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172 Rabbit Field Lane Lot 5M-57 ,DAVIE COUNTY HEALTH DEPARTMENT Ne'1�11� r'�f ` Environmental Health Section PROPERTY INFORMATION P OB . ox 848 y �A Directions to property: {- r�1f < r�f } %!it 4 ille, NC 27028 Subdivision Name: s C., Phone #: 336-751-8760 ✓.:��!" Sectio Lot: _ AUTHORIZATION FOR WASTEWATER Tax Office PIN:45 / a- j SYSTEM CONSTRUCTION AUTHORIZATION NO:24.9U A Road Name: Zip: **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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION jjc [ r� /i": _> IS VALID FOR A PERIOD OF FIVE YEARS.�r�.j J ' ENVIRONMEi4 'AL HEALTH SPECIALIST DATE ISS UED RESIDENTIAL SPECIFICATION: BUILDING TYPE,". # BEDROOMS � # BATHS _,,?— # OCCUPANTS C-, GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY �� �` / DESIGN WASTEWATER FLOW (GPD)�v NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ---tom—' OCK DEPTH �ELINEAR q r , OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED 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 02/02 (Revised) _-3,5 G 3 �ti � q-7 2 **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,'——. r` ,•;' F -' IS VALID FOR A PERIOD OF FIVE YEARS. N ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS jf # 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 �'"✓('f DESIGN WASTEWATER FLOW (GPD) 7 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK r" Y GAL. TRENCH WIDTH = -'/ rROCK DEPTH 3'.{f LINEARF�� 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. i OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. 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 02/02 (Revised) ®M DAVIE COUNTY HEALTH DEPARTMENT Name:l" i , ' �' Environmental Health Section PROPERTY INFORMATION d4 z ... r i W ' PO. Box 848 l�ections to property: ,r �' - 'f �.- p` Ivlocksville, NC 27028 Subdivision Name: r1 Phone #: 336-751-8760i, Section:"--VI-1 __ Lot: _ AUTHORIZATION FOR WASTEWATER ff Tax Office PIN:#' 70- SYSTEM CONSTRUCTION AUTHORIZATION NO:` �F °p A Road Name: Zip: f **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,'——. r` ,•;' F -' IS VALID FOR A PERIOD OF FIVE YEARS. N ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS jf # 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 �'"✓('f DESIGN WASTEWATER FLOW (GPD) 7 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK r" Y GAL. TRENCH WIDTH = -'/ rROCK DEPTH 3'.{f LINEARF�� 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. i OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. 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 02/02 (Revised) ®M ~; iLT14ORIZAT ON NO: 0 68 5 DAVIE COUNTY HEALTH DEPARTMENT >' Environmental Health Section PROPERTY INFORMATION tPermittee'sI -P.O. Box 848 Q \ Name: e`er` , Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Dijectidns to property: - �N'CN Section: � Lot: AUTHORIZATION FOR —� WASTEWATER Tax Office"PIN:#-�, SYSTEM CONSTRUCTION --?— <. Road Name }\n�=.��k **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. ENV HE LTH DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT ' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFpRMATION t ; I, 'Name. P Subdivision Name: Direptions to property: / - ` �. �' Section: Lot: �- _ IMPROVEMENT PERMIT Tax Office PIN.#. JA ti ti _ Road Name. t "i Zip i (� **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 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 :r PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER _ } SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENV HE THS DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS -!� # BATHS # OCCUPANTS GARBAGE DISPOSAL Yes br No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No L ITE ✓ REPAIR SITE LOT SIZE �- ' � � TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) �- NEW S�t SYSTEM SPECIFICATIONS: TANK SIZE1000 GAL. PUMP TANK GAL. TRENCH WIDTH �' ROCK DEPTH{ ( LINEAR FT. OTHER �'\ e G�y��x:, % tuC� y �t�\ GV�4 �':i 1 a. ce•.;a, A REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ox . C 9 too,� �'� ad d° StfG CQQS no j,i �SVIP jr lg'gg' **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 PE IT b �(, go ' SYSTEM INSTALLED BY. �O0 0 �0 3� C� AUTHORIZATION NO. - 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 05/96 (Revised) 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 If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City' 0' Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes E"No INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: lv !O %�t, 5 1 WRITE DIRECTIONS (from / Mocksville) TO PROPERTY: Tax Office PIN: # .�� 7 O - (O 1 �� Esus VL ," '57-� Property Address: Road Name L4 it& r- m �z�'r pa , Ci /Zi U h' P � If in Subdivision provide information, as follows: Name: � Fl r ni 1 I / Section: Lot #: 1 a 4 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 charge, 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 by as necessary to determine the site suitability. DATE _ _ 9 —5 - % in7 SIGNATURE Revised DCHD (06-96) conduct all testing procedures THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed .ALL ? J, /7 / Contact Person _ /vR e p"J Mailing Address _3 3 a V r/` d Home Phone _ 7/9 qd City/State/Zip k ''1'4 oZ/ .14 /on,/, -2 le to Business Phone -274 L9 � 20 2. Name on Permit/ATC if Different than Above ?11) Q A 2?,62 Q Mailing Address _ W2 11 �� C g —City/State,/Zip/YY'--,5-,'i / 3. Application For: 2"'S ite Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: 5 ---House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 23 ishwasher ®2�a bage Disposal E / Washing Machine E�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: ❑ County/City' 0' Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes E"No INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: lv !O %�t, 5 1 WRITE DIRECTIONS (from / Mocksville) TO PROPERTY: Tax Office PIN: # .�� 7 O - (O 1 �� Esus VL ," '57-� Property Address: Road Name L4 it& r- m �z�'r pa , Ci /Zi U h' P � If in Subdivision provide information, as follows: Name: � Fl r ni 1 I / Section: Lot #: 1 a 4 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 charge, 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 by as necessary to determine the site suitability. DATE _ _ 9 —5 - % in7 SIGNATURE Revised DCHD (06-96) conduct all testing procedures c�pf:L��s tts��,yq ; � nm•n rinuc 1co1■ c••a1■. t. J tQlnit a fQfi11M SEAL ® LINDA W. (,12tN5Kl S L-1540 my cor t N VI � ! � I► 1•y h I I . D t - ice''' 1vt-� � . ! 1Ilk kzz�oz.• -,1.... 1 -1 L ; �[LLt� JT ~rte• 0 Lai;" �7 �� � `t.{,, � =vJ O.�/t . } ! �- I• 1.1FK O Y 1f2-4. I �st•Kh � / o S J 1 o1;G•6 I -ti;l — Sal ec• — 1 .D 6 I V Q FI SC.D --3e' oa•i..a ec<s ss� )r.a �t•�a I or- I - '� - •oa `. RaAD" 1n3r z� - � •, �'�. ww�l ; v+ws il1 t � G'a i ci• `;� a -L•�r.CV t ►.p.�. - .� 1�c•470r, I afi 34. 07 p,ceEs' DAVIE COUNTY HEALTH DEPARTMENT _!Z j • Environmental Health Section SECTION -1 LOT 25 Soil/Site Evaluation APPLICANT'S NAME@� DATE EVALUATED'�S PROPOSED FACILITY �b� g-� PROPERTY SIZE CO• b'' SUBDIVISION �P�`�'fi" ROAD NAMEc' Water Supply: On -Site Well " Community Public Evaluation ByZ.'�__L Auger Boring Pit Cut_ FACTORS 1 2 3 4 5 6 7 Landscape position S .S Sloe %- HORIZON I DEPTH Texture group Consistence 3 Structure ` Mineralogy HORIZON II DEPTH 2 Texture group Consistence F� Structure 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 3 SITE CLASSIFICATION; LONG-TERM ACCEPTANCE RATE. " REMARKS:l \1 DCHD (01-90) EVALUATION BY:�� OTHER(S) PRESENT: V30.g 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-term acceptance rate - gal/day/ft2 ■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■111\\■■■■■/■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■\ii���/■'�i/■1\a■rel■■■■■■■■■Ori■ ■■■■■■■■■■■■■■■■■■■■■■wt■■■■■■■■■■!1■■■■■■■■■I1■■f/■■■■tai ■ ■■MEM■EMEM■ ■OMEN■■■■■■ ■■MEMEMMEM■ ■■MEM■MMEM■ ■E■■■M■■ME■ ■E■■M■■M■■■ ■MEMEM■EME■ ■OMMEMMM■M■ ■M■MME■ME■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION 07ION FOR IMPROVEMENT PERMIT (REPAIR) 4� NAME PA PHONE NUMBER G� S �1 ADDRESS di SUBDIVISION NAM i /��'%%� % LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED (X/,;L Y 1/4 NAME SYSTEM INSTALLED UNDER IK -,t -r t' TYPE FACILITY - NUMBE BEDROOMS S-7 NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY �,�Wzz This is to certify that the information provided is correct to the best of my knovfleogle� and that 1 understand I epi responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGE Rev. 1/93