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750 Sain Road Lot 6� � _ � �, �^ �,�.� �� :� .. i �. , .. ` „q; ; �r�',•'-+_`,rt:k-'.` _"-`vet'�.'•ta-l",�.'-�.,�.��,:,,i-.ti.: �—.-.ice' � 'tt,•r.v.',�;e,z T ,_ t `''+t.. o-��;�.�sA�,�.L3ir• E�y�i�u: i,�Y"c�,aY1?'i=.F'h",::f;::'97'�"GU:r-s'�.��-:;J'i-�iL .�. Per ittee's='` A,�i DAVIE COUNTY HEALTH DEPARTMENT Name:. ..'� Environmental Health Section PROPERTY INFORMATION � `i� P.O: Box 848 SAt,-j PZ t 8 Subdivision Name: Directions to Property: Mocksville, NC 2702 Phone #: 3367751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002647 A Road Name -750 -CAN A zip:-) o7k- **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. ' (1n compliance w" �Arti"cle I orG: er 130A,' Wastewater Systems, Section .1900 Sewage Treatment and. Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION. VU IS VALID FOR A PERIOD OF FIVE YEARS.VIRON ESP I LIST% DA 1 J RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS �_ # OCCUPANTS _ GARBAGE DISPOSAL: Yes or' COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ' LOT SIZE TYPE WATER SUPPLY Jwwrr DESIGN WASTEWATER FLOW (GPD) 3A NEW SITE REPAIR Sr.M 1 SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ---GAL. TRENCH WIDTH' • ROCK DEPTH A► LINEAR Fr. 220 OTHER' &.'Tti�l0LP 1 t.VV `VAA-V 2 DL5T(ZfA.VrtD+j —4&lVs REQUIRED SITE MODIFICATIONS/CONDITIONS: T�y7 _ ' a � �"'�" +'`� T K I!'^ a rii� _ b)p Ct W IMPROVEMENT PERMIT LAYOUT WC �K MA 'a%ftT1+ , 3d' v4TO S� QD,QA � STc'i S A,*5 S*QIAA- FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL OPERATION PERMIT �tGC ►�gtD e.l�aw.�L mim +-lug A%_T. Fww Vow's ON THE DAY OF INSTALL( nON. TELEPHONE # IS (336) 751-8760. S TEM STAL AUTHORIZATION NO. /Lr7Au OPERATION PERMIT BY: DATE: (� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE ATHESYSD CRIBED ABOVE EEN 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 MW MrAW) L'T' 347 6 —_ _rAlW iCeW �3-q (47 Perrrliit�ee%- ` ` ► f DAVIE COUNTY HEALTH DEPARTMENT f Nanie:� t '' ` `` Environmental Health Section PROPERTY INFORMATION R.O. Box 848 �^ Directions to property: 1 ! �-~' In,I ``' Mocksville NC 27028 Subdivision Name: SAl ^� t< -D f=�rtn'it;� Phone #: 336-751-8760 ' Section:_ AUTHORIZATION FOR WASTEWATER Lot: b r SYSTEM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002647 A Road Name:' ame �t,� t' I ' 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 Pen -nits. (In compliance. with Article I 1 of G.S..Ehapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) j' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION t ! `f ^ IS VALID FOR A PERIOD OF FIVE YEARS. ___EN'Vi ONMENTAL•NEALTH SPECIALIST DATt IS UED RESIDENTIAL SPECIFICATION: BUILDING TYPE if)l ; # BEDROOMS K' # BATHS # OCCUPANTS -_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE y # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY " t DESIGN WASTEWATER FLOW. (GPD) T ` l_ d 7 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH --'L+ , ROCK DEPTH NJ 1Q LINEAR FT. U' OTHER 1"\"%- u;fr /s t ltl L- j"" L r>v5J VAt-*JF- REQUIRED SITE MODIFICATIbNS/CONDITIONS: � I �'�' 'v�k L I \,)e IMPROVEMENT PERMIT LAYOUT 'Si IT r1 o r /?v ,vGr NC4 AI l Lt)MD FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL OPERATION PERMIT QU I(IX 021 F) D lav_& Z A.M. ON THE DAY OF BY: TELEPHONE # IS (336) 751-8760. a r iwu-✓rJ ILL%_ AUTHORIZATION NO. OPERATION PERMIT BY: -- DATE: i "*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEr D SCRIBED ABOVE H EEN 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 01!02 (Revised) 3 q-7 —/ �� �( DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiySite Evaluation APPLICANT INFORMATION Account #: Billed To: -V_XGL cz&q_� Reference Name: Proposed Facility: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 11 Subdivision Info: -7,"D3111N Rb Location/Address: Property Size: Date Evaluated: J 1 l Community Evaluation By: Auger Boring Pit Public ✓ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH ' Texture Eroup Consistence SSS Structure Mineralogy HORIZON I1 DEPTH - 2 Texture group G Consistence 1`r S Structure sok— Mineralo Mineralogy s°X HORIZON III DEPTH 3Z - 112 Texture group G S.. Consistence s Structure Mineralogy.. HORIZON IV DEPTH Texture groupZUGE( Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE p. SITE CLASSIFICATION: EVALUATION BY: ��' � hmtki-14 LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: , REMARKS:�IIIZ 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 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name /. - — Date Location Subdivision Name Lot No. Sec. or Block No Lot Size House Mobile Home _ Business __ Speculation No. Bedrooms — No. Baths — No. in Family` _ Garbage Disposal YES ❑ NO ❑. Specifications for System:., Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue Improvements permit by *Contact a representative of the Davie CountyAealth Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of,completion. Telephone Number: 704-634-5985. Final Installation Diagram: / \\�System\lnstalled by Certificate of Completion Date *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, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date GAY7 Lot SizeZw2vo FACTORS AREA 1 ARFA 9 ARFA I AREA A 1) Topography/ Landscape Position P S S PS U S PS U ?) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) FI PS S PS U S PS U 3) Soil Structure (12-36 in.) Clayey Soils PS '/PS) LU/ S PS U S PS U 1) Soil Depth (inches) PS PS S PS U S PS U i) Soil Drainage: Internal PS PS S PS U S PS U External PS PS S PS U S PS U i) Restrictive Horizons Available Space S S S PS S PS 1) Other (Specify) S PS U S PS U S PS U S PS U i) Site Classification 57 U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by SITE DIAGRAM DCHD (6-82) Title Dat APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. 0. Box 665 'R'ECEIVED FEB 2 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. THome Phone �� yO 1. Permit Requested e;r�/� /�l 5 mixes, " / lir/�� /,� b / T � Business Phone 2. Address a6X 2 I Z 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions .2 9 X Li ' Bed Rooms_ Bath RoomsDen w/Closet_ b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes urinals garbage disposal lavatory 2 showers Z washing machine 1 dishwasher rye) sinks 1 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes t� No 9. a) Property Dimensions FS -'5 b) Land area designated to building site VAS c) Sewage Disposal Contractor - o 'J w 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 14/6 What type? This is to certify that the information is c rrect to the est of my knowledge. F --vZK— Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82)