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P1205 Michaels RdAUTHORIZATION NO: 1205 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Perl i'ttee's/ I P.O. Box 848 Name: —F',e" e �,+3a ..._,� Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to prop: ��� f C w Section: Lot: AUTHORIZATION FOR WASTEWATER d� f �/ ' Tax Office PIN:#5/1 < <? _ ej SYlSTET CONSTRUCTION %t�/ , ` `i' i /i Road Name: -� ,�.? �' r'Zlp: ���► ©i **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 a 1205 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pe ttee s /j��/ ,✓,! Name ek :- t -n Directions to property: Subdivision Name: Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# f Road Name s !�// . xf G: �'' ip: **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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE 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 h2IS'- # BEDROOMS -T # BATHS 2— # OCCUPANTS _,2 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No �C LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)eONEW SITE 4�� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 1406 GAL. PUMP TANK GAL. TRENCH WIDTH a ROCK DEPTH 1.:� LINEAR FT. REQUIRED. SITE MODIFICATIONS/CONDITIONS: "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. F IP OPERATION PERMIT SYSTEM INSTALLED BY: i AUTHORIZATION NO. �6 S OPERATION PERMIT BY: y DATE: "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 05/96 (Revised) V.9,S) f �' tI ,, f �Qt9� l .,-APPLICATION FOR SITE EVA LUATIONAMPROVEMENT PERMIT& i `� ` Davie County Health Department L5 C .� Environmental Health Section D P. O. Box 848 FEB Mocksville, NC 27028 L! �✓� (704) 634-8760 1. EVE 3. ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED NL -E8 ALL THE REQUIRED REQUIRED INFORMATION IS PROVIDED. Name to be Billed Qf'p, �p f tt �a� Contact Person D Mailing Address V ��� Home Phone City/State/Zip eool�emee, ' , c�-10 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: ❑'bishwasher 6. If Business/Other: # Commodes If Foodservice: 7. Type of water supply ❑ Site Evaluati4bile n ❑ House Home # People City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms Lr Both ❑ Other # Bathrooms ❑ Garbage Disposal C�- Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type # People # Sinks # Showers # Urinals # Water Coolers # Seats C V County/City Estimated Water Usage (gallons per day) ❑ Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Ye s Zed PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �VWRITE DIRECTIONS (from �� , t 60-70 Mocksville) TO PROPERTY: Tax Office PIN: # � (�' - - O' S �aa"e'B � Property Address: Road Name V11 1 dy `� oYt City/Zip awl U l�l.(� , IV If in Subdivision provide information, as follows: 1 fT%1 i' Name: Section: Lot #: 1 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 County Health Department to enter upon above described property located in Davie County and owned by koo� `�� rKa.o to conduct all testing procedures as necessary to determine the site suitability. DATE ) —Z(O —R15 SIGNATURE Revised DCHD (06-96) k I/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE s'O t%Q, SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit ROAD NAME 9&" Z Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L ,L Sloe % •t - HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �� 3 Texture groupL 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 SITE CLASSIFICATION: K /0/ir LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) EVALUATION BY: 1i 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 ■E■■E■■■■■■■■M■ ■E■ME■■ME■M■■M■ ■E■EME■M■MME■■■ ■EMME■■E■■■■■E■ ■E■MEMMEMME■M■■ ■MME■■M■■EMEME■ ■■ME■■■■■EMEME■ ■■ME■■■■■E■EME■ ■■E■■ME■ME■ME■■ ■■M■■M■■■■■■■M■ ■■EMEME■E■E■■■■ ■■E■■EM■M■■EMEM ■■E■M■■E■■MEAM■ ■■■M■MMMMMM[WM■ ■E■■E■■EE■E■■■■ ■E■■■■■M■■■NMER ■■■MEMMEMMEMME■ ■■■■■UMEMEMEIH1 ■■■■■ ■■■■■■ ■■■■■■E■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■N■■■■■■■■■■■■ ■NNN■■■■■■■■■■■ ■■■■E■■■■■M■■■■ ■■N■■■■■■WM■■■ ■■■■■■■■■Rmumm. ■■■■■■■■■■■NM■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■E■ ■■■■■■■■■■■■E■■ ■■■■■EE■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■E■E■E■ME■■ ■■M■E■ME■ME■E■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■EMEMEMMEMEMEM■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■MMEMEMEMME■ ■E■ME■E■■■■■■■■ ■EENAMEMEN■■■■■ ■■■■HEMEM■M■ME■ ■M■■HE■E■■■■■■■ ■E■■11■■■■■MM■■" ■■■■I/■MEMEMEMEW ■EMMIA■EM■■■E■■■ ■■■■I■■■■R■■■M■■ ■■■■INMERNEMOMM■ ■E■■INEREME■EMI ■■■■11■ M■■■■■ ■E■■It■■■■■M■■■■ ■■■■It■■■■■■■■■■ ■■■■11■■■■■■■■■■ ■■■■It■■■■■■■■■■ ■■■■It■■■■■■■■■■ ■■■■It■■■■■■■■■■ ■■■■11■■■■■■■■■■ ■...r■■■■■■■■■■ EMENNE■■■■■■■■■ NOME ■■M■ MEMO ■■■■ ■■■■