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304 Elmore Rdttee's,'iri tj DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property:. ��� ✓', r`> ; J`y. Mocksville, NC 27028 Subdivision Name: �f } i, 1, Phone #: 336-751-8760 ��. �� • Section: Lot: AUTHORIZATION NO. AUTHORIZATION FOR WASTEWATER Tax Office PIN*SYSTF,M CONSTRUCTION 2 169 A 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r f <` % 1•>-,%J ' ^Z IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _� # BEDROOMS —!�4 # BATHS a # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) /� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE" GAL. PUMP TANK GAL. TRENCH WIDTH S6 " ROCK DEPTH -0 ' LINEAR FT.;�i REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT o�d�� "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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: V" AUTHORIZATION NO. OPERATION PERMIT BY: DATE: //✓ v **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 02/02 (Revised) o 1109 A=U' #H' ' 05 -TON f. DAVIE COUNTY HEALTH DEPARTMENT +� Q�k` 4W.1 � Qy v Environmental Health Section PROPERTY INFORMATION r Permittee s`,a P.O. Box 848 .i Name: w 006" Mocksville NC 27028 Subdivision Name: Directions to property: �� �`� _ ��� Phone #: 704-634-8760 Section: Lot: _ AUTHORIZATION FOR WASTEWATER Tax Office PIN:#D" SYSTEM CONSTRUCTION Road Name:, !MoT-e-? . Zip: ; � Vim= **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 41 41 DAVIE COUNTY HEALTH DEPARTMENT 3 �� IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION •' ;-PU'itfee s Name: Subdivision Name: Directions to property:r Section: Lot:_ s•. IMPROVEMENT PERMIT Tay Offira PTN•ft.? Road **NOTE** This Improvement Permit DOES NOT authorize the constriction 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) r ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE + `•` ;: .- ��F' ' ' " s 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 rs X52 # BEDROOMS '-�- # BATHS '-)— # OCCUPANTS �_ GARBAGE DISPOSAL: Yes o COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE i SYSTEM SPECIFICATIONS: TANKS 6Q D GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH t i LINEAR FT.3aj 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 0 f LED BY: ' '�+ )r) M 1 y'�, 1 i v'�I��-Ila✓ G P�Oq ► tz I S � �D%'fl i 7 �LS Y,rl'7 SSS R-�GC.Y A`2-�Q LlOu_� e AUTHORIZATION NO. =1 �{— OPERATION PERMIT BY: ATE:FL "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED AB VE H 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 EVALUATIONAM[PROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 OCT 1 3 1907 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed / y,4 L H"fi is Mailing Address 34 FLm fz IZID ( ) City/State/Zip bCkSyILLE /,/G \ (J)%a ?I 2. Name on Permit/ATC/ if Different than Above W 00 p iI 1 L L Mailing Address 4,232 I QrnP.I 1 US 1:� Cl . 3. Application For: [vKsite Evaluation [ ] Improvement Per Contact Person NEA L- r p"p-R-1 S Home Phone '7v� V9-?- 734,/S 6K+�nlOm&) Business Phone01-9/6 769, -996o tv- : -�/3/,/ L6G PV M as City/State/Zip EG15t l3P1'ld Q 70 19 mit & ATC [l"Both 4. System to Serve: [vJ House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People_ # Bedrooms # Bathrooms a [vfDishwasher [ ) Garbage Disposal VWashing Machine [ ] Basement/Plumbing [ ] 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: M/ounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [. To If yes, what type? ra�.r.�acs �rr•��rlc�.���:�rr•r•�a PROPERTY INFORMATION REQUIRED: *** IMPORTANT **��TT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ri 3� acres WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # n 0 - 00 O - C) r, L Q t 00(-�' %, Property Address: Road I}Iame 1-t� l Obi✓ R l7 . l� t � Qm � ., O11 �aV 1 -P , C: h00 Cl c> -i z City/Zip 1,��(-'KSV I LL.E *-70aV -6 CLQ A OYl -Me- If in Subdivision provide information, as follows:1 P� . :: _ 7PA n1C rP Name: C7esn dr t 6Y1 h 1 Section: Lot #: l 1 n., _t.— t L n 0 A n 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 Count y Health Department to enter upon above described property located in Davie County and owned by C [� ( 660b 2 - 0 . 1 r f-lS to conduct all testing procedures as necessary to determine the site suitability. DATE 3 - 9 7 SIGNATURE Rah 1 n '-A n "' t--6 Revised DCHD (06-96) THIS AREA MAY 8E USED FOR DRAWING YOUR SITE PLAN: , - d-4 d�4- k -"Lw ' -b .� 1; DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME V4.3_ \\Xclz� DATE EVALUATED b " 0 - 91 PROPOSED FACILITY PROPERTY SIZE •� 3 15.bO� SUBDIVISION ROAD NAME Water Supply: On -Site Well / Community Public Evaluation By:Auger Boring V Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position S Sloe % �JS HORIZON I DEPTH " Texture group 0 LC L Consistence - Tyr Structure Mineralogy HORIZON II DEPTH 14 Y Texture Eroup Consistence V -I F T Structure (3IV $ k Mineralo 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 '3 SITE CLASSIFICATION:_ LONG-TERM ACCEPTANCE RATE: REMARKS:yr)ly " \ END Landscaue Position EVALUATION BY: \'5?� 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 DCHD (01-90) NOMMEN■■■■■ ■E■■M■■■E■■ ■■■■m■■■■■■ ■N■■M■■MM■■ ■■■ME■■EM■■ ■NOMM■■■MM■ ■■■ME■■EE■■ ■E■E■M■■EM■ ■E■■M■■EE■■ ■■■■■NNEM■■ ■■■■■M■■■■■ ■E■■■M■■EM■ ■E■■■M■■■E■ ■EMM■E■■ME■ ■E■■■M■NM■■ ■E■■■E■■E■■ ■E■■■O■■■E■ ■■M■■MEN■E■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ UEEMMEMMENNENSENSE ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■Ori ■■N■■ SEMEN MOOR■ SOMME MOOR■ ■■■■■ ■■R■■ NEER NEON NONE NONE NONE SOON NONE MERE ■■E■ MEMO MEMO SEEN NONE ■■■■ ■■M■ moos MOON SEEM ■N■■ NONE NONE SEEN EWER ■■II■■■ ■■I!■■■ ■■I!■■■ ■■i!■■■ ■■■■■■ ■■EMM■ ■MEM■■ ■EM■M■ ■■EM■■ ■EMN■■ ■EM■■■ ■E■■N■ ■MMEM■ ■N■■■■ ■■■E■■ ■■E■■■ MEN ■■■■MEMSNN■■■EM ■MMEME■Emom■omm ■■■■MOM■1!■M■■!1■ ■NEE■E■OMMENNE■ ■■MMM■■■I!■■E■E■ ■E■■■SEEEEM■■S■ ■■M■E■EME■■■■■E ■■M■■■■E■MEM■■M ■EMEMM■■■■■■■■M ■■■■■■MENEME■■N ■MMMMM■E■MMM■M■ ■■EMM■■■INSE■■EM NOON■!1 ■■■!I■ ■■■N■■SlIM■■SSS■ NOON■■■!1R■■■■N■ NOON■■■D■■■■M■■ ■■■■■■■ISE■O■■O■ ■■MMM■■11■■■■■■■ ■■■■■■Eli■EE■■■■ ■■■■■■■■■■■■■■■ ■■MM■M■ ■■E■E■■ ■■■■■■■ "ME ■■■■ ■■E■ ■■E■ ■■M■ ■■M■ ■■M■ ■■M■ ■■M■ ■■E■ ■■■■ NONE ■E■■ NONE ■E■■ ■O■■ ■O■■ MEMO MEMO DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME --k- PHONE NUMBER ADDRESS a SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93