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106 Canton Rd Lot 20, Sec 2 (2) s, Davie County Health Department -��-9(� ENVIRONMENTAL HEALTH SECTION P.O. Box 665 J ,rg Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIONB/Q (Issued in compliance with Article 11 of _ P G.S. Chapter 13OA Wastewater Systems) / ***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 A• Office when applying for Building Permits.*** �f-a/ Jj��',�0�'��v N AUTNORIZRTIpN NUMBER NAME if`/�1 S[�i DATE r NAME ON IMPROVEMENT PERMIT (If different than above) SITE'LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR WASTE TER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALW SPECIALIST DATE DCHD 10/95 l T DAVIE COUNTY HEALTH DEPARTMENT i IMPROVEMENT PERMIT and OPERATION PERMIT 9� IMPROVEMENT:PERMIT -N bl **MOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater ,8 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) NAME Ci✓l/r isd 4 PROPERTY ADDRESS AL�7/O 4 I CL . —DJ 0 6 DATE LOCATION SUBDIVISION NAME (1-71d �Y� w LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE Mee # BEDROOMS S # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE /00 A 30 0 TYPE WATER SUPPLY ((> DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL.' PUMP TANK GAL. -TRENCH WIDTH �� ROCK DEPTH LINEAR FT. SOD OTHER 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. kc 's 1 M1•T /•I // ... 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:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704)634-8760. 4 y. OPERATION PERMIT SYSTE)QNSTALLED BY r 4 �y AUTHORIZATION N0. 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 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT /Z,/ r Davie County Health Department ' ' Environmental Health Section !,t;.,�� r 1993 P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By A1 0D/-),S % -zwC, iliZ �.ti7 Y�� 1`-i tS X Wi z..__ /?-70 C14 SV,,( Home Phone `v fes- 7J�%y Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: 5,40use ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown hh 5. If house, mobile home: Subdivision gc.L/-1!L J-16 e-46CJSection Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms Is [Washing Machine No. of Bathrooms __ r=;2 7-0 oZ X� [T"Dishwasher Dwelling Dimensions GYGarbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No, of Sinks No. of Commodes a /'- - No. of Urinals No. of Lavatories mF•_ —' No.of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: QXUbiic ❑ Private ❑ Community 8. Property Dimensions l A C.4-0E- 4.0 73% Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Ci-'No If yes,what type? '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: This is to certify that the information provided is correct to the best cLwy knowledge, and I understand I am responsible for all charges incurred from this application. � .3 /v q,3 DATE SIGNATURE CONSEN FOR SITE EVALUATION!Q BE DONE ON ABOVE DESCRIBED PROPE7hn MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO Nperty. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized I hereby give consent to the authorized representative of the Davie County Health Department to enter ribedproperty located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorpment and disposal system. DATE SIGNATURE , f ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation rD�� p � � tom . NAME 'N � 1 DATE EVALUATE) ADDRESS SA 26 S'-) b `�o(Alf PROPERTY SIZE PROPOSED FACIILTY V\o s Q LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By:C C L Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position Sloe % -- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 3( 3 6 Texture group Consistence r Structure Mineralogyi 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: /I ( EVALUATED BY: � - LONG-TERM ACCEPTANCE RATE: - L� 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 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 ................................................ ............■.... .....................................................■......■.■... . ............................................................... ........................... ...................................... .............................................. ...... . .......... ..............................................CNS■=..CNC...■..■.■■ ................................ ................................ .................................................................. ■■■■..■■■.■..■...............n1�J7..■■■.■■■..■■...Oe..■■.■■.■■.NONE ■■■.■..■.M.M....M.■...M.S■■■■ri■..■ ■�.S ■.u. ■.■■.■E■■■C..e ■.■■C ......................■...........C....0=....C......e.......e■.■■■ .......■................................ ........... ■O■■■■■■■�O■■ ...................■.... ....... ................................ ...............................................■■...........■.■■•C ................................................................ ■EMNOO ■..■■■...■■.O.■■■.....N....■......E■O.■■OO.MO■O..■0...■r:M■ ■....■...E.O■■■. ■■..■■.......■. ..■�.■■.■■.■r:�...■.■...■....YO.0 ■N■E■N■■M■MEMME■ ■■■ME■■■EEMMEME OEM .■■.■■.l.E�7■■.■■■■■ ■■.■.►1�! ........................■............■.■.■O..L�E...■.�..■■CSO■../!.■ ■■.■■■■■■■■■■.■■■■■.■■■■..■■■■■■■■■■■■■.■■.■■■■...■■ MENNEEN■.iA11 ■.■....■....■......■.■...■.■..■...■■■.■■............MEMINE�■■.■//.M ■...■■�■..■■■�..■..■�......�N..■.. ■■MONS ■■E■. u ■■..r . ■■MOM■ ■■M■■■ ■■■NOM ■■■■■■ ' ■■■ ■ ■■ ■M ■ ■■■■ ■M■■■su ■.N■■.■■■■.M.■.■M.■■■■■■ ■■■.■■.■ NOON ■ ■..■.M. ■ ■■■■...■■N■[ SCSCCSSS'SSSSS.�CSeeeeee�eee:eee�■ee:e=C=C::CeC:89C:eSCCCCeaSee0 ■ ■ME■S■.O.N■■■...............�■■M■e■■MMN■M■. .NONE ■..,.�. 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