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2657 Hwy 801NPhone: (336) - 753 - 6780 Davie County Health Department C E 1 V vironmental Health Section P.O. Box 848 UL 15 2011 210 Hospital Street' Courier #: 09-40-06 Mocksville. NC 27028 ON-SITE WASTEWATg1t�C-ERICATION (Check One) Replacement K Remodeling Reconnection Fax: (336) - 753-1680 Name: Phone Number 33(DQg q g l q 8 (Home) Mailing Address: K) & / 7 7, Ll (Work) nn o�, :,; e tQC a '?C>a g Detailed Directions To Site: 1 '' Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: h C CbveTypeOf Facility: Date System Installed (Month/Date/Year): ? 1 1p Number Of Bedrooms:__Number Of People: Is The Facility Currently Vacant? Yes (2N If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: P(,)61 Number Of Bedrooms: fj "N Number of People AJ A Pool Size: d O X 40 Garage Size: 4 J A--- ` Other: 1V I*::l Requested By: 1 Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Environmental Health Specialist` Date: —71 ?- I *The signing of this form by the Environmental Health Staff Min 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 # Amount:$ ZVU.QU Date: -/— /K—// Paid By: & rVlcl UA%'G Received By: Account #: 671- -S Invoice #: ' 7�d� •- ,. ,.. ,.. �,,. 's. -q.:. ... ,.: i.: ,�-h . , yr -r '4^ae...- wC .. �'. F, - .Y 'f7 sl S:.. r. r ... 4.: ;�� t r r - ..`. '. // DAVIE COUNTY HEALTH DEPARTMENT 'x IMPROVEMENT PERMIT and OPERATION PERMIT tri. (IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize 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 11 of G.S. Chapter 138A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME /7ie/D1/11 if& 4 1& PROPERTY ADDRESS � UEM / DATE �C1i!s-/9r IL LOCATION AY— (/�C_�OrS� � r.� A� /ivr DD �r'f le— SUBU1Vi51UN NHMt LUI NURUtK btL./15LULK NUMMK RESIDENTAL SPECIFICATION: BUILDING TYPE RC1 # BEDROOMS # BATHS # OCCUPANTS -Y GARBAGE DISPOSAL: Yes Nb COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE jtf!f REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /DIY GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ,1 LINEAR FT. 1pd OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: " >�U�� A191' A, !/,Gr1W ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE DANS OR THE INTENDED USE CHAFE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. r - 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 csr�r • I �-� -d Ds� I 661 AUTHORIZATION NO. ` RATI Aj '1 1� DATE 6 4 4 **THE ISSUANCE OF THIS OPERATION PERMIT SHAL IN T T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 " 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 10/95 a',y •:.N,� �1 .4 wi'�a yy� t; �� a +rG '" �7y(e .'� fs y>: y .r`t ^.,�"a. �rfr F . 5..... '� " _ `t+. ,:` j` Y t. r * . Davie:County Health Department ENV I �_ RONMENTAL.HEALTH SECTION s „s P.O. Box 665 Mocksville, N.C. 27028 ;F AUTHORIZATION FOR WASTEWATER SYSTEM tONSTRUCTIO! in compliance with Article 11 of 6:5 Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must'be•issued.,by the Davie County ,Envi`romental Health Section prior to issuance of any Building Permits. This Fore/Authorization Number should be presented to the Davie County Buildiq Inspections . Office when applying for Building Permits.***. �K AUTHORIZATION NUMBER NAME ,T DATE S = 95 N 0.i 9r WE ON IMPROVEMENT PERMIT (If different than above) SITE LOCATIO! ` r COMMENTS/CONDITIONS ON AUTHORIZATION`'TO CO15TRl1CT WASTEWATER SYSTEM ' **MICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FW A PERIOD OF FIVE (5) YEARS. ENYIRONNEAITAL HEALTH WgIALIST, DATE DCHD 10/95 :APPLICATION FOR SITE EVA UATIO PROV Davie County Health Department Environmental Hedlth Section/B P. O. o� 665 Mocksville, ; 27028 1. Application/Permit Requested By _ Mailing Address O 2. Name on Permit if Different than Above 3. Application for: �/; 4. System to Serve: us`e ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No. of People / 5M 013 [E 0 NOV 14 t T1-/-' r Home Phone / / U/ 7(� -C7-// /C - 70669 Business Phone 7b zZ/�79 7` 6 42(-) )/al Evalu tion i' q•8eptic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Other No. of Bedrooms No. of Bathrooms J f Dwelling Dimensions (0 Zl9 6. If business, industry, place of public assem y, other. Specify type No. of People Served No. of Sinks ❑ Unknown Section Lot # M-19-a'sement/Plumbing ❑ Basement/No Plumbing EP Washing Machine ishwasher a>` ❑ Garbage Disposal No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Publicrivate ❑ Community 8. Property Dimensions 5 GLS% Sewage Disposal Contractor 9.'Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes &Nd-- If yes, what type? t 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvement3 Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY INFORMATION Directions to Property: Tax Of f ic�i Road Name 1 c>& --7s • ��� -9- a-��� p t� Box # (if avail/able) �no City 111 1Ylj) I '�vrUle -I-o E C'-ro s5 kc;c c. h� e- 0 OLA a5 fi LJ -V -)a- ire, w t kbe o � �t� c�-1-, }� lQrhSe � a t � w ►z -c_ ►-L � a � Cpm o u 4- . -Tk o -4e s 4o Vri►/e(.VaiS 1 r nacfisv� 0.. p sf2c'--e 'S W W his is to certify that the information provided is correct to the best f my kno incurred from this application. A!) DATE amp edge, and I understand 1 am responsible for all SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DEESaCaRlB PROPERTY UVJ MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. 1 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 _A -I-Q ) 1-ky�AM*1 to conduct all testing procedures as necessary to determin said site's suitability f ground absorption sewage treatment and disposal system. 11-1�3' J ull DATE 91GNATURE DCHD (193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME /" 01 FZ 4/ ADDRESS PROPOSED FACIILTY !` ' DATE EVALUATED ey/y/oS PROPERTY SIZE /S ",7 e LOCATION OF SITE �D%%Ay,•r. Water Supply: On -Site Well �/ _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position F I Sloe % _V HORIZON I DEPTH e- 5pe o Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture groupG 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 71 T7 LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: /�J ✓ �'® �L` EVALUATED BY:� LONG-TERM ACCEPTANCE R TE: OTHER(S) PRESENT: REMARKS: �fl1CfL - /!l : i`� ! y✓ C� 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- V1�--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 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(01-901 ■■■.......e.e■■...e...e....e...■ ■...Mee.■.=■.■■■■.■■.■..■e..e■.■ ■■■■■■..■■...■■■■■■■■■.■..■■■...�N......e■Oe■eee■ ■■■■■■■■■■■■e■ iiiiiiiiiiiii'iSOMEONE iii ....■...■.■................�MMMM■M■M■M■M■M■MMe■=ONO■_■■.■■■■..moo . ■■■.■■■■■■■■M■■■e■■ee■■e■■■e■M.e.■■.■■MN■ ■■■ ■ ■■■.■.■■■■■■■■..■■■■■■■■■■.■■.■..■■■■■■■Ne■■■■■■■■.■■■■■■■■.■■.e■.■■..■■■■■■ee■s■■■e.s■■■■■e■e■.■■■■M■■■.■■■■■■■■■�■■■■■_ ■ MINN ■Iiii i■ on ■ ■■■■■■■M■■■■■■■■ ■■■■■■■■ ■■■■■■ ■ ■.■M■e■■ee■■■■■■■Me.ee■■e■.e■■■ ■■■■■■■N■..■■■■■■■■■■■■■■■■■■■■ ■■■.e......■■e........■■.e...■eee.■■■■■■■■■■■■■�.�■.■■■■H..■■N.■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii=i'�iiiiii=iiiiii■i°■■iii=i=iiiii=■� iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiieiii■iiiiiiiiiiiii°■ii�iiiiii■ii=°i.i ■■■..■.u...■■e.■■ee...■......■■ ■■e.■M■N�■■■M■■N■■■■■■■■■■=■N■ 11 ■......■........■.....■....■.■.■ ■. ..■■■ ■■ N■.■■e.■.....■■■. ■..■■■■■■■■■■■e■..■e.H■■■■e■■■M■■■e�1w■■e.■■■■ S■■■ ■■■■■■■Oe■■I ....................................ii��.......... 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All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the information. All information contained herein was created for the Davie County's Internal use. Davie County, Its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or Implied, in fact or in law, Including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnet/View.aspx?prid=1472688 9/22/2016