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196 Sonora Drive Lot 8HDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT .` IMIObEMENT PERMIT ` **MOTE** This improvement permit DOES NOVauthorize 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 it of G.S. Chapter 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME /�' PROPERTY ADDRESS c }10 Y' � M • DATE LOCATION .'f t/i9 .� �. /', i' 1q& 80 SUBDIVISION NAME LOT NUMBER SEC. /BLOC{ NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 0 BATHS r # OCCUPANTS GARBAGE DISPOSAL: Yes/,No.-"­- COMMERCIAL es/,Nom -COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY . DESIGN WASTEWATER FLOW (GPD) -.f'X G} NEW SITE R✓ ---PAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/.rC 7%) GAL. PUMP TANK GAL. TRENCH WIDTH 7,1 ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:WI :30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY **THE ISSUANCE OF THIS OPERATION PERMIIT SHALL INDICATE THAT THE SYSTEM;DESCRIBED ABOVE HAS BEEN INSTALLED IN COMMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 13OA, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE TMT THE SYSTEM WILL F1lMrTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME DCHI) 10/95 . t 74 Y 1: Application/Permit Mailing Address _ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 wMl Home Phone Business Phone .4�! 2, /&-a 2. Name on Permit if Different than Above t- 3. Application for: ❑ General Evaluation optic Tank Installation Permit 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly t' ❑ Business ❑ Induhtry0 Unknown home: v� D Section Lot # S0 5. If house, mobile Subdivision ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher' Z x Q Dwelling Dimensions Y' a ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type s. No. of People Served No. of Sinks. No. of Commodes No. of Urinals r No. of Lavatories No. of Water Coolers f No. of Showers Water Usage Figures t 7. Type of water supply:,ublic YPl�P ❑ Private ❑ Community I 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? ❑ No t 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. E ective October 1, 1989. PROPERTY INFORMATION REQUIRED: Directions to Property: F Tax Office PIN // Ju, Z Road Name Box # if available) f J Cit: Ila y p� This is to certify that the information provided is correct tri), �.pest of �owle �,Ierstand I am responsible for all charges incurred from tF s application. _ 7 DATE `— '--- MATURE CONSENT FOR SITE EVALUAT TO BE DONE ON ABOVE DESCRIBED PROPERTY UST CHECK ONE: I OWN the property. ❑ 2. 1 DO NOT OWN the property. rIand you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described operty located in Davie County and owned by conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment disposal system. DATE DCHD (1193) SIGNATURE DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/Site Evaluation / NAME �i% DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH f' Texture group Ci 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: • ' (7 EVALUATED BY: 1&Z_._1 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 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 3C --Single grain M -Massive CR -Crumb GR -Granular SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 1:1, 2:1, Mixed Notes ABK-Angular hlnrlev 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 with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 Davie County Health Department -W IENVIRONMENTAL HEALTH SECTION Z : ob P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 13OA, Wastewater Systems) ***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.*** NAME l/ DATE /�� AUTHORIZATION NUMBER No € 97 NAME ON IMPROVEMENT PERMIT _(If different than above) SITE LOCATION Od<! 1//� — D pl ^ �a COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION EOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.