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1324 Yadkin Valley Rd . � . , DAVIE COUNTY HEALTH DEPARTMENT �� �,���U • , Environmental Health Section ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990000939 Tax PIN/EH#: 5863-45-4544 Billed To: Yadkin Valley Baptist Church Subdivision Info: Reference Name: Larry Parker Location/Address: Yadkin Valley Road-27006 Proposed Facility: SanGSun.Sch Rm Property Size: 298 x 330 �T� b r: 2319 **NOTE*�'�iis gmprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 1 l of G.S.Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: 0 Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ CoSo M�'n�p,e�`f n.-tr�a�•x� Commercial Specification: Facility Type �l��N #People��MA#People/Shift #Seats Industrial Waste: ❑ 231 ��n�C Lot Size Type Water Supply��C32'+J� Design Wastewater Flow(GPD)3(c[���5� ite: New d Repair� °� �t f System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�Co Rock Depth �� Linear Ft.�� Other: � �1�T�L1 �jVVV�"toeJ �jG Required Site Modifications/Conditions: i IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis j system between 830 a.m.to 9:30 a.m. or 1:00 p.m.to 1: 0 p.m.on the day of installation. Telephone#is(336)751-8760.**** � �)c,�5�1►�� ���..Xis�l�b SA�SC,TVI�-'�' P���7 S��i�,Y /��Dr1 • �-too� C.L�SSQ�O�.�. ��u��� 'DIU v� �,'souD �1 � 30' �L�� I So' x 3Co� x��" l50' Environmental Health SpecialisYs Signature: Date: � i o DCHD OS/99(Revised) .Q 1 �� . s , . ' e ' � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990000939 Tax PIN/EH#: 5863-45-4544 Billed To: Yadkin Valley Baptist Church Subdivision Info: Reference Name: Larry Parker Location/Address: Yadkin Valley Road-27006 Proposed Facility: SanGSun.Sch Rm Property Size: 298 x 330 ATC Number: 2319 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONST,UC N I ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � D CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit 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. ��d���� �� 1� --`-_ � � �'� � r Septic System Installed By: /�C�/ �� � Environmental Health Specialist's Signature: �/ ?S��(�� Date: C� �-���� DCHD OS/99(Revised) � , APPIJCATION fOR SITE EVAWATION/IMPROVEMEM'PEAMIT&ATC �� ��, I�, y ',� �;� , � Davle County Health Department '��' �`'��'I!�'' �m��-��'' ! Env�►�vnmenbal Nea/th Se�ctfon ' ' P.O. Boz 8�{8/210 Hos ital Str��t � �; `I ; � ' p � �� � � o � , �Soaksvill�, NC 27028 ,� ✓�� �!�-� I336)751-8760 . y ,� . .a ti � � ` , � ' E..��,�:f,� �!il� .'�,� **�Zl�ORTANT*** THIS 7�PPLICATION CANNO? � PROG'6$BED tJNI.a88 ALL T ' D ' INSO1t�ATiON =8 IIROVIDED. R�faz to th� ZNH'ORMATiON BUI.I�TIN �or inatruationa. i. �v.�. r.o b. aiii.n f/�1J�n/ t�9�le% �Ai�fSf �����cont.ot r�,on 1.9ti'R� 1°!��?.�P.4 ��� �... �3_ -��fT�nk,� �/�lle� �'d': 8�. ��. 9 9� ��.�d' r�t..iatar../:za ,��i�l//��'r/�.? /2�� ,���fl� a�•s�.�... rh�. S�`Aa/ CA4�C� �f��oZ03/`" 2. Itas+ oa P�sait/7lTC i= Dilt�syat !lsan �bov� 1ttl.liaq �dd=��• City/Ytat�/Eip a. llppliaatioa ror: $,81t� !va].uation 0 Improv�muit B�rmit/11TC �Bot� G�i�/��h �. eY.c.. to s•=.so.: � Hous• 0 Mobile Bom� ❑ Busiasss 0 iadustry � Oth�r `� /%�_N� G_f�J�2/ � S��da y s��,� �2o�r+ a. �t ��idu�c�: t B�opi� f Badrooms � Bathrooms O Di�h�ra��r p Oasbaq� Di�po�al 0 lhahinq ltaohin� 0 Baau�nt/pluabiaq U Darpas�tk�o Dltimbiaq 6. i! suai���/Indu�try/oth�r: fp�oit7f t]tP� �ANGTil1�R s � d•v'��%��� p�opl� ���tf ink� � � Cossocl�• ��^ / BhoM�r� ,✓Y.� f Oriaal• �_ Z��lfat�i Co�ol��D� _ 5����,�A�r?cR Ip' �'OODSBRVIQ: � S�ats 3ttimat�d l�ater Osaqa (4a11oaa p�r eay) 2..3� �. Typ� ot xatsr suppiy: � Couaty/City 0 1P�11 0 Community e. Do yon anNcipAte nddiNow or e�paneion�o[the tacWty t6ie aystem Ia intended to urve? �Yes �No V yes,w6at type? . *�'�IMPORTANT"**CLIETIT3 M(T.ST C�OMPLETETHE REQUIRED PItOPERTY INFOTZMATION REO[JF..59'ED � BELOW. Either a P1.AT or SITE PLAN MI/ST BESUBMITlED by t6e client �vith TliI3 APPWCATION. q�- vo , o� Property Dimeaaions: _ � /b X 33a WRITE DIRECt10NS(from Makaville)to PROPEATY: Ts:08ice PQI: �t �l`", ���3�5—y`SY� 6�0 �s 8' E.�st'�o �lb� 7-u��v �e�i= y,�a�� �,��ey ,��• � ,��� Property Addreas: Rosd N�me S�E'_ /5r s2 /JiY �d/ � Fo �a yi'n�a�%� G�/,���� ,�q� � CIty21p /��d,o.✓r� ��Do� ��^✓ �', ��i`T� 6'0 ..3'2 /}7 .'t�� v n1 , V In�3abdlviaioa pravide iaformaHon,sa follows: h�,��+�fF ,�ia/'�;'.�t� l�r���e'� �''/�r�:�,�g'`' , N�me: � �' � ' �l7 tJk'..� SecHont Block: Lott D�te Property Flag�cdt l — � – "� This i�to certiPy th�t the Intorm�Non prwtded ls corcect to the beat of my knawledga I anderat�nd that any per�ait(e) iasned henaRer are aabJect to taspenslon or revocaHon,t[the eite plans or intended aae change,or if the informallon eabmitted in thV AppllcaHon I�fslsllied or e6anged I,also,understand tbat I arrt responsl6lc jor all charg�s lncurred jroni tbJs appllcudon. I,hereby,Qive couaent to the Aathorized Representative of the Davie Coanty Hai1W Department to enter apon above deacribed property locsted in Dsvie Cannty aud o�waed by to conrlact�il tatinQ procedara�u neceaaary to determine the�Ite�I Wty. DATE J T - �� SIGNATURE THIS AR.EA MAY BE USED FOR DRAWING YOUR SITL PI.AN(lnclndc All of tLe followingt EsieHn�and propa�ecd property Unes and dimeaetons, etractares, aetbAcks, •nd uptic locadons). 3tte Rcvbit Charge Ihte{a): Cllent NoHticaHon Date: EAS: Acconnt Na �� Revlsed DCHD(07/99) Invoice Na ��� �_�_ov � � JG� � �^'" ., � - - /?� /-ell��7.a ��'�( s���� ��- ��''a� Sj�a�' R1�,�., '� � � �I i �d S'.�rcf��izy , /�� --------_.__--.— ��f TgD..� �3, ory � �X °'� �� . � .7s' 4� �.b � �---- d.--� <So � �du �a Q3 � s o , � ,�� � %-- � � G � .� � � � o , G � ' - ' I v° �,�7 ; \� � � � --.�..w_� �� ``-�- .. .�.._�_ --�--`-"`._._ l r".""'_.,_-,-._l�� __, _ � �r,��,,v (�,���� ,Rv�S'� /�� _ /`'„� tail eip (bent) eip ' � ' ' S 85° 39 23�� E— . ' � , 396.77 • . N \ - 4 \� A O A � �. \ � \ I \ N AREA = 7.993 ACRES \ � AREA iNCLU0E5 S.R. 1454 8�452 R\W's �;p \ N I o DEBRA S. SMITH I 0 o D8. 117 PG. 767 .' -- $ o � I , � \ � I �--- — P�P N 85° 54� 52�� W mon � \ �� 298.26 — � \ \ ' � \ \ I � � LEE ROY HOWELL � W.B. 81-E-124 � 1` ` I c � � . ,, o; N �`v � 10 � w� .�. � �,� � o w p.v'f" , Q g �n; I , � i 6` � I ,\ ` � I ' 1, ,1 1` PAPK,�� LOT � � I I i � 1,\ `1 , , \ ��- `` I � ' � -- 1 � _ -_ � I _ I 40�8���W �-- - --—_. _ I - " �10 40/ � _ � � _�_` _ I I _ i � _� .. � � --_ f\W �'' ( ` . (IOi� I �mon 8 cap _ " � / , . . ��11/11411j .13p?5 .. `,..`�.� C A RO..,�.,, o p1� 3�' W � ^�Z , `���'`� w..,.�/�' -S 8° 5 R. �`'t LEE ROY HOWELL i ;O::Q�,G�STfqfo S y: �Ap 1, W.B. 81-E-124 � =Z; SEAL = '� L•2527 Q s " .� . . , � • , DAVIE COUNTY HEALTH DEPART'MENT • � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000939 Tax PIN/EH#: 5863-45-4544 Billed To: Yadkin Valley Baptist Church Subdivision Info: Reference Name: Larry Parker Location/Address: Yadkin Valley Road-2 006 Proposed Facility: SanGSun.Sch Rm Property Size: 298 x 330 Date Evaluated: 2 � �� Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition L �. Slo e% 2 HORIZON I DEPTH �-1 -� 1 Texture rou C C�2., Consistence • S Structure � �'�2 c �Z Mineralo [' 1 ' ;` �;" HORIZON II DEPTH 2c� - iZ-� 'Z7 Texture rou C Consistence -5 r i ' ; Structure � , 5'1� ` Mineralo �: ; � 1 HORIZON III DEPTH �l' 2 � � Texture rou Consistence r `'j Swcture z 5 c Mineralo r : 1 HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE � , p , t�� SITE CLASSIFICATION: I�S EVALUATION BY: ����C�l�l' LONG-TERM ACCEPTANCE RATE: � '� OTHER(S)PRESENT: �^�T �a��.1 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 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 SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineraloev 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-gaUday/ft2 DCHD OS/99(Revised) ■���■��■�■�■�■■�■�■■������■�■�■���■��■���■�■��■����■■■�■■�■�■�■��■ ■������■����■�����������������■■�■�■�����■■■����■���■��■������■�■■ ■����■�■��■■���■��■�■�■■■��■�����■���■�■■■■����■�■■��■�■��■�■■�■■ ■■�■���■■�■�����■���■�■�■�����■■ ■��������■������■���■�■����■��■■ ■���■■�����■�■■�■�■■�■��■■��■���■■■�����■■�■��■■�■■������■��■■■�■■ 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' - r.� t �j"yi��,!�4'�°� � � ,. - r� . :�,;• `��� � . , = .� . ..: 1-- ��sT ._.clt�ass ,_ren: . �, , :'F E�t� _ „ r4��;:,� ;.• � exr�r_ ---F�rune - ---- --- � rARK�rv .----_ , a-�---L": I I = - c Exi� Fr�rr � _ - '-' ' o- :r' �--- NYORci.1F' _. . �. .. . . � v �� " I AUTHORIZATION NO: U 7$z DAVIE COUNTY HEALTH DEPARTMENT �'''�� ' Environmental Health Section PROPERTY INFORMATION '�errriittee's ' / , � , Name: � , �, ,� a P•O.Box 848 ��� w � ��it�Mocksville,NC 27028 Subdivision Name: � , �;, Phone#:704-634-8760 Directions to property:d�d����� Section: Lot: AUTHORIZATION FOR ���� �,, _ ���� SYSTEM CO STRUCTION Tax Office PIN:# ? � '� � !r�.:j 'l-r. i i%'- Road Name: •:aL / )"t /`II/�p�l ' U 0� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior � to issuance of any Building Pemuts.This Fom�/Authorization Number should be presented to the Davie County Building Inspec6ons O�ce when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � I / . ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' ��G.�.���y�.l�`�� "";'"'�;'/ �i�� IS VALID FOR A PERIOD OF FIVE YFARS. ` ENVIRONMENTAL HEALT SPECIALIST DATE ISSUED � _.._.--. --,•--.._.... :_...._. . ..._ .. ___ _ .._ .. .._ ___,.,... _. ...._.._.._. _..�.__...... .. .---- ,.. ._.:._..�y .._...___ .._. _._......�... �.�..._.._._... .._._.__�._.�_.._.�.___ ._ ..... � RFSIDENTIAL SPECIFTCATION:BUII.DING TYPE #BEDROOMS #BA1'HS #OCCUPANTS GARBAGE DISPOSAL:Yes or No ` ��N��� � � COMMERCIAL SPECIFTCATION: FACII.TfY TYP� #PEOPLE� #PEOPLFJSHIFT #SEATS INDUSTRIAL WAS1'E:Yes or No LOT SIZE TYPE WATER SUPPLY � l> DESIGN WASTEWATER FI-OW(GPD)�_ NEW S1TE� REPAIR STTE I I ., � I SYSTEM SPECIFICATIONS: TANK SIZE��,GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEP'I'H.L� LINEAR Ff.�� o�R I REQUIRED SITE MODIFiCATIONS/CONDITIONS: ' !' I IMPROVEMENT PERMIT LAYOUT � ' I �A��:'�9 1 �— ���,$)��� i �`� �t��i� � � � �;. . i ��A r�/'�..!) �, :J i i i I I •*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH.DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM � BETWEEN 8:30-930 A.M.OR 1:00-130 P.M.ON Tf�DAY OF INSTALLATION.T'ELEPHONE#IS(704)6348760. i i OPERATION PERMIT /� / � SYSTEM INSTALLED BY:_�/1...�. �t� � ; � /Jn' /(/Y� i � � - ' . J i � i �� � " t^" '� , � i .� , , �:., ��� I � � � � ����C.�xr� '� � i i AUTHORIZATION NO._.�rL L OdL OPERATION PERMIT BY: � DATE:_�!d��Q� � I *'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ' i WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECfION.1900"SEWAGE TREATMENT AND DISPOSAL SYST'EMS",BUT SHALL IN NO WAY BE TAKEN AS A � GUARANTEB THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. i DCHD OS/96(Revised) � � I � � l . . :..,� ., ..,...��, �__., x:•�:. - _ ' . .-. _. . _ Y`.. .. .. . . . ' . ' . , . _ ._" tr . . . f 1�. �. . , . .. ,. r. . ' " . . i � . . . . , � � ��� .. AiJTH�'�'iZATION NO: 0?$2 DAVIE COUNTY HEALTH DEPARTMENT � � . � Environmental Health Section PROPERTY INFORMATION -- Permittee's � � �+ � �r ��f ��; � P.O.Box 848 Name: ' � +�f �• t'ft .r%�' 'S �f„{,;�Mocksville,NC 27028 Subdivision Name: '' / Phone#: 704-634-8760 Directions to property:��`�� �� ��,�,T,,,�'„f• Section: Lot: A�WS TEWATER�R �f}fl f...�� � ..1����� SYSTEM CONSTRUCTION Tax Office PIN:# 7��-��� ���l .�r:i: %�!.�i Road Name: r :��i�t �If`�� '��l(�Q� --e�'nrrt-- **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pemuts.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pernuts. � (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �,/ �.��j ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � �"����,i7'c�rli''`�'� "��.,.��=Ti�j� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEA T SPEC� DATE ISSUED : ,. . , : . . . . . _ _ , , . � 'r; -- �- -�� , y' .� ; . . ,�.;K... - . DAVIE COUNTY HEALTH DEPARTMENT • ...� - �.,+ IMPROVEMENT AND OPERATION PERMITS PROPERT'7�INFORMATION � f W �`�ernuttee's _i t,/, 1:�' �� _"' ,; -�, � � Name•� ��•`; �`«z��/ F r;��, 'i` '��#,�:��,��,s,j�'�;�`� Subdivision Name: ` � ,'-t ` . t ; f f , ��Directions to property: � r'�~l �f-''��' f �'t:� Section: Lot:� a�� T_ f� • ��. ,; IlVIPROVEMENT r -� �„� � ° � :��, '�;� PERMIT " Tax Office PIN:#���'%�-~- '���-�y - �' �"'� ,� , �, ROadName l��t`:.�,'�� / �l �r1�l�Zl�jl� °�rT�r��7!� ✓ **NOTE**This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this Department prior to the consiruction/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) ; o � �-� ***NOTICE***THIS PERNIIT IS SUBJECT TO REVOCATION IF S1TE '`_� , ;,-.=, �;e,-•'� �' , ,`% PLANS OR TI�INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RFSIDENTIAL SPECIFICAT'ION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No �r1�L�ii ? COMMERCIAL SPECIFICATION: FACILITY TYP� #PEOPLE� #PEOPLF✓SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY_L_ DESIGN WASTEWATER FLOW(GPD) "i%�' NEW SITE �/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE � GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ��'���LINEAR FT.��j�/ OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ` IMPROVEMENT PERMIT LAYOUT Pp�ti Q � / S� �� � r���v� �,tiil 1� l+FlrNJ'� rJ 8 **CONTACT A REPRESENTATIVE OF TI�DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-930 A.M.OR I:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. OPERATION PERMIT �J���_,��.'G/cR SYSTEM INSTALLED BY: � -� ._ GV'_ /(h� l � F` ! " �„"��, , ��--� ,, - 1� ��� ' �'��� � , ' ����.�xr� AUTHORIZATION NO. 2g�OPERATION PERMIT BY: ��[�C�C DATE: �����`fa **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ' WITH ARTICLE 11 OF G.S.CHAP'TER 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 OSN6(Revised) I :� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER ' ' K�-'� Davie County Health Department n _ L� 0 V � � '� � Environmental Health Section U ' P.O. Box 848 � P�1,Q 2 . R 7 f997 , Mocksville, NC 27028 � (704) 634-8760 '�'�'�'�IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL i THE REQUIRED INFORMATION IS PROVIDED. ; . j 1. Name to be Billed ��d1� �/4���-°< Contact Person �7�e9/�/ Cir�� � Mailing Address , D�%9��/y l//���.c,'f° /°�Gf� Home Phone 5/� '"'�9� -�0 3G : City/State/Zip��d/1�I�LG ��,��'(JCJ� Business Phone S/�-�r.�-- . 2. Name on PermibATC if Different than Above Mailing Address City/State/Zip , 3. Application For: �j Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: [ ] House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other �/C �.�/_� ; 5. If Residence: #People #Bedrooms #Bathrooms [�Dishwasher[ ]Garbage Disposal , [ ]Washing Machine [ ]Basement/Plumbing [ ]BasemenUNo Plumbing 6. If Business/Other: Specify type P//.S �� .�i4`L #People��/D #Sinks r� #Commodes C� #Showers #Urinals�_ #Water Coolers_� , If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply: �County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes �(]No If yes,what type? ' EITHEIz tl PLttT OIZ SZTE �LftN PROPERTY INFORMATION REQUIRED:***IMPORTANT***��'OF THE PROPERTY MUST BE ' SUBMITTED WITH �S APPLICATION. �y � 3�i�-6�� S�`� � , Property Dimensions: ,� /��G �WRITE DIRECTIONS(from ocksville)TO PROPERTI': Ta�c O�ce PIN: #�6 3 -�s - �s�Y ; — — ' f � `�� � lC � Z�, Property Address: Road Name 1/a DKi�n/ UA,/�t/ ���_� �p �.z /i'��`LP S dN /4'yLif' City/Zip –��l.��/fy/�/G2 /,YG ��"c��J � ; Y�v r, ,'n/ �/��Ge� 13�9��';'S�" C�f��f2G� � If in Subdivision provide information,as follows: � � Name: � � , � Section: Lot#: ; This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all chazges incurred from this application. 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 �/��'C�N (/!�-�L2 �1 j�¢' G�fJRL� conduct al testing procedures as necessary to determine the site suitability. ' ; DATE �'��'97� SIGNATURE � Revised DCHD(06-96) . THIS ttnEA h1ttJ $E USEb �OR �b1Zt11VZNC� t�fOUR SZZE PLAN: r + I I I : : - � � � , � 3 . ' � i �� Y . _` - - � - � , � . . � ' � . �` < �r � � . . . � . . - r�.l � {� . i � `-�" - �:�: ., _ � . , � � _ . _. : , t� .. :_ .: _ ,�_�o.— __ . . rm � - - - � • I So �4�= -;� ; ---- - : ;. .. . �� �� � -� .�c . _--� ,� /�,�—''` � �... . ...�iir Gria�i==7�R`A--� d? �--'/.. - _ _ ,Yr'� . �, ' _ . PS��{p�'C , b �� y , : : :. �IJG �.�'� - ' A� �Q �, - � ,',, £y.�SS.-�� . } . - � � �/ ,�'. ` ��S_.-, , . , � RilLT \ ` `'_ T \ � 1 ` :_ . ' r�`S� S ' ` . - � y. - ` 0 � ' ' . � . . 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' _. � : ��, �� FutURfi 1y,oRsctNC��- �yi,, �; � s�ri r� -- _.. _.__ , t .� �ti s. - . � �- Exi{T �.. � . . -� r- r :z � ���� ti . � . . . . �--�+-,_--_� I . : - �,�,s ` �Sr.� Fk��� FJ2c :�S . . _ ` r'_ a.A .x,._ _ "_�'r.�� : , "`r, - N YD�i6*1T^ .-r rs s. . _ �. . •-� , . . ` "�` DAVIE COUNTY HEALTH DEPARTMENT z � Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME l�'. C DATE EVALUATED 7 6/l✓ �� PROPOSED FACILITY ��ioi✓�'L�. PROPERTY SIZE �0`1�" SUBDNISION ROAD NAME . Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring a� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � � � Texture rou ' Consistence � Structure " ,� f � 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 �/ � SITE CLASSIFICATION: �S 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 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 SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloav 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-gaUday/ft2 DCHD(01-90) ■■■■■��■■■■����■�■■■�■■��■�■■■■■��■■������■��■■■■���������■■■■■��■ ■■■�����■■■�■�■■��■�■���■���■�■■��■■�■■�■■■■■■������■■�■��■�■���■■ ■����■��■■■■■■■�������■■■�■■■■�■ ■��■�■�■���■����■�■��■�■■����■�■ ■�■������������■■■■■■■■■��■����■�■■�■��■■■■■■����■�■��■����■■���■ ■�■�■■■■���■�■■�■■��■��■■■■�■■�������■�■■�����■■■■�■�������■■■■��■ 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