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405 Hobson Drive Lot 13Vx0 AVUTffbk-.TION. NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's r'`" / P.O. Box 848 Name:'' �,� �' %� Mocksville, NC 27028 Subdivision Name: > `•!"' `�'� Phone #: 704-634-8760 Directions to property: %-'�' r Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN*551d"415- .1 2-.7 .,�-.�� ' SYSTEM CONSTRUCTION --� Q Road Name:,ri•'% Zip: A %40' u **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 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED tlxo ' . �.. DAVIE COUNTY HEALTH DEPARTMENT 356 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION = iI PeI r`n�ttees "'' y f I ,► Name 1.tar ani f� Subdivision Name: Directions to property: ���<''�"r ' ' Section: 13 Lot: IMPROVEMENT i f 1 i PERMIT Tax OWc?e Road Nairle Zip: C c }© **NOTE** This Improvement Permit DOES NOT authorize the conkruction 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 PERNUT IS SUBJECT TO REVOCATION IF SITE cs••. ?;�f �: 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 A? # BEDROOMS 3 # BATHS 2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZEA6 &() TYPE WATER SUPPLY (/' o DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �`GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH _,"T LINEAR FT. "9 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 (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: �S� r AUTHORIZATION NO.—) OPERATION PERMIT BY: Ail DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTEM 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 EVALUATION/IMPROVEMENT PE R Davie County Health Department Environmental Health Section P. O. Box 848 24 M Mocksville NC 27028 (70T13-@XX7GX (336)751-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCE SED EI1VI1tOt2F.1E000NT HEALTH ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 9he-,0'- T S' _ ���/yi a,-) Contact Person Mailing Address �% ///4/%/J ��, Home Phone _ :2,�� City/State/Zip P/00 tw //,� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: ❑ Dishwasher ❑ Site Evaluation ❑ House bonMobile Home # People L City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms .2o r 3 Both ❑ Other # Bathrooms _ 2 ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: 7. Type of water supply: # Showers # Seats /� ® County/City # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Well 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 PLS HE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 1 '�� 1 WRITE DIRECTIONS (from - 1 Mocksville) TO PROPERTY: Tax Office PIN: # 1 II� Property Address: Road Name �or'X at 1 City/zip C 3V �.��� 1 1 an L�sl►� t3`f 1 If in Subdivision provide information, as follows: 1 AXy � 1 DA T�`� t !c'fl Name: - AC e 1 1 Section: 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 Health Department to enter upon above described property located in Davie County and owned by � L � � �4'- — to conduct all testing procedures as necessary to determine the site suitability. DATE o? GI SIGNATURE Revised DCHD (06-96) YOU MAY USE THE 13ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. 0 - - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME '(! PROPOSED FACILITY SUBDIVISION 7/D/%C,;Q bl 6`/G Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit L/ SECTION LOT DATE EVALUATED �� T /�/ PROPERTY SIZE �/��482) ROAD NAME 1koh 5?_ Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure le Mineralogy1, 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: PC LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (0I-90) LEGEND Landscape Position EVALUATION BY: G/ OTHER(S) PRESENT: 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 ■EMME■E■■ME■E■■■ ■■■■■ME■ ■■E■ME■■ ■EMEM■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO MEMO ■NN■■ M■■E■ ■■■■■EME■■ME■M■M■■ ■EMEM■■■EM■■M■■E■■ ■EM■E■■■ME■EME■E■■ ■■MEM■■E■E■MEM■ME■ ■M■MMEME■E■MME■■M■ ■M■■■■EMO■■■MEM■M■ ■■■MEME■■■EMEM■■■■ ■EM■■■■MEME■■■ME■■ ■EME■M■■■■E■■■EME■ ■MMM■■MMMMN■■M■M■■ ■EMEMME■■■■■ME■E■■ ■■ME■■■■EM■■■MMO■■ ■EME■■E■■■■■E■■ME■ ■ME■EM■E■E■MEM■ME■ ■■■E■■MEMMMEMEM■■■ ■■■EMEM■M■■■EME■E■ ■E■■MEMM■■■■EM■■E■ ■E■OMME■M■M■■■EME■ ■E■■M■M■EMMMME■■M■ ■■M■N■■■■■■■■■ME■■ ■■■EEE■■■■■■■■NE■■ ■■■■■■E■M■M■■■■■M■ ■E■■■■■■EEEE■E■■N■ ■M■■■■■■■■■■■MEE■■ ■■■MM■■■■■■M■EE■■■ ■EE■■■■■■■M■■EE■■■ ■■■■■MMMEMMMM■■■■■ ■EE■■■■■■■■■■■■■■■ ■■■■■■■MNEME■■■■■■ ■E■■■■■■M■■■■■■E■■ ■■M■■■■■EM■■EE■■■■ ■M■■■■■■EE■EEMM■■■ ■■■■■■■■■■■■■■■■■■ ■■■■EE■■■■■■■MM■■■ ■■■■■EEM■■■■■■■■M■ ■MME■■■■SEMEN■■■■■ ■■■■MMM■■■■■■EE■M■ ■■M■M■■■■MMM■■E■■■ ■■■■MNE■MMM■■■■■■■ ■■■■■EE■■M■■■■E■M■ ■■■MM■■■■MM■M■■■■■ �iEMEMMEMENNEN ■EN■■■■ME■■■■■■E■■ ■■■■■■■MM■■■■■■■■■ ■■NONE■■■MNEME■■■N ■■■■■■■■■M■■■E■E■■ ■■■■EE■■■■■EE■■M■■ ■■■■EE■■■■■E■E■■■■ ■■M■■EEE■■■■ME■■■■ ■E■■M■EN■■■■■■EN■■ ■■■■■EE■■■■E■N■■■■ 0 Davie County Health Department �P$ RECEIW@mx'ironmental Health Section P.O. BOX 848 -,/ PA..r4.. Data. r7-01111 210 Hospital Street JDA Q Courier #: 09-40-06; Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection r Name: Phone Number 2 � 2 Q7 (Home) Mailing Address: 12 (Work) /14i'�//�fP 'rY� �, 12?12� Email Address: Detailed Directions To Site: (DI / > i%iJ /!'t 1 �(��/I _'O/L S TA Ri Property Address: Rn AN 6 110 A 00 f; Please Fill In The Following 6&4 Innformattion AAbout The EXISTING Facility:/j/%Name System Installed Under: -!"OfiW If 1J Type Of Facility: /' Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People:_ Is The Facility Currently Vacant? s No If Yes, For How Long? Any Known Problems? Yes o If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: S',MH Number Of Bedrooms: 1-8 Number of People Pool Size: ,Requested By: \\ (Signature) proved isapproved Environmental Health Specialist Other: Requested: I a -q — /S For Environmental Health Office Use Only r s _7,6r , � 7r/a` irr, Date: T— /3, /J-- *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Paymen . Cashh k MoneyOrder # Amount:$ IPO, OU / Date:_ Paid By:� J Received By: Account #: 1 q 5 g5 Z Invoice #: /s"lr;�e-f 4 65`F-e-e--� 7 /S "j=ee-I T