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523 Boxwood Church Rd. �. _ � � ;�:. , ,. : .. , ..:,,,_ , ;,.;: v ic b: - , , . .., : . .. ...., o . � . �F� . . ._ -. - � ` - ' . . .. . " , � .. _''� XO'i .� .� . , �. .. ; . . .. �. ., Y� I Au'rHORizA'riolv No: O$ � 3 DAVIE COUNTY HEALTH DEPARTMENT sW A �� r,- ' Environmental Health Section PROPERTY INFORMATION Permittee's ` ---�-� P.O. Box 848 O� �� Name: ,,��,�,4�—�'J✓� _.rJOJy'�S Mocksville, NC 27028 Subdivision Name: '7-�S-�J7 ' �� ' � ^ �' / Phone #: 704-634-8760 ��� .�, Directions to property: .: ����',�.U�^G'�/ � �' �' " � Section: Lot: AUTHORIZATION FOR / �j WASTEWATER Tax Office PIN:# r'�'� ��",U' -�� � d SYSTEM CONSTRUCTION Road Name:���CriDc�;-l_ %��1 • l�p;� `°� � {�v�s'� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pemuts. " '(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) , J � `� , � �,,'� � ***NOTICE**:x THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' " j�r.�� y J.f��:=�=� �'`'i �` '' '%"i' IS VALID FOR A PERIOD OF FIVE YEARS. . ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED �y .._. ,,. , „' _. ; . .. ,� �. •,: ,�r � �t.t ; r � .- .. „ . .. � P�� ; -� , . _ . ._. . , :' �, ,. � � j �. ,� -0_� � S�`� � DAVIE , COUNTY HEALTH DEPARTMENT ,,� ��- l f -' '-� �.��.�; .� " I M P R O V E M E N T A N D O P E R A T I O N P E R M I T S P R O P E R T Y I N F O R M A T I O N � j J,�; E! Pernuttee's'� "� '� � ;� Name �' ��" �l`��� ...-f.' r�y�?�� � ` 1; ' Directions to,property: r� ; af� �'F! Subdivision Name: ''�-?y'-�� Section: Lot: " ��A IlVIPROVEMENT �..� r-: ,.� !, : �, : ..1. ';, PERNIIT Ta�c Office PIN:# : ' /' � "' : �.. �' - i � � , Road Name �� •� f �(f - r�� f 1 �. �, P: � **NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMTf IS SUBJECT TO REVOCATION IF SITE s ,,; . , , ; ,� ,, , ' , j <;, -. PLANS OR Tf� INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �Q,1L,� # BEDROOMS �,_ # BATHS �� # OCCUPANTS _L GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY Tl'PE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE l TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) -� ��i �'} NEW SITE /,�/ REPAIIZ SITE SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK GAL. TRENCH WIDTH ,� l� ROCK DEPTH �� LINEAR FT. � OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMTf 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: � i� . �� �� � � ab� r AUTHORIZATION NO. c/ v OPERATION PERMIT BY: � DATE: �I � , **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 OS/96 (Revised) ' ,, APPLICATION FOR SITE EVALUATION/IMPROVEMENT � � Davie County Health Department w Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 [�'I� ��A�I'�� ,r � � �'�i��..� �-,.� , ; ��"' ��� APR 2 I 1997 � ' i .- ****IMPORTANT�*** THIS APPLICATION CANNOT BE PROCESSED UNLE5S ALL THE REQUIRED INFORMATION IS PROVIDED. � . 1. Name to be Billed ' � Contact Person E'� �- � '� 9� Mailing Address � Home Phone City/State/Zip�J��'�SrI�T�� ���� ��l "'�,� Business Phone �d � 1-- l 0�-- (D L��s - 2. Name on PermibATC if Different than Above Mailing Address 3. Application For: [] Site Evaluation City/State/Zip [ ] Improvement Permit & ATC [�oth 4. System to Serve: [] House [] Mobile Home [] Business [] Industry [] Other 5. If Residence: # People� # Bedrooms� # Bathrooms� [�Dishwasher [� Garbage Disposal [/] Washing Machine [] Basement/f'lumbing [] 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: [�unty/City [] Well [ J Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes �].No If yes, what type? E I Tt1E1Z tL YLtIT OR S Z TE 1'L�IN PROPERTY IN ORMATION REQUIRED: *** IMPORTANT *** �r".�`I:�ffiT�OF THE PROPERTY MUST BE �ho�� r�C�d-�� �i�l�° j hom�L/�t,�21"'�� SUBMITTEDWITH SAPPLICATION. Property Dimensions: -' aC-�-�- � r W� DIRECTIONS (from�cksville TO PROI � �' -� �� 'aac Office PIN: #� - � � - ��7 l �� � _._�`1��._,_/�2�/��� — /U�dJ '� � Property Address: Road Name z�c�x- �0d� �Vl • t��- � �%r� � �l � tt>C�_!C� � k � City/Zip � %�o� 0 � t If in Subdivision provide information, as follows: � � Name: � � � � _ Section: Lot #: ; U -5 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 chazges 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 e E. �` e 1 la.. � DATE � T � ��' � � SIG: Revised DCHD (06-96) to co�ct all � THZS ttREA �1t1� $E USEb �OL� bltAIVZNC �OU1Z SZTE YLAN: �.�- I �.- E�� �.`.�,-c��� � to determine the site suitability. �... , .. . . ,.. _ �t. � _ . � ry. . , „ : . . 4 , � . . ' . ' ' . �.�5 5 7 � � .. 1J. .. . / 3 a{ � , `' 1 � . . . . .. � . ' ' Y f . �� `;..., . . � . . . .. . . ;.'4�. .. . . . ��'<�DO n \ �: , � . � . . ' F � ��� j � i`':,� � h � t:�� �� . . � � \ i �:h ,��o �I Z y\ O�'� �\ � s. t� ��{ r ': ! Q $ � M T� r a a a y 'V< . � OINIOD ry' . . � } 6 .V b� y..- ��� � + .M (n \." 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' � . . , ' � '} ` � A�l ���: r � R1 $1 I . . .. �. I �, �i `�,' { t r * i•. F ���I . . � . i ti� .. I t � � � �� ' s i� �� � � � a ' � tt��' . I � � � � ' r ' t t �I_ . . . My: I , i. I � . . . . . . . . . . . . I I � . . :� , ,. � . � : � �. .�. ,. • . .- �.. � ... ..:..' ,,r_i� . . . � � r , . .. . � ..: r.- �y:: �...,... _.--� Ir is 0 � • DAVIE COUNTY HEALTH DEPARTMENT �• w -� Environmental Health Section SECTION LOT SoiUSite Evaluation --.�-{--� / APPLICANT'S NAME �l D/U�S DATE EVALUATED �< �% � PROPOSED FACILITY �%%� PROPERTY SIZE � SUBDIVISION ROAD NAME ��iYl�/'G� �� Water Supply: Evaluation By: FACTORS Landscape position Slope % 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 On-Site Well Community Auger Boring E� Pit SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 1 L SITE CLASSIFICATION: �S LONG-TERM ACCEPTANCE RATE: � REMARKS: DCHD (01-90) � � 2 0 Public v Cut 3 4 5 6 7 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineralo�v 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 - gallday/ft2 ■ ■ ■■■�■ ■■��■ ■■��■ ■■��■ ■�■■■■■■���■�■��■■�■■■���■■�■■■■■■����■���■■� ■■■■���■■■■■�■��■■■■�■■��■�����■■�■■■�������� ■■��■��■��■■����■■■■■■���■��■�■■■�■■��■■■■■■� ■���■■�■��������■�■■�■■�■����������■■■������� ■■■■■■■■■�■�■���■�■■�■■■■■�■■�■���■�■■�■�■��� ■�■�■�■���■�■��■��■■��■■■��■■�■��■■��■��i■�■� ■■�■���■■■■�■�■■��■����■���■■�■■ ■��■�■■��■� ■■���■�■�■��■�■■�■■���■■■�■■■■■�����■��■■�■� ■■�■■■■�������■■�■■■■■��������■■■■■■■■����■�� ■��■�■��������■��■��■■■■■■■��■��■■�■■�■�■■■�� ■■■����■■■■■��■��■��■�■■�■■����■■��■■�■������ ■■■■�■■�■��■�■��■■����■��■�■■■■■■��■��■■■■■�� ■������■���■�■��■■i��■■■■■■����■��■■�■�■�■��� ■■■■��■■■■■■�■��■��■�■■�■■��■�■■��■■�■�����■� ■■�■■��■��■■■■■■��������■■■■■�■■ ■��■�■■■■■� ■�■����■��■■■������■■■��■���■�■��■�■■������� ■�■�■��■�����■■■■��■����■■■■■■■■■■■���������� ■■■■■■■■��■�■��■��■■���■■���!=������i���■���� ■�■����■■■■�■��■�����C�i���■��■��■��■��■���■� ■■��■�■��■��■�■■�■■�■�1����■�■■■�■■�■������■■� ■■��■■■�■■�■�■■��■��■■11��■■��■�■■��■■�■■�■��� ■��■�■�������■■�■■■■■�11��■■���■■■�■■�■���■��� �i������������������11������������������1 ■������■■�■�■��■��■���11■■�■■��■��■■�■��■■��■11 ■■■�■�■���■�■�■■�■■■��11���■■■■■�■■����■■■■■�� ■�■�■�■■�■����■��■■�■�I�■�/!!== ::���:iiiiiiii�■ ■��■�■���■��■■■��■����`i��■■��■�����■■■■����■■ ■■���■������■�■�■■�■■■�������■■■■��■■����■■■■ ■����■■■■■������■���■■■��■������ii�I■���■�■��� ■��■��t�■■■■�■�����■�■■�■■������r-■■�■�����■■ ■������■■■■■■��■��■■���■■��■■�■i�■����■■�■■■ ■�■����■��■�■■■■��■����■■�■■��■��■■��■■■■���■ ■■■■■�■■��■�■�����■�■■■■■�■■��■��■��■■�■��■�■ ■■■�■�■�■�■�■��■■■■�■��■��■■�■■■■■��■■■■■■■■■ ■�■���■�■�■S��■■�■��■��■��■��■��■��■■�■��■��■ ■��������■��■■■��■���■■■�■�����■■�■■��■��■■■■ ■�■ ■■■ ■�■ ■��■ ■��■ ■�■■ ■�■■ ■■■■ ■�■ ■■■ ■�■ ■■■ ■�■ ■���■ ■■■■■ ■���■ ■■ ■■ ■�����■■ ■��■■■�■ ■�■��■�■ ■■■�■��■ ■��■■■�■ ■■���■■■ ■■�����■ ■�■■■��■ ■■■■■�■■ ■��■��■■ ■��■■■■■ ■�����■ ■■����■ ■��■■■■ ■�■■��■ ■��■■■■ ■��■��■ ■��■�■■ ��■■ ���■ ■■�■ ■■�■ ■��■ ■��■