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178 Oakland Avenue Lot 35}: 7 i1.,., f - ''^_{ •�:4 if ..Ta.r .�� f)._ Y.,,i .➢ . `T riF-,�4Y.f 'fe �z. ,Y �,, .~k r}. �p. •.t • ��D•. AUTHORIZATION NO: 0751- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION _ Permitt_ee's � - P.O-Box-848 � ,r Nam e: �.y�"+'� % :Fw''. �° Mocksville,NC 27028 Subdivision Name: CJ.•J=_r�:'�r p, Phone #: 704-634-8760 C Directions to property: f`r F i tt, , ; , '" Section: Lot: 12-Y AUTHORIZATION - AUTHORIZATION FOR WASTEWATER Tax Office PIN: SYSTEM CONSTRUCTION j 1e f/ ,qP 1pZip: f Road Name: r C3 r1 **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 Fonn/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) 1 j ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ��...�.- 1 L't i:" •C tea. ��>�Y ti ,r . _ ENVIRONMENTAL HEALTH SPECIALIST, 'DATE ISSUED f DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION r Permitt6o'- 4 > f . •`E t Name: f r �. "r1 �, Subdivision Name. Directions to property: Section: `, f°�f?' ' r � µ'" ySection: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road ..Zip; **NOTE** This Improvement Permit DOES NOT authorize the construction or installaii-on 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 - PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. i, RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS --.F # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE00?(`�r.� TYPE WATER SUPPLY a DESIGN WASTEWATER FLOW (GP NEW SITE z ----REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE LSO P GAL. PUMP TANK GAL. TRENCH WIDTH ---F/-" ROCK DEPTH /) LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � I j **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. j OPERATION PERMIT SYSTEM INSTALLED BY: it 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 EVALUATIONAMIPROVEMENT 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 - L r- , e I Contact Person Mailing Address�v[� r(i wnJ_ Home Phone J City/State/Zip �v i 1� -� Iv - C- W Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: M'site Evaluation 4. System to Serve: [Mouse [ ] Mobile Home City/State/Zip [ ] Improvement Permit & ATC [ ] Both [ ] Business [ ] Industry [ ] Other 5. If Residence: #People # Bedrooms _# Bathrooms_ [&]'1Sshwasher [ ]Garbage Disposal [,a -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: [VT-C--Ounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** c Property Dimensions: _ U U WRITE Tax Office PIN: # Property Address: Road Name 1, rt I �— , City/Zip If in Subdivision rovide information, as follows: Name: , , , Section: Lot #: S ; This is to certify that the information provided is correct to the best of my kno'A subject to suspension or revocation, if the site plans or intended use change, or if [ ] Yes [ i -Wo THEP A PLAT OR SITE PLAN LAJOF THE PROPERTY MUST BE 3MITTED WITH 1 T�APPLICATION. RECTION S (from ocksville) TO II PROPERTY: -1J fA �v? f �Jarl evr�l f Ai 1 I1 �— I understand that any permit(s) issued hereafter are 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 DATE SIGNATURES Revised DCHD (06-96) all testing progNures as nepossary to determine the site suitability. THIS AREA AIAIY BE USED FOR DRAIVINC7 YOUR SITE PLAN: • _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT 3S-"" Soil/Site Evaluation APPLICANT'S NAME /% /A9,0 / " / D TE EVALUATED PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring 11---' Pit PROPERTY SIZE 'Oe 410' ROAD NAME D A k ►a� [d- A Ve— Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence I Structure MineralogyI HORIZON II DEPTH Texture groupG Consistences i Structure <74 / Mineralogy " / / HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE I CLASSIFICATION / LONG-TERM ACCEPTANCE RATE I SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) ALUATION BY: ')/ZZ 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 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 - Gri ular 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 ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■E■■E■ ■E■■■■■ ■■ ■E■■EE■■■■■ ■EM■EME■OE■ ■■EEE■■■■■■ MEMO■■■■■■■ ■■■ME■■■■■■ ■OE■E■EM■E■ ■■M■■■■E■■■ ■EE■■■■■E■■ ■E■E■■■E■■■ ■EEEEEEE■E■ ■■■OEM■■O■■ ■■EEEEE■EM■ ■E■■■■■EE■■ ■EMM■■■■M■■ ■■■EE■E■EE■ ■■■MME■■M■■ ■M■■■■■EEE■ ■EE■■■■EEE■ ■■E■■EM■EE■ ■ ■ ■ ■ ■■