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141 La Quinta Drive Lot 1.`:i S-. ,'y �.. �:' :fir.. -(-...,J '4.•�'�. �..h i'"�..-�A fwy�.i:r ` r �_3:-'� , .�il,��lu '1 :.:.: '. 60 f 'Pemiitteb's-w DAVIE COUNTY HEALTH DEPARTMENT L1 ' Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name:`' 1- L r�. t \" a 1 r�' 1 n, 4 Phone#: 336-751-8760 Section: Lot: ` AUTHORIZATION FOR E WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - - 002704 A 1 t` ' AUTHORIZATION NO: 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.&rett"r 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. '-ENVIRO _ME AL HEAL H SPKdAL ST DATf ISSUE _. _. RESIDENTIAL SPECIFICATION: BUILDING TYPE �.t BEDROOMS # BATHS 2 # OCCUPANTS - GARBAGE DISPOSAL: Yes or No / r COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)7__4 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 22'`S+ -OTHER- ' OTHER' REQUIRED SITE MODIFICATIONS/CONDITIONS: V 4—T �u r'f`Xe WA TL-' IMPROVEMENT PERMIT LAYOUT FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. I OPERATION PERMIT QV 1CA� � •� AUTHORIZATION NO. v ` 8 ` 4OPERATION PERMIT BY: DATE: -7 l62 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DE IBED ABO AS 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. DCHD02/02(Revised) flee -r.. TT y?7y �/VVQ(a C f T ll U � 'ter. :.:.:.::..,.�. T: rT.;:'ti; w.. -'-a`... e-�.(a.ra..:r-f'a-t e.•ays-..,n,:i-rw.o:..:.:-�---r:.,.�;,'-"�" - .-'-9w �,?`r'r; t . �, .<.- r .., T• ". �. -•.., •-Y�._ • Ve'rrt it%�'s==' - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 i 1aL L L wt ctros to nproperty: ! , , t I, t •Diie p perty: Mocksville, NC 27028 Subdivision Name Phone #: 336-751-8760 - 1 Section: Lot: LF - AUTHORIZATION FOR • WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO: 002784 A Road Name: y • � � ` � }� 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. ehapy 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) )) ' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION • L_ r �- - ! t IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMEN AL HEALTH SPECIALIST DATE ISSUE RESIDENTIAL SPECIFICATION: 4UILDING TYPE 1).&) BEDROOMS ^-)# 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 %ESIGN WASTEWATER FLOW (GPD) •�y- NEW SITE REPAIR SITE ✓ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH • t rs ROCK DEPTH , LINEAR FT. 22"S OTHER CL'"j` REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 V �1^ i -�57i)" C e W !' i T C` IMPROVEMENT PERMIT LAYOUT FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 1-7 CA sm -es r-�l �sl�c T 12 ` r Q 12' c off' 1 ,IAV AUTHORIZATION NO. I vu �` OPERATION PERMIT BY: DATE: -7 1 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DE IBED ABOAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I,yOF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS BUT SHALL IN NO WAY BE TAKEN X GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ;VMD 02102 (Revised) 0 Geta �; t 7� IV kt`. FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 1-7 CA sm -es r-�l �sl�c T 12 ` r Q 12' c off' 1 ,IAV AUTHORIZATION NO. I vu �` OPERATION PERMIT BY: DATE: -7 1 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DE IBED ABOAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I,yOF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS BUT SHALL IN NO WAY BE TAKEN X GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ;VMD 02102 (Revised) 0 Geta �; t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation c NAME �4 I/ SP ADDRESS PROPOSED FACIILTY /1 /' // DATE EVALUATED PROPERTY SIZE.49G LOCATION OF SITE 0�r7 ' U fGUO dc-fcL.11_QAJ Water Supply: On -Site Well Community Public !i' Evaluation By: Auger Boring ;,/ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe %`.,Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t +� Texture group A/ G Consistence 1 r 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 i SITE CLASSIFICATION: EVALUATED 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 SC --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralog 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 K APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil / Site Evaluation PROPERTY INFORMATION Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit FACTORS 1 2 3 4 *Landscape sition Slope % HORIZON I DEPTH TPPhirP arnnn t,onsistence Structure Mineralogy HORIZON H DEPTH r Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Cut 5 6 7 iriiuc►aiv SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE MQiat VFR - Very friable FR - Friable FI.- Firm VFI - Very firm EFI - Extremely firm Set 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 DCHD 05105 (Revised) inty Health Department rental Health Section P.O. Box 848 210 Hospital Street Courier #: 09-40.06 ��locksville, NC 2I Phone: (336) - 751.8760 V Q 4 AJ l%}deq Fax: (336) - 751- 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING jo y..&WZ_,00� (Check One) Replacement Remodeling Reconnection W 700— g7L' q& q1 Name: Pcu�� CO X Phone Number 33(o %r G �-j O - 2_c, 89 (Home)? Mailing Address: IL11 L c%, Q.3i AQ- AC 334,131 1 - Z2-33 (Work) Detailed Directions To Site: -X-L4Q a -1-o RwU ZQ1 . 6o 46- mAe-5 470 C u C •• r Property Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: .yu Fl e 5 jk'sC'­S'r�C_k-" Type Of Facility: Date System Installed (Month/Date/Year): 19 rl Number Of Bedrooms:. Number Of People: Is The Facility Currently Vacant? Yes ED If Yes, For How Long? Any Known Problems? YesN�o If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: ioL61 ke e. Number Of Bedrooms: _Number of People_ Requested By: Date Requested:y� Z�l�ZQ For Environmental Health Office Use Only Approved Disapproved �n%�,,,� ' Comments: IAi�i`�-t�/L'i'�r Environmental Health .P *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. Payment: Cash Check , Money Order Paid By: Received By: Account #:__T4 Invoice #:_ LIE0