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295 Michaels Road Lot 32AUTRORIZATION No: 112 DAVIE COUNTY HEALTH DEPARTMENT r Environmental Health Section PROPERTY INFORMATION -'Perrnktte's i P.O. Box 848 c7 �s,i Name: / Mocksville, NC 27028 Subdivision Name.:- ,?� Z�''. ' -_ L ;I Phone #: 704-634-8760 �^' - Directions to property: �O`r1 ! / i ,"' C Section: j_. Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# A(P* - q SYSTEM CONSTRUCTION 1 �J Road Name: !� ICIi 1- Zip: Qc�c7 **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. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED �� � a ,p�y }n�.. .�v eti• b,'. ' � ".e., � a•. .t'cif''�'�:.L'L8•-`-�.�,fJt�i`./`i/.,' +>„"`�4r `.DAME COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION r.. Naiile:n ' _ Subdivision Namai-a motions to property a s/, F t7�p �+1��L 1�1T Section:_ Lot: j 1111FA0 1 G1�iGl\ 1 - -. ,w► —PERMIT, r�s. Tax Office PIN:# �t t e .` f Qwfi4, Zi A104AX ,. ✓ x _ Road Namp: **NOTE** This Improvement Permit DOES NOT authorize the1donst<uctlon 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 construc tion/msmllation of a system or the issuance of a building permit. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems; Section .1900 Sewage Treatment and Disposal Systems) a ***NOTICE*** TRIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TI•>E INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH°SPECIALIST -DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE , INSTALLING TIDE SYSTEM. 'RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 2 #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No 1 LOT SIZE, TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) Z6 NEW SITE. -REPAIR SITE. SYSTEM SPECIFICATIONS: TANK SIZE _".GAL, PUMP TANK • GAL. TRENCH WIDTH 3G ROCK DEPTH J� LINEAR FT. QW OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: !*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. AUTHORIZATION NO._-�' OPERATION PERMIT BY:' Y DATE: I c �/ "THE ISSU OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTI 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. .,a,nv vino �iccnaea� . r APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �.`1 a `� l rn Contact Person Ro uL' Mailing Address Py 04 --735 Home Phone N'[Y20— 0-7 +--1 City/State/Zip o o l `�� �,P�e,t Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation 4. System to Serve: El House 51 Mobile Home 5. If Residence: Dishwasher # People City/State/Zip BitImprovement Permit & ATC ❑ Business # Bedrooms 3 ❑ Industry ❑ Other _ # Bathrooms ❑ Both ❑ Garbage Disposal @,"Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: 7. Type of water supply: # Showers _ # Seats LR' County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) ❑ Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions.. 10 1 x 3 a3' Tax Office PIN: # 5 -7 T (P - a , - g J q-7 Property Address: Road Name MiPJAakA fK City/Zip a 7 02 If in Subdivision provide information, as follows: Name: a cv,,q,,g Section: Lot #: 219 - WRITE DIRECTIONS (from Mocksville) TO PROPERTY: 14l v-�,> 67 o 1 s 43 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 Representative of the DavieCounty Health Department to enter upon above described property located in Davie County and owned by Spt L ] t to conduct all testing procedures as necessary to determine the site suitability. %, DATE / I //;-) SIGNATURE A I //) , , Revised DCHD (06-96) - APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM) Davie County Health Department �� • ,' Environmental Health Section JUL 2 1 1995 �r f P. O. Box 665 F[ I !!!! I Mocksville, NC 27028�H 1. Application/Permit Requested By ! 0h o '�✓�>m�Jer�/� C• fMan Mailing Address �1. �? !✓_. . _ 6 3g ;33 fi/! ,� on Home Phe Business Phone -k 7 ;Z 2. Name on Permit if Different than Above 3. Application for: W General Evaluation E)Septic Tank Installation Permit 4. System to Serve: ®'/House ❑ Mobile Home ❑ Place of Public Assembly) ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # �.. i No. of People No. of Bedrooms No. of Bathrooms T Dwelling Dimensions � %DD 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine Igoo s ❑ Dishwasher ❑ .Garbage Disposal No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply:ublic ❑ Private 8. Property Dimensions..../O!Q F72- �4©F S we age Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes "o ❑ Community '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: �0/ S°•A 9 --/-- P 6 1 C 4 ej V This is to certify that the information provided is correct to the best of my knowledge, incurred from th'iJ%$j application. DATE I understand I am responsible for all charges SIGNATURE' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED FfROPERTY MUST CHECK ONE: ❑ 1. 1 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 representativ of the D e Co my Health De artment to enter upon above described property located in Davie County and owned by cid ecruies �h� . to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. /y--' 5 DATE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT - . Environmental Health Section Ir ° ' Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE -� PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well _ Community Public_ Evaluation By: Auger Boring Pit t/ Cut FACTORS 1 2 3 4 Landscape position Sloe R HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence r Structure S" 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: LONG-TERM ACCEPTANCE RATE: _J REMARKS: DCHD(01-901 EVALUATED BY: �41 f� 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- Vc-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 ,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/ftz ---------------- ■■■■■■■■■■■■■■■■■■ UMEM ■■■■■MC■■mom C■■CCCC■■ ■■■■■■■■■■■■■■■■■■ MEN M■■■■M■■CM■■MEMEM MAIN E■ MEMO■■■■ ■■N■E■■■C■N■■M■■■■ on ■EMEMEMMEE■ ONC ■■■■■■E■■■■■ ■■ ■■ ■M■■■ M■ MEMO CIMMCC IMMEN ■■■■M■EE■■E■EE NONE MIMMEMAIMMEN SOON ■EMEE■■■E■ ■M■■N■E■■M■MM■■■■ ■■■■■■NENESE■ME■ ■■■■■EEE■■■■E■■■■■ ■EN■■SEEN■■■■■EE■