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450 Oakland Avenue Lot 71` r y v5r 0, AUTHORIZATION. NO: DAVIE COUNTY HEALTH DEPARTMENT "r A. Environmental Health Section PROPERTY INFORMATION Permliwt,s J P.O. Box 848 �."/ Mocksville, 'Name.. �� t..� ,7�%� .��3r�i� NC 27028. Subdivision Name: �;-�= e ' l61�<►,�sf�'" Phone #: 704-634-8760 l Directions to property: Section: / Lot:. AUTHORIZATION FOR WASTEWATER Tax Office PIN:#Jd� Q SYSTEM CONSTRUCTION _ Road Name:zip:�i **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 1 t t DAVIE COINTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION x 'Name: - >..CS4 'l"',: i/!" �',te �,>�✓f ,' Directions to property: . Subdivision Name: 4 In" 4--;4"' ib'. JE Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: r'/f�ir��'%�> Zip:_ **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) y ***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. RESIDENTIAL SPECIFICATION: BUILDING TYPE // # BEDROOMS `-7 # BATHS Q # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPES/ # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE GG )/)TYPE WATER SUPPLY / DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE SIG) GAL. PUMP TANK GAL. TRENCH WIDTH S ROCK DEPTH /-'' LINEAR FT. -fid REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT r - **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) 6348760. OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT SYSTEM INSTALLED BY: �.,j t t L A 1L.C� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SITSTENtrl�SCRIBED ABOVE HATREEN 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 Davie County Health Department flaw-" 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 1•.:: Billed A L= Contact Person Mailing :=,.ddressv Home Phone City/State/Zip L, Business Phone 2. Name on 'ermit/ATC if Different than Above I Mailing Ac.dress City/State/Zip 3. Application For: [ate Evaluation [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: INTrouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms_. # Bathrooms [ tjl6ishwasher [ ] Garbage Disposal r [kKashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing i 6. If Business/Other: Specify type # People #Sinks # Commodes I # Showers. # Urinals # Water Coolers If Foodservice: # Seats,_Estimated Water Usage (gallons per day) 7. Type of water supply: [0-county/City [ ] Well [ ] Community `5 j 8. Do you ar:ticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No If yes, what type? i EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***XtEMT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 1 d WRITE DIRECTIONS (from 4ocksville) TO PROPERTY: Tax Office PIN: Property . ! ddress: Road ame � ' 1 d 1� � T' 0rJ city/zip _ % �� If in Subs .vision rovide information, as follows: Name: Section: Lot #: 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 i 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 D vie Coun Health Department to enter upon above described property located in Davie County and owned by to c uct all te'tin roced s as necessary to determine the site suitability. DATE] \ __ 1 -_-_l _ SIGNATURE j SL DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION---/ LOT Soil/Site Evaluation APPLICANT'S NAME O! / �r / DATE EVALUATED PROPOSED FACILITY i1_1Z PROPERTY SIZE Jt�LF2� SUBDIVISION Ur'�/�l/��CL;5 ROADNAME Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy 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 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE:_ REMARKS: DCHD (01-90) EVALUATION BY: 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 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 ■E■■EE■ ■N■NME■ ■■■M■E■ ■■M■■■■ MEMO■■■ ME ■■ No No ■EEE■ ■■■E■ ■E■■■ ■ ■ ■E■ ■■■ ■E■ ■■■ ■■■ MEN MEN ■ ■I■EEM■■■■■ ■IEE■E■ , ■■ ■I■EE■■ ■■ MEMO ■ ■ No i ■■■■■ ■■E■■