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212 Shady Grove Lane Lot 10�r - yV . UTIIo)2ITION NO. .0697 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION PtAi itte" / IS 1 P.O. Box 848 Name D P .fiAe / OD �/� MocksvIlle,NC 27028 Subdivision Name: Phone #: 704-634-8760 �O Directions to property: C " Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# �f d 1- SYSTEM CONSTRUCTION:. , Road Name: 6 A � les -,Zip: **NOTE** This Authorization for Was System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Fonm(Authorization Number should be presented to the Davie County Building Inspections Office when applying forBuilding Permits. (In compliance with Article 11 of G.S. Chapter I30A, Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems) { **NOTICE***, THIS AUTHORIZATIONFOR WASTEWATER CONSTRUCTION ' IS VALID FORA PERIOD OF FP✓E.YEARS , ENVIRONMENTALHEAL ECIALIST.: DATE,ISSUED , DAVIE COUNTY H] IMPROVEMENT ANI NatlieuD+�lA,rdr"l%� r Ds to property f 1614 49nm�1n 5 N ,�y a B1�Ri off � PI . S✓Xci LTH; DEPARTMENT OPERATION PERMITS PROPERTY INFORMATION Subdivision Name:111"Ir -.a' /O —Section:% Lot: VEMENT IMIT-.;? Tai OfficePIN:# Q t C Zip: Road Name: !.J **NOTE** This Improvement Permit DOES NOT authorize the constriction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained frodthis 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS � SYSTEM R THE INIT MUST SEE THISED USE E. YOUR BEFORE TER r' ENVIRONMENTAL HEAL PECIAL19T' y. DATE ISSUED INSTALLING THE SYSTEM. RESIDENTL4I. SPECIFICATION: BUILDING TYPE # BEDROOMS �f # BATHS _-# OCCUPANTS _ GARBAGE DISPOSAL: Yes or No / COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No LOTS/ZE rte% TYPEWATERSUPPLYDESIGN WASTEWATER FLOW (GPD) NEW SITE !/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /aoD GAL. PUMPTANK GAL. TRENCHWIDTH --;"/ROCK DEPTH , -V MLiNEAR Fr. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �l **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) 6348760. OPERATION PERMIT - �, SYSTEM INSTALLED BY: r - AUTHORIZATION NO. —&k—#10PERATION 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 05/96 (Revised) .` 09 APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT Z�o Davie County Health.Department i> 'Environmental Health Section f P. O. Box 665 Mocksville, NC 27028 .� C. ation/Permit Requested By sJ kare;n \l I[� er a Address,' -T` , T_-�oY; .QOGZ Home Phone f Business Phi iK-uM9 '399 2& fS ' ❑ Septic Tank Installation Permit Mobile Home ❑ Place of. Public Asseoibl i� Other ❑ .Unknown /'U Section Lot #.la { u:: ❑.Basement/Plumbing }n! ❑ Basement/No Plumbing,, . ❑ Washing Machine j r ❑ Dishwasher ❑ Garbage Disposal 6 'If business; industry, place of public assembly, other: Specify type c: No of People Served No. of Sinks' No of Commodes No. of Urinals No of Lavatories fn No, of Water Coolers V4S3 _ NW of Showers Water Usage Figures "" w cf p 7 "Type of water supply Public ❑ Private ❑ Community Property Dimensions Sewage Disposal Contractor Do you anticipate additions/ex anion of the facility this sytem isdntended to serve? ❑Yes ❑ No If ye chat type? f.SLI NOTE, Improvements P rmits shall be valid, from date Issued. Improvements Permits are subjela to I revocation; if sit�'plans or the Intended use change Efle�gtisve October i, 1989. !! tV,Ent .' Ali fl}P 9 f KA . IJ IYT +i V Direptfons to Properly ' i4f PROPERTI,� INFORMATION REQUZI2Eb: ; �r /. , ,cs Tax Office PIN: #5%901-441t.0RDq1 ti PROPZRTy ADDRE'S'S, as( fall ows j r \ !em Road' Name: ' city: AA %f'rLn a g 61,1=7 A PLAT WZIH THZ3 APPLICATION. Revisions effective October1, .1995. r{ p ai •, r `r - i , . .. 1 ' t �.JT' ���vp This is to certify that the Information' rovided is correct to the best of my knowledge, and i understand I am responsible for all charges •• Incurred from this aooiication. _ e 1\ n - i \ � DA SI TUR --- l�clyarncc IJC a -26c( 1 on Permit if DiNeredt than Above w�fA_ for " ' oLcation f m to Serve Evaluation.— h! Genera(Evaluation, .-Housekl Business ❑Indust t 1 ry. fuse, mobile home Subdivision''- i property located in Davie County and owned by 4 ,,i to?oonducVall tatting.,procq� ures as necessary to determine said site's suitability for a ground absorption sewage treatment of.People of Bedrooms �'' -� of'Bathrooms ' : s LL DATE SIGNATURE lit '•'nt-i-"„e'. . Business Phi iK-uM9 '399 2& fS ' ❑ Septic Tank Installation Permit Mobile Home ❑ Place of. Public Asseoibl i� Other ❑ .Unknown /'U Section Lot #.la { u:: ❑.Basement/Plumbing }n! ❑ Basement/No Plumbing,, . ❑ Washing Machine j r ❑ Dishwasher ❑ Garbage Disposal 6 'If business; industry, place of public assembly, other: Specify type c: No of People Served No. of Sinks' No of Commodes No. of Urinals No of Lavatories fn No, of Water Coolers V4S3 _ NW of Showers Water Usage Figures "" w cf p 7 "Type of water supply Public ❑ Private ❑ Community Property Dimensions Sewage Disposal Contractor Do you anticipate additions/ex anion of the facility this sytem isdntended to serve? ❑Yes ❑ No If ye chat type? f.SLI NOTE, Improvements P rmits shall be valid, from date Issued. Improvements Permits are subjela to I revocation; if sit�'plans or the Intended use change Efle�gtisve October i, 1989. !! tV,Ent .' Ali fl}P 9 f KA . IJ IYT +i V Direptfons to Properly ' i4f PROPERTI,� INFORMATION REQUZI2Eb: ; �r /. , ,cs Tax Office PIN: #5%901-441t.0RDq1 ti PROPZRTy ADDRE'S'S, as( fall ows j r \ !em Road' Name: ' city: AA %f'rLn a g 61,1=7 A PLAT WZIH THZ3 APPLICATION. Revisions effective October1, .1995. r{ p ai •, r `r - i , . .. 1 ' t �.JT' ���vp This is to certify that the Information' rovided is correct to the best of my knowledge, and i understand I am responsible for all charges •• Incurred from this aooiication. _ e 1\ n - i \ � DA SI TUR --- J� rayl., , CONSENT EQB SITE EVALUATION ZQ BE DONE ON ABOVE DESCRIBED PROPERTY MUS, CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. I 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 4 ,,i to?oonducVall tatting.,procq� ures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system:'•' LL DATE SIGNATURE i s < DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �D� DATE EVALUATED _ ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE dew/ter Water Supply: On -Site Well Community Public • L� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 11 Texture group Consistence. Structure Mineralogy." HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 7t 7T LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: G LDNG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY:i// OTHER(S) PRESENT: 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- Vcry friable FR -Friable FI-Fiml 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 .3C -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/fu APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 �I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 115;—"c % —Z C Contact Person YOC icAa-" r Mailing Address '55'177 Home Phone City/State/Zip G�Svi�LG /I C o9'i025" Business Phone 1 nz0, 7/7 2. Name on Pemtit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: XJ Site Evaluation [ ] Improvement Permit "& ATC 4. System to Serve: [XJ House [" ] Mobile Home [ ] Business [ ] Industry [ ] Other []Both i 5. If Residence: # People 3 # Bedrooms # Bathrooms. � y(] Dishwasher [ ] Garbage Disposal Al Washing Machine [ ] Basement/Plumbing [ ] Basement/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: [N County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes ]7[j No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** SOF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: l d k Q/, X a7 fV X 2yKWRITE DD2ECTIONS (from [[vIocksville) TO PROPERTY: Tax Office PIN: Property Address:" Road Name "1/0 City/Zip nce /l�C If in Subdivision provide information, as follows: Name: Section: Lot#: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued 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 Rep five a Davie County Health Department to enter upon above described property located in Davie County and owned by �1 to duct all testing procedures necessary to determine the site suitability. SIGNATURE C Revised DCHD (06-96) THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:.