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1905 Yadkin Valley Rd . �„ �.� :���r"'�'" . . � ,1 . . .-a,.-.•..- . . -- .__. --+ � ;.!',,,� ,..=�r� .,� � �, i `r. . :, �Pemutte�'S .-� `�' ,'�' �:' �����i,������ ��.f��.�����.�f.�������' r: ' . �Name `�,�'�`�'��`��� � �� ��h- ; Environmental:Health Section PROPERTY�INFORMATION - *'.�-� -- � . . , � %�� ':` �. �` r,�=��: � � . P O. Box 848 . j . _ � , '`Directions to•property;: � ° ' .i��` �� .�',�;: + ,j�qocksvil']e. NC 27�28 � r Su6d�vision Name: � " `� �' "� ��, � >ti ` Phone#: 336-751-8760 " : � ��+�',t��,tr;.�'��`� 4�,�:..;� �:��`��+� ��,�..�„����;�a�.h���'-.� � � �Section:; Lot: .:' �: , ,;�, � ¢ , , : : , i AUTHORI7.ATION FOR . . � .. , . � �.. . . �,� , _ . ' :: ,�,F:p, � �, t,�y >�. �.WASTEWATER Tax Of.fice PIN:# - - . ALITHORIZ.t : �j} . J' ' :. . SYSTFNI CONSTRUCTION- . :.. . , ,� + � ATION NO: � z.��'�.�.. �� . . � .� „ .���, . }� ��i�t4.�� � :;,+ . . A ,:' Road Name ��':'^� # d � Z�p' �. �, �, - **NOTE*;,Ttiis A�thorization for�Wastewater System Construction MUST BE"ISSUED by ttie Davie Counry Environmental'Health Section prior , ' to_issuance`of any Building Permits.This Fonn/Authorization Numbershould.be presented to the Davie County Building Inspections , : . . . - Office wtien applying for"Building Pennits. : < . ; � ' ,` . . . � , � (ln compliance with Article l 1�of G.S.�Ch�pter,130A,Wastewater Systems,Section.I900 Sewage Treatment�and Disposal Systems) ' a:,�• ..�9 t� ' 'w"„�y,. - . � x ' °°'�"``�"`"��'� • .-�''� ' �� ' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION . � S ; 1i�y `�� fi� . . ' • „�,,,,,..�,��`��. ,{� � C �=" . �'� � � . IS VALID FOR A PERIOD OF FIVE YEARS. �ENV[RONMENTAL HEALTH`.SPECtALIS{ �� � _ . .a��'. x � ..,:- ... "� T�..' D�1T 9SSUED. ' . � . . LL � � , . . _ _ , , . , ' � . : . .. , • _ :, . RESIDENTIAL SPECIFICATION:BUILDING,TYPE�_ �#BEllROOMS.�_#BATHS .�.- � #OCCUPANTS � GARBAGE DISPO$AL:Yes orNo - . . , . . . . : , , . . . , y / . COMMERCIAL SPECIFICATION; FAC[LITY TYRE � #PEORLE #REOPLE/SHIFT #SE S� INDUSTRIAL WASTE:Yes or No LOT SIZE�'� �� T.YPE WATER SUPPLY �� ,' �t DESIGN WASTEWATER FLOW(GRD) ��� , NEW SITE .REPAIR SITE �r � . �• SYSTEM SPECIF.ICATIONS: TANK SIZE ���:GAL. 'PUMP TANK •GAL. �TRENCH�WIDTH�:�� ;� 'ROCK DEPTH I� , LINEAR FT.�8.�.'�R • � �';j���5.-��)1f�JE::�� � t,6r 'e ; � � ' OTHER � . . ' � � ., , • - eREQUI • . .' . . . , , .; . , k i Y � ! �� � - / i,� a.� - RED SITE MODIFICATIONS/CONDITIONS: ���'�+!�� ,.'��.'� ��.',�t:+Ke,� �'C:�~ . �+�.�,"'�r�� � C:+�:�� '�tsL.,t`d , :�+� Ii:.�'�'� �+�•++.•1� i"+�c,�l ; � .:IMPROVEMENT PERMIT LAYOU;T.�;,,�,,.,,;�„� t . � r:, „ . ; �:�,"�„ 6;���-1� ���;.�.�,.-1'�' �.,s�..<.�"q;�`::��� , . . , . . o_ : , • •.. �l. r . ' .. ' . , . . .� , -�yt 4�.��r.� !'� � i`1 .' � . . � , . . . � ' - . . g �1�.�� _'"� ._'f� I�t/th.JOMn . . , . , , i'"�. #��"` . , �1U � . t q �s:.� � >: . �.�;, � `" ' F ....w.,...�,.:..�.-."«._..�........�.,�.........,:.�:_..:..:�:, , • . � _ . �^ , � �A.; �..���•. ''�- 1 .� # ` ' � . . �-_--., ....�._.�,�,..-.�..._..��..w_y_ � , • . .�� . , . , • �< Y-c.h.++:, � � s� , p.n���w3•�44t�' ' . ,. ::. . ,' r , �, . . _. , . . ' . � , . � , . , . . . . . ^ v . �i �,n. 'i i t,;l Pf�3{ ^�1%;._-.....��-+,....-�.,a""^`o„� r. ., ` ~� � � . � . :: ;, . � . . . ,��„� i �" .,...�:.�....}.y.�.-.�.�,.�,:e. , �r�:��.,i� :{,,.,��.�; �� Cn.,�.:�..��, . . ,. ���}#`t�� �.,..,_. �- t�, ,^ t; ,� � ' '� ' �'�.�,:�,�.,��� , �„ ,,",�'����;,;.l�,,�"�,�;;,�� t_i�1;�. 1 ��.»*�.,.r . ` : � , ���:./.\�'��'� ��'��,��.��" . . . ` ' ,. ' .: � r° . r . , � , _ I _ , �. . , � : ��.�°�tii"�:�.��t__� f ,��r��'�,`_ `i',���a»���..�:�•` . . . , ' , . ' ! - . . � . �, - - . . . , � , ' . . � — , ' . .' . ,. . . . . . : ._ . . . - r . . . ' . . �,�' . . . ... :�. ' � ' 'i" .-. I' . , . : . �. .e . :-�. . , . ,. . , . , � � . . .� . -' . . .. ' . . ., ii i.-..�. . � . ' • .• � , � **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DERARTMENT FOR FINAL"INSPECTION OF THIS SYSTEM; • ' , BETWEEN 8:30-9:30 A.Ivl:OR 1:00-.1:30 P.Ivt.ON THE DAY OF tNSTALLATION.TELEPHONE#'IS (336)751-8760.. � . . ,. . _. , ,,, ; .,. . � . . . . , , . � ,, . . ,:. . ,,.: ,. _. , : � _ , : , ` . , DPERATION PERMIT- � '�� j�,�C� . w� , � . , � "•SYSTEM INSTA�LLED BY: � ���l�/`T� `" � �L ` � ' * • � f' . � . , . . . . . . . � � . . � . . � . . . . . - . . . . . ,-. � . . . ' .�- ' . . (7 . r .,, : . .'.. . �. . . .. -^.,`V'� .. � .. - ,. '. . . . ` • . . ' . ` . .N •� � � , ' . � . " . .. � • • .• . ���'�t�� ' .. ' ` . . � . . . ' , . . . . � • �.. . .. i . �. '' � . . � . . :. ' pn .. ' ►�t . ����`. ,��'1'c�,� . , ' . . � , . :. ' ' . : ' `,. . . , , �, . .. . . . . . . , `� . . , ;, , ' ,.... � -71�1,,1 ( LI 1` . . . � � � s� ° � / � ��� � • � _ . ; T � ; �^ .����a : . . � �� . . . � . ,. , I y � (,� � �,���..�)� r r • . - . ��..�, . . , , . . — G . � � . � . . ,, � _ ..'. �` : , . . . � , , • .��.. ..: , � . . _ ., _ , , " . � . �. _ . .. ���� ,� .. , . . . ' ,. .,; . , ....._ . , , . . . , : �. �q� . �,,:1�-� . -------,. . , , � , � ... � . � .. , + _ AUTHORIZATION NO °����'�"QPERATION PERMIT BY.''� � I ' D'.ATE: � ` - � ' "*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S NI •ESCRIBED ABOVE H BEEN INSTALLED IN COMPLIANCE WITH�ARTICLE.11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE�TREATIvIENT AND DISPOSAL�SYSTEMS`', T SHALL"IN NO`VUAY BE TAKEN AS A ` � GUARANTEE THAT THE SYSTEM WILL FIJNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME, � � • �DCHD 07IO2_(Revised).' . . . .�.: �..-. .. ':. .. ....:.. . .. . .. ... ' . .. . . __ . . .� . � . .. � � � ' . ' , -- . . _ �. . , �. , � ����` �.�.� �: � � , ; � � . . , , , . . � � � . . . . .. .. - . . � �. � ,. . . . , .�,� �"� . . , - �'�;�,.� . . . .. � _. . *. .� , . .. , . , , . , , �, � �° �?',�'. , , � �- `� � P�r S�.,� ��� �5�.-n, �5�-� . ��' ���� CATION FOR SITE EVALUATION/IMPROV[MENT PERMIT&ATC G/� J913 ��f�L �0�3 Davie County Health Department , , ,�'�, Environmenta/Hea/th Section O Q� P.O. Box 848/210 Hospital Street �, ��,cA�� Mocksville, NC 27028 ,��`�P�\����� (336)751-8760 �` ***IMPO *** THI5 APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INF TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �Q��Q{�a �r' �� Contact Person Mailing Addresa �_Slo 1 Q/�e1�2�L+1, 1-�� Home Phone /J /�' (���� City/State/ZIP �C�C -�jCj✓j�� �r l r . a���0 Buainess Phono 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �Site Evaluation �Improvement Permit/ATC � Both �` a. syatem to service: ❑ House �Mobile Home ❑ Business ❑ Industry �Other 5. Type aystem requested: �CA Conventional ❑ conventional modified ❑ innovative /� s 6. If Rasidence: # People �_ # Bedrooms � # Bathrooms � ❑Diahwasher ❑Garbage Disposal �+Iashing Machina ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type � ,People # Sinks � # Commodas # Showers # Urinals � #k Water Coolera IF FOODSERVICE:: # Seats Estimated Water Usage (gallona per day) e. �ype of water auPp y: County/City ❑ Well ❑ Community �. � 9. no You anticipate �itions or expansions of the facility tliis system is intended to scrve? ❑Yes ��10 �. � If yes,what typc? 1 �'� T'.� • ***IMPORTANT±�**CLIENTS tIiUST COMPLETB TIi� RLQUIRLD PROPLI2'TY INFOKMATION RGQUGS'I'GD BELOW. Eitl�cr a�PLAT or SITE PLAN MUST BE SUB�IITTED by thc clicnt with TIIIS APPLICATION. Property Dimensions: �`"e ,i'�—�'� WRITE DIRLCTIONS(from Mocicsvillc)to PROI'1?RTY: Tax Officc PIN: # ����'�-� ^ ��i-S Z ��-� �-c� �y �e.� ���� ��° s I� l�. �'� ,, Property Address: Road Name � w� a �J • ��__���� ���--~�� c,cy�z;p J �n� cc,� � If in a Subdivision provide information,as follo�vs: C (/ �/La� � Namc: --'�—✓�Gt�/� d'Y` /Z--��C�-!y-- �N��e�« � � Section: Block: Lot: Datc l�omc corncrs flaggcd: t� 0 11� - lY X�� This is to ccrtify that tlie information provided is correct to tlie best of my knowlcdge. I understand tliat any permit(s) issucd hereafter are subject to suspension or revocation,if the site plans or intended use changc,or if the informalion submitted in tl�is application is falsiFed or changed. I,also,tuiderstaud t/iat I ain responsiGle for all cliurgCS 1liClll7'L'lI f!'011l tlris application. I,hereby,give consent to the Authorized Rcpresentativc of thc Davic County Hcalth Dcpartmcnt lo enter u�on above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine tl�e site suitability. DATE___ ��-- ( 3-—� � SIGNATURE -F- � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc follo�ving: �xisting aud proposcd property lines and dimensions, structures, setbacks, and septic locations). ' 3 SYr • v /� `� Sitc Revisit Cl�ar�;c �—r��Le�- �',�`, � � v�t�(s): d l � � s,c.� /_�,b e �,�,o��� � � Clicnt Notification Datc: �r-�:. L,v cr-�.� � �^-�" �.�o �.1�����v�, EHS: Sign given � Account No. O Revised DCHD(OS/03 Invoice No. C=�.e� ��-�y y w �..,...,,�: . _ �,.,`, �" p:' OOA) ; �� �,ca o � 0o r- ----- - _____�'" ___-_ . �- � � �� � �. � � v � 180 I � � �� � -------- ------y -------- -----�----------- ------ - � , � (1 . 50A) � M � 2652 � � . �� r � ����� ____��___�����A �. � .. N � � � �� 9� �. ) 212 �-�- t� . � 0 ry � f 1 .43A � � � ) �� ,� ,� � 68 � � ,� ` o �� �,,`� ; � � � � � Q DAVIE COUNTY �r ... .. \�� � !' tbja .;.:F � � .. y� a,. .. .. ..., ... . .:# ... ... . �.�_ .. . . ..... ........ � - � � DAVIE COUNTY HEALTH DEPARTIVIENT ` Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION � � �� PROPERTY INFORMATION Account #: 990002989 Tax PIN/EH#: 5862-28-2652 Billed To: Tamara Fritz Subdivision Info: Reference Name: Location/Address: 1905 Yadkin Valley Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring 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 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: 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 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-gal/day/ft2 DCHD OS/99(Revised)