttttt■■■■■tt■t■■tt■■tm ■■■■■■■■ ■■■■■■■■■■■■■ ................................t.........C....■...�■■■■...■.■... ■....■t■■■t/atttt■■tt■.t■ttt.tttttt■■■t/t■E■t/■■■t■= ■■t■t■.t..■O■ ■.■...■■t■■tttm■./.■ttt..■tttt■. tttttm■t/■■/t■■■■ ■■■■■■■■■■■■t■ ■■ttt■■.■■■t■tmtt.tt■tttttttt■t■ ■■t■■OM■■■■■■in=■■■■■■■■■■■■■■ ■ ■■ t■ ■.■.tt.■■t.ttt.■.■..t■t..t■ ■ttt.t.tttttt■■t■/t ■■■■■■■■tot■■ ■■■■■■■■■■■■■■ ....C■...........■ ■■■■■■■■O■■■■■■■■/■■O■■■t■■tttt■■■■■■■■■■ ■■■ ■ ■ MONSON no ■/■■■E■■■■t■■■E■■/■t■■■/t■■ttt■■./■■■.■■NCMENC EC1CC■■NoCm■MEEE■CC/■ ■■■■■■■■■■■■■■■■■■■■Ott■■■■■■■■■■■■■■■■■■■■■■/■■■ ■■m■mm■■mm■■■■■■ ■■■■■■t■■■■t■■■t■■■tt■■t■■t■■t■■ t■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■ttttttt■■tmttmt■■tttt ■tot■■tN■■/tCCC ■CH■■t■■■■■tot■ ■■■MOONtttttt■■■■■.t■■■/■t.■■■■■t■■■■■■■■■■■■■■ MM■MM■NMMMMMM■ ■■■■tot■■M■■ttO■■tttttt■Ott■■■■■■■■■t■■■t■■■■■■ � ■Mt■■■■■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC:CC CommonommommoCCCCCCE CCCC''C CCCCCC:CCCCCCC:CCCCCCCC:CCCCCCCCCCCCCCCCCCCCC'CCCCCCCCCCCCCCCC'CCC CCCCCCC:'CCCCCCCCCCCCCCC:C:000CC�CCCCC:CC'.CCC' CCCCCCCCCNNW Cmom .....................■.............tE■t■■■...MCCC■mom=■■■■..■...■� ..............................................No C'CC..C......'C ■■■■tO■■H■■■EM■t/Ot■■■/■■/Mott■t■■■■E■tE■■■n■■■ OMEN mom■■■ ■.■o■t■t■■■■■■■t■OOttOtt■■/■tOtt■t.■■■■t■■■■■■■■� ■C CCC:s CCCC�CCCCCCCCCCCC:C�C:CCC','C:uCCCCCCCC■C■CCC CCCCCCCC CCCCCCCCCCCC�tCCCC�.C■HtC�tCCCCCC�CCCCHCCC0 ■am■■CCCCCCCC CC MONO CCCCCCCCCC■iC't'teit�CCCCCCCCCCCCCCCC'CCCCCCC■CC"'nCC ■t■tt■■ CCCCCCCCCCCCCCCCCCCCCCC'.CCCCCCCCCCC C. 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