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1326 Underpass Rd , C...-� �-� �,' tl C.:�y F;.�U Y'L (`i �, �i r.r �"G� .:� Permittee's , DAVIE COUNTY HEALTH DEPARTMENT Name: t'`''��• "'"t��`i' � �'��� � [, ot���* t, Environmental Health Section PROPERTY INFORMATION -�---._.,__.,. P.O. Box 848 Directions to property: '���'' +� ��� ��! % hlocksville.NC 27028 Subdivision Name: f _{ Phone#: 336-751-8760 +�-��J (,�ca�}•+".�f�.{ �r�'r 7 Ci �� '�.- ,�1' Section: Lot: ' ' AUTHORIZATION FOK ,�,,, WASTEWATER � /" �' � ��(r �� ��� SYSTF,M CONSTRUCTION Tax Office P1N:#�,�- } "` - �a r?��� C..�<<���.,,d,o�fr f'�c� t . AUTHORIZATION NO: ����'��� A Road Name: Zip:� �� **NOTE**This Authonzation for Wastewater System Construction MUST B�ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pennits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pennits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �" �' ,-a ��,,`��'�=�� i _ �.�,� ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION �'',�/� :�.''�?" !�, ,.- � ;�. � �-��Gr ��r, ;%TMr� r��''r"�,,�'r''.���- a _ IS VALID FOR A PERIOD OF FIVE YEARS. EIVVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ��1 RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS�#BATHS�#OCCUPANTS �� GARBAGE DISPOSAL:Yes or No �:+ �y � COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No .f � LOT SIZE �� �C TYPE WATER SUPPLY " � �/ DESIGN WASTEWATER FLOW(GPD) ��'� NEW SITE REPAIR SITE 1� 3 , ������y � � \� �,/ �i� SYSTEM SPECIFICATIONS: TANK SIZE � GAL. PUMP TANK/� � GAL. TRENCH WIDTH '` ROCK DEPTH 7• LINEAR Ff.�_ l�.. ` OTHE��L G�II'��hrn�'�7�P� �TOI//1 4 �V� � REQUIRED SITE MODIFICATIONS/CONDITIONS: � IMPROVEMENT PERMIT LAYOUT �'., I `u� � 4 � ' �i Y c'�i ���n �— `� 1 1 vc ,n I , t�'"`�S � P 1 , !� �:5 cc:n �" -�'�c.� � +��,�1---_`-``7� �� ) � /+���,5 �1 Cr r� 1 Ci L � L1.f'C � ( (� � �i (� --..._,—.^ � "' V O X `� �`�'Gc � • a ' 1 � � � ,� '` � ` � '���� r-. t� � `` f `� � qP� q'w. `. - \ �, �n ,.. �� c� �vt���r � �`i'r �. '� ��;�� � ` �`�► �O�I ,�G - A �o � , � �.� I � �.�� �� t,/% G' — � O��, � ia O�t^ -�'lf l. 4___G ��..��--� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT L �j� SYSTEM INSTALLED BY: \ f�� V'�— �CC�LS 0 t..J i i ; �,S SI,� d�, ,� Q,�O v ,�� � � I i i I , � � � , � 'AUTHORIZATION NO. OPERATION PERMIT BY: DATE�� � •'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTfH 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 07/02(Revised) .: : . .... . . � . -�' ; . DAVIE COUNTY HE .... . . . .. . , ,,: - .. , ;-. . : . ; _j� I.x ,7 <,}�.�>t,� .�.;� t; , ,t<�. f �; . ._ . Pernuttee s , , ALTH DEPARTMENT Name: '�'t' � ''�° r'� � �' ! fr �. �� ;�,�E:<< �:. Environmental Health Section PROPERTY II�iFORMATION r (� '' " f, ' P.O. Box 848 � Directions to property: tf?-. � �►��' !-�^`� .� 1�1ocksville,NC 27028 Subdivision Name: ,� `� � � Phone#:336-751-8760 ''� ��.r: - �.., ,:!,r, ;, f. �=, 7c: r a} 'i. ,��- Section: Lor. � ° � AUTHORI7.ATION FOR t, ��� ,� R'ASTEWATER Tax Office PIN:# 3 i=',� - � �'- -��° '�� SYSTF.M CONSTRUCTION , AiJTHORIZATION NO: d����t�� A R ad�Name�_����! r''±r�ti t,j,c� y' _�'!�J � Zip:—' �r - **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 Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pennits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � pr;; .� r�,�� :':},.` ���:%.., ,.�'i„ �- ��% ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION ,>,��r rr .. i''•�'"! ,:�',3''�%�'.`_:'-`+�� t �' ��'�' IS VALID FOR A PERIOD OF FIVE YF.ARS. EIVVIRONMENTAL HEALTH SPECIALIST DATE ISSUED L� RESIDENTIAL SPECIFICATION:BUILDING TYPE�-� #BEllROOMS�#BATHS�#OCCUPANTS '-i GARBAGE DISPOSAL:Yes or No �� COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No ) ��� ,��l��f ; LOT SIZE �� TYPE WATER SUPPLY �"� �� DESIGN WASTEWATER FLOW(GPD) �� NEW SITE REPAIR SITE �/'�� J .��ll i"f,� � � �� SYSTEM SPECIFICATIONS: TANK SIZE °'x 4 GAL.�PUMP TANK !I�'�GAL. TRENCH WIDTH ��' ROCK DEPTH x LINEAR FI'.� � � OTHER���P� v1 �1!'�hn,�:P��(�LI, S�O�/�YI t �CC>Cr� �;�REQUIRED SITE MODIFICATIONS/CONDITIONS: f + � IMPROVEMENT PERMIT LAYOUT �,i>, . k � � � 4 � ! Y c�i `'�,�� �,} /� ` , �<< ,� p �-.. .��t,+ / ,�,i �(�G�` t 4 � {� �" ��4.t'� �'� O,c� � C�4a f=. � (.��'� CG�1 i��•�"C 1 't r'G+ti^ 1� �'��} � i'""'i' � 1 l i l � ti.f 1� --�----�--- �� - L�G r �� 5� c� � . � ; � ; ,_ �,,� i ;s ' �� � � i��'jt�r �" � , Lk--c�....�----- �, , �n �. .. - �tvu�a� � ,,,�.;�,. ti � � � . .�, ��U T �.�✓, y.�,�,r„�.... '�� �.Y 1.5"�i.r,q ` �} l •�w � `'(j�� f�.(I . . v —f� .. �+ . ...�J �, L.t N-r� �, �- - ------� t%����c.c � � N �,�P �� f.�i a� �G ..� - - � _ _ � 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.. I OPERATION PERMIT r � SYSTEM INSTALLED BY: � y �t t/� �� � �-�.r v( � p G,./ � � i I � ! I � � . /�� .� �� D 1..�� If�. � � G � -P � v 's � i 4 � � ��� � , 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 02d12(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION �.�1�ncw� �"��,r'h��cr �ac�.r.Lt ti��� Ua�-�.���c�s5 �� y � ,�vc�.v�c��N C�70G� . �'��! 3 �, a� �d • ✓ Public Water Supply: On-Site Well Community Evaluation By: Auger Boring � Pit Cut �� 7 � FACTORS 1 2 3 4 5 6 7 Landscape position � Slope % � HORIZON I DEPTH � � `t Texture grou . � Consistence �' , S tructure u Mineralo � HORIZON II DEPTH � Texture rou � - Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence • Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE . 7 SITE CLASSIFICATION: (�� EVALUATION BY: 1 2�t c�, �� / LONG-TERM ACCEPTANCE RATE: � • �7/ OTHER(S)PRESENT: l-�/-�'c .�ri�'l�tsC��' T / `lNf REMARKS: � (J / �i"�,.lf�✓� LEGEND T,andsc�pe Pocition , R-Ridge S- Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC -Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texturc 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 D�i�f� VFR-Very friable FR-Friable FI-Firm VFI-Very�rm EFI-Extremely firm YY�� 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 Mineralo.gy " 1:1,2:1,Mixed LY4i� Horizon depth-In inches Depth of fill -In inches ` Res[rictive 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 DCHI)O5/(15 (Revi�ecil �irL 29,2008 13.:10 ......_ ,.y�.,,� , 000-000-OOD00 Paqe 1 �,, ..., ..���.�,�,u �sui�itJivu p.:i . . • � I:)i��•�t� C�'c�uiu.�� I.I�.��1cli 1)r.����,�.�U.r��•!�� �Pvrfi L'.T1�'11:c:)IXztic•r►t,�l t-ic�.l���� ,5�c�ri�:,la . . 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I:,�nr bs'th�CCt1Vlf���.::.1::11..� -C�1�:�1 1i�;"1 1:lTl nU t�'�b Ili'.�'AC�C(I,:tirsl:��u1J hC�:1�::;l::la��a `'fF11�G� • (:s;.ri:ti;rJ�1r1i1..i:�::lj�c::�: iha�i�rsitc a•u.:C•s.r.�: �y::li•m�c:1' f'1`::i.i)n 1;'r•�:t�rly `.��,-::iiy✓�vC^�,rTlU:1��E�IirhC. • __ ... .__. ... ^•--' ---._.. .__. --- .. _�_ .._ .__ ...._.. ._ ���)•ir�nl: f.:•isl-(' �:!:Gtl:L i�uur; f)nl•'t _ '� ---- . �im�t::7�hy, -- Ll:trr. ��J��i��'��'•— -.. _. .__._.. ._. , �:c•.��iu•:•!B}'----• -- _ ._ '- . . . .. .. . �•.l.l:,.�l�•: �: j;��••�:,^,�!•; .:l:iJ :!'��7.110u 1J:!ih 33f'!51l3'!Nf E'�y�j�• J J;1L 29,2008 13:10 000-000-00000 Page 2 > , . � • APYI.I(:A'f1QN FUR S1TG GVALUATION/IMYRUVHMF.NT PF.RMIT&ATC Davia Cuaaty Eovironment�l Heelth Y.f).Bax 1i�8/210 H�idl St�'Ret Moekerille.NC 270ZIt ()36)7t1-a760!F�x(»6)751-blsb Appliuqion I��n: SiG:Eveluetiudlnqpvvemcn�ItT+mt ulhorirAtion To Con.�qATC)__ Tt��ih-_ _(.-1 'f���k nf npplie:+tinn Ne�v SYsteni Ftepnir w Existing tiyskm �wneinn7tulinTlTca�icm�ol'Iiui�tinF System ar Fa.,iliry ) /MPORTA.V7`••THIS APM.1(:n77�)N('ANNUI'!�ti PR[N:liSS6D I1NI.F_SS Afd.111'TlfTi NItI�tnKlil7 INI�I.IHMA7'IUN IS PROVIDED. Rcfcc to th�iNPUNMA'I'IUN ItULLL•"fIN lor instructions. I AI'1'LIC:AN'1'INI�URMA'1'I()N N;uue lu be Tiilled���::�:.i ��i��.:�., ri� �f;:,�-r�(�emtacl Per!uin t,7,�N h�l ..� b�'1.+►yo" HillingAdA�Css �� �,,..,f��"i � 'h. Ilomel�l�one � O� 16 I�� �as�- R�`l�C� � City/SIWelLII' �✓q_�I.C� . . . Husinec�PhUi�� '�✓�' �_ .. . NrinC�fl PetttuVATC ifUifjrru,t th,n Ah�rv¢ __ M��i�,F n�s�in« '�r..�iy�si�i,��.�r.__.... _ ' � N!l.Ut�l;k'I'Y INFUI2MA'llON •DMte lluusell�nc:ility C:omers Fla td �I�� NUTE: A+urrcy p1.��M�i1e plen must ncr,omEmm�tl�is np��ti�;a�tiv�, In�luJeJ: Suc Plon�Platlw scalc) /ti/�' �f ��� lYcrtrtil�s volid lor 40 month�with t�u plsn.ni�expnnlian with wropldt ploll (�Ul, � W Owner'x Namc V7� �, .�� --• • „ ('hnnc NumtkY �G-�`J�•s� i� B�n Nev�•5 wm7 c AdAross � !'•I fS On;:•�. C:ity/5irt�'rr.�r r.^•t�.".�.� :1 � �.���� � f'Yupvrty AdJn;s��/� �/' _ .. .�'ih. C -G. . Lol ti�zc!/3 w�Csrc; 'u�c PIN� � SutMivisiou Narne(if uppliwblc). _ --rN 4 ' -- _ Section/l ntM — �D/-��'�/ � `S �,�- f;ir��;tinnn'I'��ifc:D�� �✓f►^- .. ...._. ia : .l� ..t ?���.•v.v T_ 6G��d/,..�L Ss : .� !l •• •--- If U�e unxdl,K lo nny o!'the follnwing yuextiun.t�a'yei'.SllppOAlOg duArtrcn�ti�m mus�Ix a�4K:hcd.. . .. . .-- A�c dk�c;m>'exnlmg w�stewaler sy�tem�nn Ihe:cil�? es)Nu 1�ucslhceitrcumninjwixJ�cti�mulw�hlnnds! �e� Are ther�um•cascnx nts w ri6htr�f-weyx�m thC m�e? Ycs � lx U�e tiie subjrc��u u�pnrvdl by snothcr puM1fic spyency'� Ye� W�Il wnatewnur mtu:r U�en�h����csUc se�.,�Ke:fK;gencraeed? Yet U�Kt;51U�NCE F'il.1,nITT T1iF.AUX ll�LU W . ..__ ...._ ... .....--- k Pcoplc ��_ H I�;�4uums ,y tl Ftadirnnms �f.s Uartia�'iuh/Whirlp�Wl Y�ti Nu Haaenxul; /'Pc�j Nu Ha.acmcnt IMumt+in��1 e� No .l%.... .. _, .. . .. _. 11�NUN-RESIDF.NCE PILL UU'I"1'l lf:AOX RT:1.pW 'I'yprnl'fl�CililV�jnSintSR,__ , TufulSyuprt:I�ontaFGn1'IimlAipP .... _ µpWple. �5inks �Cixom�xla , �tiAowcn U Urinnls � F:slimsta!Wa1Ci 11WIgC(gallcros�daY) (AIUK;h du�umcnlalinn p�Sif�1117V�8�ilily wOtCt tn2�umpli�n) ���K1(�SLRVICt;'UNLY: N$qlt5 ... ..._ ..-:�.__ -,...._ ... . . . '!'Y�MSrt4micquesietl- C'.onveNin�ul nciY�teJ Iruwv�tivc_ Alrcrnaiive UtherMo��A�.. f .-�_n` -�d�.�'�f'�^c� d W��e+��qply��ye�Cvunt�•/(:ily Wp�+__� New Wtll 1{ai��in�Well . Cummuni�•Wcll .r•--- Do��ou antici�ra�e adJ�hons or expwions af thc luril�iy lhis aystem is intcnded m vervc? Yes � Ni) ICycs.whntry•pc? .... . . �"- � , TNis is tn ccrtifr ilwq thc inlixmativn providnl m��his eppG�aiiun ia troe and wrrect ui ttk Iti�s�ol my knuWlc�c. 1 umtcrxrand �hal any pemiit(s)or ATC(s)isnu�J hrnmllnr ure cubject to suspension�s,�vow�wn if�hc sitc is altcrcd,Uk iete�td�u changcs,cw if d,e inf��rmntion wbmittc�i in this up�di�w�im is f'alsifieel or clunged 1 herelry�,n�n�ri�l�t ul'entry tu 1hc Autl�orizcJ rtcprracmlative of tlx Uavio CeHmry I Ienllh Ihputuacnt to cwwlw;t ncce�wy i�pectioru to daenninc cumplia�wc wi�h ap�hc�ibk laws nnd cuhc I urxlerslnnd lhat I am respansiAle Gn Uw yrvper ukrtifiealiort and IaAclingN'pn,pe„y tines nnd wmm md I�,cuiing nml llagging taking iC M���se�l'acilily location.ptu��c1��U hwntinn enJ thc tucation nf eny nther enkniuet �--%��^`._ ' ..._ . .... tiitr Itcviai[c:l��ry,r. Prnpert�•m�mcr'x m„�er';�le��l teprecenalivr sigrwturc p Datetst: 7-C�7� � (:I�em Natif'wation nstc:� �,u,c � EHS:_.. .._. . . '�-}����f�L��...,�� �/ � +. 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Phone# 336-751-8760 Directions to property: �u� !L' Section: Lor. r•—� AUTHORIZATION EOR ����(����_ ��, WASTEWATER Tax Office PIN:# - - _ - SYSTF.M�ONSTRUCTION � / o � ti�2� � i (�r� � d lY� • li� �/�1�1/I� Road Name: Ur���flt��'� ��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 icle 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ` _ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � ..�� "7 ,'"��. IS VALID FOR A PERIOD OE FIVE YEARS. ENVIR N AL� ALTH S ECIAL,IS DA t SUED � ; � , . _ . .. . ,. . - ,:; . . . . . � _�----.4�,'`'� y ` ; ,� �r �;��'�DAVIE COUNTY HEALTH DEPARTMENT ��C�� � ����- � �--- ' f� � -` TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION , ,. . , -..- :.,, � .o , +Permitt'ee's" � � � � Name: � 1 ����-- � ` "�'r�`-"'j � �'.' Subdivision Name: ` �> Directions to property: " '- � � ' Section: Lot: � _ IMPROVEMENT � � �-•!���; ��'x c'� a:'�' `. ��:..,1`_ � �PERMIT � Tax Office PIN:# � - - � �I ) � ,• - 'y��t G:� iL�� !� �,�� � � �/!�1 � ✓ l� (/��'V NI�U � Road�Tame.���`�` � i `-� :d Zip: —rJ �:...; � **NOTE**This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZAT'ION FOR WASTEWAI'ER SYSTEM CONSTRUCTION must be obtained frc�m this Deparnnent priar to the constcvction/installation of a system or the issuance of a building pernut. (In compliance with Article 11�of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) %:-� . � ;,.•��• `,�-�:, f � "''"-• 1 ***NOTICE***THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE _, � i,; �!� .!)L.../'�� 1 / ,;,„; PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIROf�iMENTAL EALTH SPECIALISI' DATE ISSUED SYSTEM CONTRACTOR MUST SEE TI-IIS PERMIT BEFORE INSTALLING TIiE SYSTEM. �.,r � RESIDENTIAL SPECIFICATION:BUILDING TYPE Gin=#BEDROOMS�#BATHS 'S,'�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILI'I'Y TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No �����( -7�� ! LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE �/ � � ,r 1 SYSTEM SPECIFICATIONS: TANK SIZE I����AL. PUMP TANK GAL. TRENCH WIDTH�� ROCK DEPTH�� LINEAR FT?�v OTHER � �� i JTI�.-��(�TIW ��1C_ REQUIRED STI'E MODIFICATIONS/CONDITIONS: r-ic.4!1 ,S' Q�� 1"��- j I4=C-� �� ��� �Q��•��'��� �'GF`� �,�F-F F�oJS�- IMPROVEMENT PERMIT LAYOUT� �'�����v`-U �t-Ir � •�' '1�' 1 tt h � tV D'6- b a C� �Q�J ls�.a S���� �. , � �X� ' � ?�,��'` Ig'"'` 3�'' � s� ,,� -�, � < L k, -r�u►�ni�4 rc' �o` �r< � � J! S��N�� �.l- � � � : � � ���� ' � , �I`I�►tro.� ' '`.l}T1� � � . , �p . _ _ _ _ . � � � � �. ,� ,r � _�,.,..�-' j **CONTACT A R SEi�ttTI�E�OF THE DAVIE COU�'£�-DE�vPEN!'F6�t FINAL INSPECT�QIV�Q��{I��YSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#�5���4���4i87��� , OPERt�TION PERMIT � �_ p /� SYSTEM INSTALLED BY: .:1��b l-t '`'i �(�E� � ���T , ' 1 � ,��� ` �o� �� � � _ � � � � � -� �r��6 a � � g- ��� �� �d� �_�� � � AUTHORIZATION NO.��OPE TIO ERMIT Y: DA : **THE ISSUANCE OF THIS OPERATION PERM S L INDI ATE THAT THE DESCRIBE BOVE HAS BEEN INSTALLED IN CO LI NCE WITH ARTICLE 1 I OF G.S.CHAPTER 130A,SEC O 1 00"SE AGE TREATMENT AND DISP SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI S FAC RILY FOR AN IV IOD OF TIME. DCHD OS/96(Revised) ' T� y � , ' ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848%210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-STTE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELINGi� RECONNECTION ❑ Name: � 0 -'�S p +'� • Phone Number: � /D ' (�� 21 � (Home) Mailing Address: .�2 � /1 � /� � (0 3�(� (Work) r!C c_ 7���r Detailed Directions To Site: �,S��' TO �0� S `}�9 leli��'%eP✓�iL.3s /�� � ProvertvAddress: /J�L� �'! ��,(JA.SS Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: � 6 e�rJ 0� Type Of Dwelling: f�Q�+'l E- Date System Installed(Month/Day/Year): um�r f edrooms: � Number Of People:� Is The Dwelling Currently Vacant? Yes❑ No C3�If Yes,Far How Long? Any Known Problems?Yes 0 No B' If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: � U e��00,M 1 l�l�i�mber Of Bedrooms: -2 (a�'� Number Of People: �� Requested By: 0% ^ Date Requested:^�� �� �� ignature) ; ' For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Comments: ��1�� ��-��1C1� ��-'"'-�T '`� 7/02 � F/�lLA�Q.E9� S 4�Sy'j��_ Environmental Health Specialist Date Z *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a � guazantee(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 #: vZ-! �� Invoice #: ��—� �i � ,: .. �� _ P�� : .-- - �� � ' �o .- . �_`.'.�:.,.�",�' • =� �--� -�'�" DAVIE COUNTY HEALTH DEPARTAAEWT f Oo. vv r�,,-�e.' ''._d:-� "� � IMPROVEMENTS PERMIT AND CERTiFICATE OF COMPLE�'IO�Pd , _ � ' � , d� - •NOTE:Issued in Compliance With Article II of G.S.Chapter 130a � �� Saniiary Sewage System � ��Pi�'t�� G�9�l�i��r Name � �c�\� `., l a J ���o c� , Date 3 " `�',`�- � �� �� [�- � � �� �a � �">� �=� a �� � f� t� .,� �� ?C« (�'AUr� � �� , Location � �- � f\ ` �. � � �� \ \ r� T � �:>��:� �_ �� �+...�r. Cr�V 1 � Y�.\ �-.i`s�,, l,l ..y�ti�..S` .�,-3-5'IJ C'� _ `--',S*.. ��� V�'.(���.., C'�..;»�4's� ..,a..:\ `�..�+'`�S-' _ � �� _�_ t`. Subdivision Name Lot No. Sec. or Block No. Lot Size�5�1 �� ������' � House �� Mobile Home ._ Business __ Industry No. Bedrooms � No. Baths ���—No. in Family y _ Public Assembly Other Garbage Disposal YES ❑ NO [� Specifications for System: �, -� Auto Dish Washer YES p' NO ❑ `�j � u �,, � �` w�� ` - �J � ����, I �-s�. .�...s �'_. Auto Wash Ma:hine YES Q'' NO � : C v .� � ti Type Water Supply _ �u ,� j, �� � ------ � 1 � J , � � �` , �'��� *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. ti' �j—� o �; � J , _. : , _. _. � '�, - `�; � �u,: _ ,� M1� `._.___________.....-_.___ .___ _._......___ ''� ` i �;� _ _-------��_. ,_-��-------- 1=1 � .` - �_._«� , . __ �._.__ ��'=,- • �. ___.._.--- ---- ..------- j�=��, , , . ,:_ _�_ , �� ���� ►mprovements 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. Fina� Installation Diagram: System Installed by ��``�� ` ��`�'��"�- � � � .. . �..""--,-_ ���� ��S\S�� _�'`��� �. � p U,S`� vn�� , _� --�-�,��` , ���Fi . � ---��-d. �` ` � � ._ . G � . � _... � '. - , �, �� . _ Certificate of Completion �• ��� Oate g - 1 q• � +�� "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, buf shall in NO way be taken as a�gLarantee that the system will function satisfactorily for any given period of time. � • , f ` �. � :� ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS ERMET,, � ..- �--- � ° Davie County Health Department '�� ' � '`� `�� Environmental Health Section P. o. BoX sss ��AR 1 5 �99� Mocksviile, NC 27028 1. Application/Permit Requested By � ������-e Q�ei'`}� �0 n M Mailing Address��'U� l�VP}7`/'/��y'P �C11'r�-t c �� /1 c° HomePhone ?��—��� 3 ���'f1��1�S �/y e- Business Phone �� 7 ^��r� �1 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation 11d'Septic Tank Installation Permit , 4. System to Serve: ouse ❑ Mobile Home O Place of Public Assembly ❑ Business ❑ Industry O Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ BasemenbPlumbing No. of People � ❑ BasemenbNo Plumbing No. of Bedrooms p'Washing Machine t No. of Bathrooms � 2 LL9��hwasher Dwelling Dimensions � � ❑ 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: L�i'Public ❑ Private ❑ Community 8. Property Dimensions �5�� � Z�Q �? 't Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? I�Yes <�:�v-�'c�� � �� �^�c�� • �<<rt� , If yes, what rype? '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: � /�-/�/..l� �l// J / 9 �C/ t�C ! Y'<"I Ss �i`I 1 Gi/j'/�f� O Xr � �I l`° , ///V y �� � , r,�, Q`I �E'-��" � ���7- ��� Pr ��ivP � �/ly e r1�S. � G��I�' �ls� . J J � � �l e /,o�r �,o U�,s e �l c�Oss -��v,�, �o�,���l S,�� ��2 U, � .s� y l ✓ s �'s � ���� �s'r���d ��' , �� /��� � �/ � 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. �� lS— 9 % , .�,a� DATE / SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. 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. DATE SIGNATURE DCHD�(1 J93) ,''� � ',� + DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation NAME J (���� � ��0��S�N DATE EVALUATED � r��-- �y ADDRESS � p'�'`�� PROPERTY SIZE �`��� x �O O d PROPOSED FACIILTY t�t� v �� LOCATION OF SITE Water Supply: R On-Site Well Community Public Evaluation By C��— AugerBoring Pit Cut FACTORS 1 2 3 4 Landsca e osition .S .S S S Slo e 7. - l�'e � _ �o . 5� ���so HORIZON I DEPTH 8 '� 8 ' � $� Texture rou �- U Consistence - 1' r� � Structure � � Mineralo '_ 1 1 : • � � HORIZON II DEPTH 3 � ' .3 0 � o`� � Texture rou �. � Consistence `z Z. L �" Y Structure sB`� s� � 9k_ S � �` Mineralo : 1 ; I 1• HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS SS S�' .� SS RESTRICTIVE HORIZON �. � —� — � SAPROLITE " _ — � CLASSZFICATION .� .5 Q,S. •s LOyG-TERM ACCEPTANCE RATE � , � SITE CLASSIFICATION: �� S EVALUATED BY: LDNG-TERM CCEPTANCE RA E: _ \ �- " �� OTHER(S) PRESENT: � °"� REMARKS: _�� � , �1 � .�.'�.���. � '?J�r`�.r--�`� LEGEND Landscape Position R-Ridge S-Shoulder L-Linearslope 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 c:lay 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 ,iC-S-ingle grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloi�y 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 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/fl2 DCHD(01-901 ■����������������/�■���������������������������■���������■ ��� ■■ ■�����■������������������������■���n■��■��■������■�������■����■■ ■�������������■����������������� �����������������������������■■■ ■�■����������������■��������������������������■����������������■■ ■�����■�■�■���■�������������������������■�����■�������■■���������■ ■����������■�/��������■/��������������������■�����������������■��� ■��■��■�������■■���■�������������\��������■����■��■��������������■ ■����E��■/�■����■��������������������������������������■��������■■ ■■����■����■���■��■�����������������������������/����■�����■����■ ■�������������������������■���������������������������■����������■ ■����������■��■■���������������� ��������■����■���������������■■■ ■��������■���/����������■������■���������/���■������\�■����■�■��� ■�����■���■����■����������■ ■�����■�����������■ ■�■��������������■ ■/■������■������■�■��������������������■����■�����������������■��■ ■�i���������■��������������������������������� �������� ���������� iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�ii�iii�i=iiii�iiiiin�iiii ■�����■���■��������������������■�����������������������■���������■ ■�■���������■�����■������������� ■�����������������■�■■���������■ ■���■���������������������������i��������■���������■�■����������■ ■���������■���������������■�������������������■�������■����������� ■����������■������■����a����■��■�������■����■����■ ■�������������■ ■���������������������������■���������������������_■��■���■����t� iiiiiiiiiiiiiiiiiiiiiiisiiiiiiiiii=iiiiiiiiiiniiiii�iiiiiiiiiii=i ■������■��■�����������■������������■���■����������������������_��■ iiiiiii�iiiiiiiiiiiiii�i������� ■�������� ���������������■� ■�■ �������■������u���■��������■���������■ ■���������������������r��n�:�����■���N�����t������r��� ����������� ■�����■����������������n�:���������������������s����►����_��� �������� ■�������N����■����■��l�rr�������������=��iiiii:��/ '� ���� ������ ■ ■�����■■�����a���������.��■��i�iiiiiiii���■��■��i����i���� ��■����■ ■�����������■�����■����■��■�����������.......����v�a��■�������■��_ ■�������������������r���:::::::ii��������������t�t�����■����������� ■�������0�■�����������ez!�=���ii iDCCGGiii���i�����������■������� ■�■����■�\�■�������������■��■■����������������I����■���■��������■ �����������������C�����iiiiiw����������������� 1 �■������ \���\��� ■��������������������������wal;������������������1��������� �������� ■����������������■��■���■/I�i►�1�tC������-��� ������1'/ ■ ■ ��■��������� ��������������������������•�������C=•�������������� ���������� ■����������������■���■■��\li����■��������1��■����l� E1��■���■�\�■����� ����������������������/������r�\��IIY������� u������������ ■���■��������������������'��������������11�■������ ����������������■ ■����������������■■�����f,��f��i��1���� 11 �����/I ■�������\ �������■ .........................►..-_.........��■ ..■..�_ .......C........ �������������������������■�����.■-:==....■ �■���� �;rac��� ������■■ ...................................... 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