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365 Michaels Road Lot 24.f, DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT .r IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank`tystes or any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTILNI must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 04!) ? NAME Q'-\ q. S ������� PROPERTY ADDRESS '72//C�%Ote-/ LOCATION SUBDIVISION NAME LOT NUMBER r,t,`1 SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 1. # OCCUPANTS GARBAGE DISPOSAL: Ye No COMMERCIAL SPECIFICATION: FACILITY TYPE''-;' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE,zYes/No LOT SIZE�Ub �(3 b o` TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) La NEW SITE REPAIR SITE SYSTEM SPECIFICATILNIS: TANK SIZE Ibn GAL.' PUMP TANK GAL. TRENCH WIDTH •�) ROCK DEPTH �� LINEAR FT. 5 OTHER h REQUIRED SITE MODIFICATIONS/CONDITIONS ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS,OR THE INTENDED USE'CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. X51 say r IMPROVEMENT PERMIT BV - **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 SYSTEM INSTALLED BY F, 1I¢ fed - h � cS du wA e ,e� P AUTHORIZATION N0. OPERATION 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 10/95 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.D. Box 665 Mocksville, N.C. 27028 ` AUT}DRIZATION FOR WASTEWATER SYSTEM CON5TRl1CTI0i! 60 00 (Issued in compliance with Article 11 of G.S.•Chaptt/r 13 , Wastewater Systems) ***This Authorization For Wastewater System Con truction must be issued by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form)Puthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** .. 'IUMIZATION MMR NAME �. \ A $ N C 2 \ 1 ' A DATE "1 " � b - / ' ` °` 00 NAW 'ON IMPROVEMENT PERMIT (If different than above) �p —,---SITE LOCATION IN, An\.5 h o S P `,1 -\N C. R 0— S ` 4 0 A COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD-10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI Davie County Health Department E t IH IthS t' nvironen a ea ec ion ,JUL 2 11995 m �r Lk P. O. Box 665 Mocksville, NC 27028E r IEWH 1. Application/Permit Requested By ro''1 U '��Y� serd�i C. 1"Ar li Mailing Address _t ,t.tl�✓'Q �:�!` f' Home Phone 6 1� 39 3.3 �—,-61-1 h��d �,/ //� Business Phone 2. Name on Permit if Different than Above 3. Application for: -21 General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: !0f -'House p Mobile Home ❑ Place of Public Assembly J.. ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision -"-'fix �T'4' �B� Section Lot # 7 No. of People No. of Bedrooms No. of Bathrooms ��• Dwelling Dimensions j00 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 ,/ )� Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/Plumbing ❑/Basement/No Plumbing l{� Washing Machine ❑ Dishwasher ❑ .Garbage Disposal ❑ 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/ So. , 6 B This is to certify that the information provided is correct to the best of my knowledge, incurred from thi a plication. � -Z�5 DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED �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 De�wwe Co my Health partment to enter upon above described property located in Davie County and owned by o;,4 Fors„ �ecw;(P_ /2hC. to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. '�, c DATE DCHD (1183) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY �1/DUr Water Supply: On -Site Well DATE EVALUATED _/ %V� PROPERTY SIZE _ -&O,k oU LOCATION OF SITE Community Public Evaluation By: Auger Boring Pit L Cut FACTORS 1 2 3 4 Lands cape position Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 4011,r Structure le 57 .0 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 RATEI Ic SITE CLASSIFICATION: 9EVALUATED 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 ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V^ -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/ft2 DCHD(01-901 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMITIfF OUR Davie County Health Department 1J L5 Environmental Health Section P. O. Box 848 0M 1 1 1997 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS -1 �pp�� ALLTHE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �bJ 1'C. P t LLPkt d A✓ Contact Person kw -&PJ Mailing Address PD 86-K —738 Home Phone —70 ;207 ^ a74 7 11, City/State/Zip 060 f!'� �� � � MJ 9 70 Business Phone 0 q 2. Name on Permit/ATC if Different than Above Mailing Address _ 3. Application For: 4. System to Serve: 5. If Residence: Q/6shwasher 6. If Business/Other: # Commodes _ If Foodservice: ❑ Site Evaluation L1UI House W/*Mobile Home 3 20 5Z #People ❑ Garbage Disposal 7. Type of water supply: Specify type # Showers City/State/Zip W Improvement Permit & ATC ❑ Both ❑ Business ❑ Industry ❑ Other # Bedrooms�rr # Bathrooms ❑' Vashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # Seats l/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: I 1 Tax Office PIN: # 5 —74 -2 e) - 0-7,94 1 Property Address: Road NameI V t p'ha City/Zip AIL d -70A 1 1 If in Subdivision provide information, as follows: sfollowss: Name: (Sa V/w Jun i ; 1 Section: Lot #: 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: &0/ s -/-V VVI bO h a X d ate- This 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. L 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 by ko&qp, 5 ty tf naA to conduct all testing procedures as necessary to determine the site suitability. DATE 'Z111Jq-7 SIGNATURE L, Y- I (T Revised DCHD (06-96)