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340 Michaels Road Lot 8AUTHORIZATION NO: 15', 2 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION �Permitteer's !lam ! P.O. Box 848 Name: -^ v : �f'-' /f I t Mocksville, NC 27028 Subdivision Name: ry Phone # 336-751-8760 Directions to property:Section: f Lot: !' AUTHORIZATION FOR ^'/ WASTEWATER Tax Office PINar rtJ -tJf SYSTEM CONSTRUCTION � Road Name:4"."77 � ip� , **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 11 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�c.�:�•ZyF 7�....:}meq-•---ny_..-n4..ar�y.t.-.. y._-Y.:s_'Y _..�-r --•-«pir'Yi',`'=w+..�- r.:,.�i•T, y;� .N.�'+.'.:�'""+ J'irf':Y ,,rte ` r _ , .N'�. _ r'4 ...a..-• >:t ' ,. y tp � �'�lJ to •' � � - `, . "DAME O'tJ1V�I'Y HEALTH DrEPARTMENT: IMPROI TMENT AND OPERATION•PERMITS PROPERTY INFORMATION N M'� t! i SubdivWon•Narne: ' Diiections toproper'tyi � YL , *� ` �L Section: Lot: IMPROVEMENT r r PERMIT Tax Office PIN: • R Nam p: — **NOTE** This ImprovementP.emiit DOES NOT authorize the construction or id WIation of a septic tank system or any wastewater system;' An AUTHORIZATION FOR: WASTEWATER• SYSTEM CONSTRUCTION must be obtained from this Department prior to the 1 . cooil of a system or theissuance of a building permit, (In compliance, with'Article 1.1 of G.S. Chapter 130A , Wastewater Systetris, Sectiom .1900 SewageTreatment and Disposal Systems) Y -i ***NOTICE*#* TE9S PERMIT IS suBJECT TO REVOCATION•IF SITE' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER '?ty . 3 h ;. ENVIRONMENTAL'HEAL•TH SPECIAtTISZ DATE ISSUED . SYSTEM CONTRACTOR MUSE SEE Tins PERMIT BEFORE . INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE% # BEDROOMS # BATHS' _.# OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATIOW FACIIITY,TYPE # PEOPLE # PEOPIEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SUES TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) NEW SITE %� REPAIR SITE �D 'SYSTEM SPECIFICATIONS: TANK SIZE dD GAL: -PUMP TANK GAL. TRENCH WIDTH -ROCK DEPTH . LINEAR FT. r 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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED S�C3—r 110 10 , AUTHORIZATION NO. OPERATIONYERMIT BY: TE:dip- . TETE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE S O ** INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AL SYSTEMS", BUT SHALL IN NO WILY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ` DM 09% (Reviad) .t APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT Davie County Health Department ` Environmental Health Section JUJ[ n`tu.P. O. Box 848 � 7 1998 Mocksville, NC 27028 (704) 634-8760 E!#1'1' ' AL HEALTH ,... - ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS cALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed POW, k1 p 1 1 /144a lei Contact Person Mailing Address PD 10 730 Home Phone 20 - )--7q-7 City/State/Zip Coo J�,erKte Iw 2-7D'4- Business Phone 20 - .2-55 / 2. Name on Permit/ATC if Different than Above Mailing Address _ 3. Application For: 4. System to Serve: 5. If Residence: fDIDishwasher 6. If Business/Other: # Commodes _ If Foodservice: ❑ Site Evaluation ❑ House # People ❑ Garbage Disposal Specify type City/State/Zip Improvement Permit & ATC (J Both ❑'Mobile Home ❑ Business ❑ Industry ❑ Other # Bedrooms 13 # Bathrooms 12-1 l/ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # Showers # Seats # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 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 Ul No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 1001302-, 1 `` I Tax Office PIN: # 7 - l 0 - -7 to U I Property Address: Road Name City/Zip / / l ©C/ V .2-70)S I If in Subdivision Ovide information, as follows: Name: I Section: I Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY: %D / S -IT 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 Davie County' QHealth Department to enter upon above described property located in Davie County and owned by "�'�' to conduct all testing procedures A as necessary to determine the site suitability. / DATE % —/ t - q SIGNATURE --- Revised DCHD (06-96) CAW, 11 / APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMID Davie County Health Department ,' Environmental Health Section L - 2 �9 r f P. O. Box 665 / Mocksville, NC 27028 EALYH 1. Application/Permit RequestedBy f 0� 'o '_agrA'n �`�i-J�e-- ^� � ter; ----� Mailing Address ..t_ _ Home Phone / J Business Phone sZ 5S/ 2. Name on Permit if Different than Above 3. Application for: � General Evaluation ❑ 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 '� `'fix °T"� �Q� Section Z Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms oQ S ❑ Dishwasher Dwelling Dimensions ❑ .Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories 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 d O F71--k,--_,:020_F-'Sewage Disposal Contractor 1-1 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:ewlr 6 QDO �t &7 % V This is to certify that the information provided is correct to the best of my knowledge{ incurred from thi a plication. DATE I understand I am responsible for all charges SIGNATURE' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY 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 Dawe Co my Health I�artment to enter upon above described property located in Davie County and owned by iis U Dodi„ eeu, i s /Glia to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 2�/y--�, 5 DATE IGNATIMP DCHD (IP3) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation �c NAME / DATE EVALUATED�� ADDRESS �( PROPOSED FACIILTY PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit � Cut FACTORS 1 2 3 4 Landscape position Sloe HORIZON I DEPTH Texture 3roup Consistence Structure MineralogX HORIZON II DEPTH 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 S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PJ LANG -TERM ACCEPTANCE RATE: REMARKS: DCHD (01-901 EVALUATED BY: A/ G/ 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- Vl--.-y friable FR -Friable FI -Finn 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/ft2