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156 Winchester Road Lot 8Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.D. Box 665 I I ► L( L/ Mocksville, N.C. 27028 T J AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 0-3'9,6 map , (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction oust 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.*** / AUTHORIZATION NUMBER // �.r� NAME /, K ey' lS' O -I DATE '/ - � N1j 2 0 2 NAME ON IMPROVEMENT PERRMII,T (If differentthanabove) �r> ��/l �'-57�%r ),, �(} SITE LOCATION , J b��_•�`j'Hr f YC%,',� ,f e�'�''- COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT X0 N 6-3-96 _U916 **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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME4 Ll PROPERTY ADDRESS _ �%C�l�S� !�/". A 7D046DATE `/2 -J,l LOCATION SUBDIVISION NAME fYlfrl7'��s /d': �� LOT NUMBER SEC. /BLOCK NUMBER i RESIDENTAL SPECIFICATION: BUILDING TYPE �r lIS # BEDROOMS # BATHS %�2 # OCCUPANTS GARBAGE DISPOSAL: Yes COMMERCIAL. SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIIE j� TYPE WATER SUPPLY / DESIGN WASTEWATER FLOW (GPDQ NEW SITE Li—REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �2L GAL. PUMP TAW OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: GAL. TRENCH WIDTH7Z,'ROCK DEPTH /.-'%� LINEAR FT. _ ***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. 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 2 ��v AUTHORIZATION NO. d a� DKRRT1 PERNI BY � DATE c **THE ISSUANCE OF THIS OPERATION PERMITSHAL INDICAIE THAT Tf(E SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION . 900 " TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL 'IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION ISFACT RILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 \i1 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) X4 -r)q NAMEs.% �' % /`/�7�'F r �= i PROPERTY ADDRESS r�f /1 C'//'N ''�'`�t_'. i' �c✓/' . '�G 6DATE `2 LOCATION SUBDIVISION NAME LOT NUMBER /t� SEC. /BLOCK NUMBER / RESIDENTAL SPECIFICATION: BUILDING TYPE JIV:I' ` ' # BEDROOMS # BATHS: " # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE"? TYPE WATER SUPPLY % DESIGN WASTEWATER FLOW (GPD),-,- NEW SITE L ---REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE ;� GAL. PUMP TANK GAL. TRENCH WIDTH " ROCK DEPTH _,Z:*L LINEAR FT. 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. A. aero/ 1 1 1 .r......-�..-.....ten... ..., ...ti............. .a. 1 j r, r 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 AUTHORIZATION NO. C7 I C) Z-1 SYSTEM INSTALLED BY�i� -4 0`-u e, IPERATIIjI PERMI BY DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHINDICATE THAT TfE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION�IISFACT 900 ' TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION RILYFOR ANY,!GIVEN PERIOD OF TIME. DCHD 10/95 �, `Iv SCP An114?40 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM O; I QUCY Davie County Health Department D k,� 1 , � Environmental Health Section JAN 2 91996 l/_ OP P. O. Box 665 � w Mocksville, NC 27028 j ,J' �9.91D �itJ�T..0 1.' Application/Permit Requested By/Gr f�NL��i'113c)�% G Mailing Address.p s W )yc,= J/i4✓Co Z_N Home Phone 5 c_ 0Q10 4 c(:� S L/) tri.-ir ll% e .2 70 _-2- F Business Phone -9 2. Name on Permit if Different than Above 3: Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit i 4. System to Serve: 2"H ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry Other ❑ Unknown f �l 5.. If house, mobile home: Subdivision Z �YaV S— Section �_ Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing`s No. of Bedrooms /� No. of Bathrooms a -- Dwelling Dimensions 6. If business, industry, place of public assembly, other: No. of People Served. No. of Commodes No. of Lavatories No. of Showers 7. Type of water supply: ZrPublic Specify type No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures ❑ Private ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ Community t `NOTE: Improvements Permits shall be valid from date issued. Improvementsi Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. FRUPEKTY 1Nk0RMXUUN REQUIRED: Directionsto Property: L ?-�)(f C -L6S /e> A40 This is to certify that the information provided is correct incurred from this application. DATE Tax Office PIN /r` Road Name tu,UCS3T%�.� jQ© Box # (if available) City best of my knowledge, and I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALWATION TO BE DONE ON ABOVE DESCRIBED PROPERTY IJI MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 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 detLeraid site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1/93) I. J" DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public z_�' Evaluation By: Auger Boring Pit Cut Texture group Consistence FACTORS 1 2 3 4 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 7- * Texture group Consistence Structure S Mineralogy,y /. 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: U' EVALUATED 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 :lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V,:. -y 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 5C -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 Ilorizon 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