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151 Grassy Cove Trail' . ~ ' - U������ ���� .H �~�~^ COUNTY ^ ^^�^��^^^ DEPARTMENT / "o0. �0 ^ IMPROVEMENTS PERMIT AND ,CERTUFUdATE OF COMPLETION |nmumdipCompliance With Article UofG.S. Chipter130a -' \ Sanitary Sewage Systems ^ Nome Date � < wv/u -A^�. Subdivision Name Lot No. Sec. or Block No. Lot p/�e X House -_-___-_Mobile nmxe.-__`-_---Business _-____-_Speculation -___-___ No. Bedrooms .No. Baths No. in Family � Garbage Disposal YES uu / Specifications for System: [] NO Auto Dish Washer YES 0' NO[] Auto Wash YWo:h}ne YES NO Tvoa Water Supply *This permit Void ifsewage system described below io not installed within 5years from data of issue. This permit insubject torevocation ifsite plans orthein1endeduoaohange. -- permit by *Contact m representative o/ the Davie County Health Department for final inspection of this oyobam between 8:30- 9:30 A.M. or :3O'9:3OA.K4'or 1:00'1:30 P.M. on day of completion. Telephone Number 704'634'5985. _ . Final Installation Diagram: System Installed by . � � ' ' . c7 ' CedUficabmofCompletion Data "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth inthe above regulation,butmha||inNOwoybatakanooaQuaranteathadthenyotemwiUfunotion satisfactorily for any given period oftime. - ~ '� , ~ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section J� , P. O. Box 665 - I Mocksville, NC 27028 ` 1. Application/PermitBy=A1^1'� G - e!Y, ��� R(e�quested 1, Mailing Address �1 �+� � �t� 16—" ,0� e_-, Home Phone %0 4 ~ 4 Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: m House ❑ Business /❑l Industry 5. If house, mobile home: Subdivision No. of People No. of Bedrooms ❑ General Evaluation ❑ Mobile Home ❑ Other No. of Bathrooms — Dwelling Dimensions 3D X 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing l� Washing Machine Dishwasher ❑ Garbage Disposal No. of Showers Water Usage Figures 7. Type of water supply:] Public ❑ Private ❑ Community 8. Property Dimensionsl � )L `;? f t? Sewage Disposal Contractor ae 00 Ci,d 2!jS 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? '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. Effective October 1, 1989. Directions to Property: /-5 This is to certify that the information provided is correct to incurred from this application. DATE my knowledge, and responsible for all charges CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I OWN the property. ❑ 2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section \ Soil/Site Evaluation NAME _ Y., RN Wt"V -P'_ DATE EVALUATED - a ADDRESS S Ccs PROPERTY SIZE loo, a 0 I' PROPOSED FACIILTY o V SAL LOCATION OF SITE O�S Water Supply: On -Site Well Community Public 1� Evaluation By:Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position S S s ----5 Sloe % b- - s HORIZON I DEPTH " a '' I Texture group C' L L Consistence I T1 FT ip T_ Structure C Mineralogy '1 '1 HORIZON II DEPTH `D. h s r Texture groupC '. Consistence "- Structure pk Vk%'r IV,, MineralogyL; 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS SS RESTRICTIVE HORIZON- SAPROLITE — — CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: Q LONG-TERM ACCEPTANCE RATE: • REMARKS: DCHD(01-901 EVALUATED 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 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 ■■MEMEMEMEM■■ ■EMEMEMSEEM■■ ■ENEEMEM■■■M■ ■NEEMEM■■EM■■ ■EM■MEMMENNEE ■NM■NNOMMENN■ ■■■NNEM■M■NN■ ■OMEMEMEMEME■ ■■■0MEMEMEME■ ■NO■MU■MENN0■ ■ENN■■■MESSOM ■EMENEE■■OMM■ ■E■EMOMMEME■■ 4 Pi# °'£' }.s y <, J r� t2; 1 •�CY. N1 AUTHORIZATION NO: 1801 DAVIE LINTY HEALTH DEPARTMENT v Environmental Health Section PROPERTY INFORMATION Permittee-s P.O. Box 848 Name:+ ' Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to property:Section: Lot: AUTHORIZATION FOR WASTEWATER Tax O SYSTEM CONSTRUCTION Office PIN: ! . Road Name: Zip: d . **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 Officewhen applying for Building Pen-nits. (In compliance with Article .l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ` ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,I :� r ✓ f' IS VALID FOR A PERIOD OF FIVE YEARS. 9 ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED *'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: <r't *'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: �l tu 1 �y� APPLICAInON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ^ � Davie County Health Department Envlrwnmenlal fleaft SeWOJ7 J P.O. Bos 848/210 Hospital Street Mocksville, NC 27028 e (336)751-8760 ***DJP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. game to be Billed L-4, Contact Person Nailing Address �tj 1 'gcog /����! ,� Same Phone tS 'Y y 4 1 City/State/ZIP ,�S ,`l�?O !�/J�. Business Phon rA5W-'— 7:2 9-1/ 2. Name on Permit/ATC if Different than Above Nailing Address City/state/Zip 3. Application For: IA'Site Evaluation 0 improvement Permit/ATC 0 Both 4. system to service: a House 0 Mobile Home 0 Business 0 Industry 0 Other a. If Residence: # People # Bedrooms -3_ # Bathrooms 0 Dishwasher 0 Garbage Disposal J:~hing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # sinks # Commodes # shovers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: a-dounty/City 0 well 0 Comounity e. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes 0 No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: h9e WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tai O 0 d ffice P[N: x #1� %�� �13 ^ l�� �, 8 bo�� Property Address: Road Name City/Zip o? 70 0Z 7 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: 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 responsiblefor 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 to conduct all testing procedures as necessary to determine the site suitability. /////,�i�i% THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account Na Invoice No. '�)/+/ _, •;.� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME L`'y PROPOSED FACILITY l SUBDIVISION Water Supply: Evaluation By On -Site Well Community Auger Boring ✓ Pit DATE EVALUATED f��0 PROPERTY SIZE ROAD NAME Public 4---_J Cut FACTORS 1 2 3 4 5 6 7 Landscape position A G Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f Texture group 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 7 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 Sl - 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) - ■■■■M■■■ ■E■■■EM■ ■■■■■M■■ ■■■■■■■■ ■■■■■■M■ MEMO■■■■ ■■■■■■■■■ ■■■■MEMO■ ■■■■■■■■■ ■■■■M■■E■ ■■■■■■U■■ MEMO■■■■■ ■■■■■M■■■ ■■MENU■■■ ■■■■NM■■■ ■M■■■■M■■ ■■■■■■■■■ ■E■■■E■E■ ■■■■■■■E■ ■■■■■■M■■ ■■■■■■■■■ ■■■MOON■E ■■■■■E■■■ ■■■■■■■E■ ■■E■■E■■■ ■■■■■■■■■ ■■M■■MM■■ ■■NEEM■■■ ■■■■■■■N■ ■■■■■EMEME" ■EE■■M■■EMA ■■■■M■■■■EM ■■■■E■■■■i■ ■■■■■EM■■■■ ■ME■■NM■■E■ ■E■■■■■E■E■ ■U■■■■■M■■■ ■E■■■MM■■■■ ■M■■■■■M■■■ ■■■■■■■■■■■ ■■■■■NEE■■■ ■M■■EEE■■■■ ■M■■EM■■■E■ ■■■■M■■■■M■ ■M■■EEE■■■■ ■■■■■■■E■■■ ■■O■ ■E■■ MEMO MEMO NEON NEON NOOSE ■MM■■ ■■N■■ ■■■■■ ■ ■EMEMME■ ■■EM■ME■ i ■E■■■■■ ■M■■■■■ ■E■■■■■ i ■ ■■MME■■EMEMME■ ■■■■MMN■■■■■M■ ■E■■MEMOMM■MM■ ■■■E■■■M■■■■■■ ■■M■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■E■■■■■■■■■■■■ ■E■MM■■■■■M■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■M■■■■ ■■M■■EEE■■■■■■ ■■MM■M■■■■■■■■ ■M■■■■MS■■■■■■ ■UMU■■E■UME■M■ ■■■■■■■■M■■■■■ ■MM■■■M■M■M■■■ ■■■■■■■■■■■N■■ ■■■■■■■■■■M■■■ ■■■N■E■■ME■EU■ ■■E■■■■■■■■■■■ MEMO■■■■■■■■E■ ■■■■■■■■■■■■■■ ■E■UE■■■■■■M■■ ■E■■■■■■■■■■■■ ■■■M■■■■E■■■■■ ■■■U■■■EU■■■E■ ■■■■■■■MM■■■■■ ■E■U■EN■■■■E■■ ■■■E■■■M■E■■■■ ■■■M■■■■■■■E■■ ■■■■■■■■M■■■■■ ■■■EM■■■MM■M■■ ■ ■■■NNE■■■■■■■■■ ■M■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■M■■■■■■M■ ■■■■■■M■■■■■■■■ ■U■■■E■MN■■NE■■ ■■■■■■■E■■■M■■■ ■M■■MM■M■■■MMM■ ■MM■■■■■M■■M■■■ ■■M■MMM■■■E■■■■ ■■MM■■■■■M■■■■■ E■■■M■■EMM■M■E■ ■M■M■M■M■M■MM■■ ■■■■NM■■M■■M■■■ ■■■■■■■■M■■■M■■ ■■■M■■MM■■■M■M■ ■■■M■■■■■■M■■■■ ■MM■M■■■■MMM■M■ ■■■■M■M■M■■MMM■ ■■MMM■M■M■M■EE■ ■■■■M■M■■M■■■M■ ■M■MM■■■■MM■MM■ ■■■M■■■E■■■■■M■ qP DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT w� - NAMEy SCS 171,-,. 1/ f -S PHONE NUMBER11f #� �7� ism 7;79 ADDRESS ,/2vr- /tee r/'4 SUBDIVISION NAME SUBDIVISION LOT # DIRECTIONS TO SITE eircC 7L��✓1 O J s-1,,cc - an se, DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER SPECIFY PROBLEMS OCCURRING DATE REQUESTED INFORMATION TAKEN BY /2/V op to /741W'E' 4Qr600a-1 /OlJlGf�1 �`'eit /- 75- oGn `�' 'S'✓ �C�. CJ /I' �/� � liS7L / ✓J ter. <i� ��