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126 Shady Grove Lane Lot 2Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 19 T 1 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection %`7-2.10// Name--//�'./fif� W LyNe Phone Number 33,6 (Home) Mailing Address: Jrl& (Work) Email Address: Detailed Directions To Site:— Property Address ite: PropertyAddress %'Jlv �`I V OiJC' a7! Please Fill In The Following Information About The EXISTING Facility: J� Name System Installed Under:li r- 57l0 6r e Ty/p pe Of Facility: Qt/Se Date System Installed (Month/Date/Year): ;97//g &77 Number Of Bedrooms:_, �?_Number OfPecple:�— Is The Facility Currently Vacant? Yes (E)If Yes, For How Any Known Problems? Yes/(D es No If Yes, Please Fill In The Following Information About The NEW Facility: Type Of Facility: .9/0 ra� IWOfk<�reO Number OfBedrooms: Number of People Pool Size:_ // Ggtage Size: Other: Requested For Environmental Health Office Use Only Environmental Health of this form by the 6 /�, q nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By:, Account .,,.— -..,.syr ......w,.v r"v a "E14•' .., +M' .Yi .iv `4�''''4 h�.."f �S..r.,�•��.t �. �;. n:i lC^Y',r �5�.;^ i _ ... A7110RIIATION 140i: Q 719 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ," PROPERTY INFORMATION Pemuttee's f P O. Box 848 Name - Mocksville, NC 27028'. Subdivision Name: Directions to property: Phone #: 704:634-8766- n P P y Section Lot�C AUTHORIZATION FOR -WASTEWATER SYSTEM CONSTRUCTION Tax Office 'Road Name Qd GrAzip: a,TOO6: **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 Atithorization Number should be presented to the Davie County Building Inspections ' Office when applying for Building Permits. (In compliance with Article l of G.S. Chapter 130A; Wastewater System's, Section;1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THISAUTHORIZATION FOR WASTEWATER CONSTRUCTION. IS VALID FOR APERIOD OFFIVEYEARS. ENVIRONMENTAL HEALTH SPECIALIST.. DATEISSUEA DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION lyermrttCe�",7�. / / NSiiie r 9r AY Suidivision Name:,-5sk`Yr' Directions to property: - 7 /. Section: �' Lot: II1IPROVEMENT PERMIT Tax 'Office PIN:#�f Q J Road Namec?clI%ipA 7e **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 . conshuction/mstallation of a system or the issuance of a building pemriL (In compliance with Article 11. of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1 ss*NOTICE""W THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST. DATE ISSUED,, SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLE/SHIFT # SEATS _ INDUSTRIAL. WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE L, - REPAiR SITE SYSTEM SPECIFICATIONS: TANK SIZE,4M—GAL. PUMP TANK ---GAL. TRENCH WIDTH?� �. ROCK DEPTH XJ' LINEAR Fr.—�91919 �.- OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: - \. IMPROVEMENT PERMIT LAYOUT - - "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. 7 OPERATION PERMIT 0 EU e N AUTHORIZATION NO. OPERATION PERMIT BY: DATE: I ` '*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 05/96 (Rev[W) Directionsto property: t F DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION > Su9division Name: Section: , Lot: IMPROVEMENT PERMIT Tax Office PIN: 1/ �f - °/j4�/ Road **NOTE**^This Improvement Permit DOES NOT authorise the construction &c Mi stallation of a septic tank system or any wastewater system. 'An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the constmcdonTmstallation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE i ( / PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED. SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE,_ # BEDROOMS - # BATHS —,V—# OCCUPANTS GARBAG&DISPOSAL: Yes or No i i E , COMMERCIAL SPECIFICATION: FACHITY TYPE # PEOPLE # PEOPLE/SH FT # SEATS _ INDUSTRIAL•WASTE: Yes or No LOTSIZE TYPE WATER SUPPLY —4�—. DESIGNWASTEWATER FLOW (GPD) NEWSITE !-� REPAiRsITE SYSTEM SPECIFICATIONS: TANK SIZE «•e/ GAL. PUMP TANK GAL. TRENCH WIDTH —17"'LL ROCK DEPTH /)' LINEAR PT., n/J REQUIRED SITE MODIFICATIONS/CONDTPIONS: f a N "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 1�. SYSTEM INSTALLED BY:__C'2�r.�^ i; AUTHORIZATION NO. U '717 OPERATION PERMIT BY: C^...,iNa "�'�/�'� 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 NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME, IXMHD U5196 (Revised) .. _ w APPLICATION FOR SITE EVALUATIONAMPROVEMENT PErvlcw n f Davie County Health Department vEnvironmental Health Section P.O. Box 848 1 1 1997 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed CAH e t S -My afca /J , 6EAry Contact Person Mailing Address Z98 az" FAreas Home Phone C91o) 6S9-fSfl7 City/State/Zip (411,4Sr0.J -54eri , nti_ 77104 Business Phone (3(0) 85-4-'Z17 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC [, Both 4. System to Serve: (Irfiouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms 3 # Bathrooms 2 (C- Dishwasher [ ] Garbage Disposal [ ]✓ Washing Machine [�+mhi� f 1 Bacement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # 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 [.4, o If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE // ff SUBMITTED WITH THIS APPLICATION. Property Dimensions: 1Zo ,S::X o -d V0Z&d)(, YJ WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #,5"7, -pp4"5 lS"Bs� 1 s9 7V 41 & M' L Property Address: Road Name city/zip If in Sub ' tst n provide info ation, as follows: 7 a aLd A-E Name: , "fit. Section: I Lot#: d This is to certify that the information provided is correct to the best of my-lfnowledge. I-Aderstand that lanyyye—rmtt(s)-isstfed-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 charges 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 DATE Z-19-97 Revised DCHD (06-96) ffvu� a,.� QST ..`S 1 .S0 4 etc' c1f — to conduct all testing procedures as necessary to determine the site suitability. A 41 J - CA b 10,t /A?.�� �t -F t �, y ♦ J � y ROY L, POTfS OFFICE (910) 998.2100 RES. (910) 998.2400 $ •'n �' " p ;',. � ...,' ',• 710 ' � , '�5°�•y �Q,J�(yvyy�'9q�a�� C�///��� R n o~ 'r' \ ' % y,.C�l� �� �� m At r e• q � 8� a ." _ `♦/ � S � \, / p" •, ,/�r r \ / � �. y� 49 Y9 \ r $ r $y�� a�° /. A "^ r r e1'I Ir rl�P,♦ y At �I a$Ai gory, ,r ~ r •� ' !� "e/'Ie o. i' n 1. HCl-.: y .1., ., ..� 41ar .-. /J $� i 1 -/ ,� ^ Ja.=e• Jql l !@f, $ h ` l• 14,10' 0/. / 1 : 1•:. .Ne�C N i .1.,,. .l•�• Nel.y 2jA !.M ily 11' .' p. IF Yti1 o r i. 'ei O 2 ?}.6 �• jy , r ' 1. /!,. IN P I I 4 � .e 1 �14�1/. .. 'bra � /••` "�,f ,/�I �♦ �., ,s'i'r i>;a 1 '� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. SECTION LOT Soil/Site Evaluation APPLICANT'S NAME Z4q If 'r. DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME �)f/�/d Water Supply: On -Site Well Community Public tip Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6` 7 Landscape position Slope % ell HORIZON I DEPTH Texture group Consistence Structure . Mineralogy HORIZON II DEPTH t Texture group Consistence r e, Structure S / s-,6 /C Mineralogy 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: y/ 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 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 -tern[ acceptance rate - gal/day/ft2 DCM(01-90) - MEN MEN