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306 Livengood RdP4rrnittee's 4�, DAVIE COUNTY HEALTH DEPARTMENT t Name: �-"'�. Environmental Health Section PROPERTY INFORMATIONI P.O. Box 848 "p Directions to property: '"l �Q �Ll� Mocksville, NC 27028 Subdivision Name: In jLy v�� �;.J Phone #: 336-751-8760 1 Section: Lot: ! AUTHORIZATION FOR L,, I1.Ikrh.,aLi. WASTEWATER Tay C)ffir 1 AUTHORIZATION NO: ' tv Road Name:'�-�'� Zip: _77 7 LtA_,;, **NOTE** This Authorization for Wastewater System Construction MUST 13E 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. th Article I I of G.S. Ch pier 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIR NME A 1 SALT S CIALI DA ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE � # BEDROOMS # BATHS Z'"5" # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE )' n `` PE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ,z + LINEAR FT. / As stated In 15A NCA,C 18A.1969(5 ` OTHER nCe tp ed Syrtems may also bc? LiseU I�Sr � c�Jc iex p... a: �a FRS RESUIRED SjTf ,' MODIFICATIONS/CONDITIONS: _ '�= 1-,(,f - r- bal \/IF - :5Q% LL M FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT 1Z� \`, FA1 �1� SYSTEM INSTALLED BY: " Ul 1Z� tr 1 1p Lo AUTHORIZATION NO. 17 90&OPERATION PERMIT BY: ` ALL LINA -M 66 A�D ve,1130? "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBn8 AB0WHA"E WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) Ip/1/► Z � 5 -W b0771 I o CALLED IN CO LIANCE IN NO WAY BE TAKEN AS A .v-• "''= no-�;,{b 1 r '> .+.A t^w':'yn= s,-2.-' "t t .4 'c' '"` � � a. 1 ✓ fj 1'-'0.'+f / "- �� _ DAVIE COUNTY HEALTH DEPARTMENT11) LG �(( Name: Environmental Health Section PROPERTY INFORMATION C �� { P.O. Box 848 ''Directions to prgperty:.. c, I L 1 "" 1"" Mocksville, NC 27028 Subdivision Name: - - '1� tj:}' s:-.1 Phone #: 336-751-8760 Section: Lot: t - --, AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION - AUTHORIZATION NO: 002788 A Road Name �` ` _ ' L x`Zip:w - 7 **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. Chap& 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. TH PECIAGIS,,Y DATL ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE t I.A. BEDROOMS L4 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No ' COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE _ WPE WATER SUPPLY 141-1-- DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKGAL. TRENCH WIDTH ROCK DEPTH f LINEAR FT. "cI \/a OTHER TIONS/CONDITIONS: I1,JST�*-Lt� C;�iC,=mil �/`=�=�1 w`'' �'�lr��L✓���ll Ii.t \ I (� t A I 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: Il+ /� i� l k�I LLE -I 1 Llo AUTHORIZATION NO. _21 1 &OPERATION PERMIT BY: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBEDABOVE HAM WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEyN( PERIOJD OF TIME. DCHD 02/02 (Revised) IIs -Fp /WAM!�)2 To ( dVe:Ly 'TE/(p CALLED IN COM LANCE IN NO WAY BE TAKEN AS A J✓'y .',ter y ¢' , } DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I 'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a `S,anitary Sewage Systems t;r Permit Number Name ��^✓F�'�'i,� _ < ,, I i ,t �� Date N2 169 Location r �i/ - �r L J�T�'' .� r /, _/ rf ,r✓�i / rte. , .,c� _ �1' ,r "` di! rd Subdivision Name Lot No. Sec. or Block No. Lot Size _'�r �l'�— _ House — Mobile Home — Business Industry No. Bedrooms Baths Baths No. in Family_— Public Assembly Other Garbage Disposal YES ❑ NO Q'' Specifications for System: Auto Dish Washer YES 0 NO ❑ ' Auto Wash Ma^hine YES dJ NO ❑ J, Type Water Supply 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. ,r Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed Certificate of Completion __ Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. _ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI' Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By / / N"Y 0 , I ©O o Mailing Address -35-,3 ,,//nn-F,oAk B'1QY W o Home Phone -1 t o -9 7/ � ' S /93 i�✓f vl/ �-tC, , lc �1i�yo(o Business Phone 9t o, !l 6y" 9 9170 2. Name on Permit if Different than Above � / AF 3. Application for: d General Evaluation V(Septic�T(aank Installation Permit 4. System to Serve: ❑ House VMobile Home &1,44, ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section No. of People No. of Bedrooms 3 No. of Bathrooms d` Dwelling Dimensions 6 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 No. of Showers Water Usage Figures _ 7. Type of water supply: ❑ Public DV Private 8. Property Dimensions ez?% a, rJhe-0 Sewage Disposal Contractor Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing Washing Machine VDishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Cid No If yes, what type? ❑ Community '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: N FOkK Q I* e0A9 M4 , (a� - � 10Max T�r�U G T ftp TUw � !c ter ON b�1/EN� � 2D D aVA) TYE ©w� Eo 13Y .Cp 9 1-.S taP, 0 m Pk# Y This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from thplication.�� ((((,/►►'DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: V1. I 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 Count �Health Department to enter upon above described property located in Davie County and owned by lT7��il/ �. gt.a()x to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE 17 SIGNATURE DCHD (1/93) r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �IJ�DI G ADDRESS PROPOSED FACIILTY zW 12 DATE EVALUATED PROPERTY SIZEiq�! LOCATION OF SITE d/ ZeAbB_7e✓ r% / 'Water Supply: On -Site Well !/ _ Community Public Evaluation By: Auger Boring 1. Pit Cut FACTORS 1 1 2 3 4 Landscape position �. Slo e' % 1 44 HORIZON I DEPTH . Texture group - Consistence Structure Mineralogy- HORIZON II DEPTH f' Texture group Consistence Structure Mineralogy, HORIZON.III DEPTH Texture ' rou Consistence Structure Mineralogy. HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED 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 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- Vc.-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 watet' 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/f(2 DCHD(01-901 ■MS ■o■ ■ APPLICANT INFORMATION Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION On -Site Well../ Community Public Auger Boring' Pit Cut '5IIq ( -0 7 Landscape position ,Text re group Consistence HO2Z_ON II TH NUMAMM®R Texture _. roup r Consistence MOMEM'��aWE ®®®®I ENO Mineralogy �0010'600 "10, HORIZON III DEPTH Texture group Consistence Mineralogy HORIZON IV DEPTH Texture group Consistence ®®®®®®® SOIL E.®®®sa® IM,• LA VAO) { 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 SI - Silt SICL -. Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C -,Clay CONSTSTENCF MQ]St VFR Very friable FR,- Friable F1- Firm VFI - Very firm EFI - Extremely firm 3't 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 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 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ es■ase■■■■■■■■■■■■■■r�o■■■■■■■■■■■■s■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENi:iiieiiiiii MENNENMENNENiiiiiiiiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 4r 64, V !A J4, A .. ... . ... �z ioz pq MLM IM MCI S A