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1451 Milling Rd (2)Permittee's,f` % DAME COUNTY HEALTH DEPARTMENT 1 /� Name: `fir '� ''� ==t`�' ` . r �'�%::!" Environmental Health Section PROPERTY INFORM v P.O. Box 848 Directions to property: r t- .%} a' f ` Mocksville, NC 27028 Subdivision Name: t Phone #: 336-751-8760 ✓r �'r c. t' r ;''. !`�� Section: AUTHORIZATION NO: 002"M5 A Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION ll16-1 A11t'W Road Name: ✓ ,Cf�p: Q7i� **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 I 1 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 RESIDENTIAL SPECIFICATION: BUILDING TYPE�� # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ---� r6ESIGN WASTEWATER FLOW (GPD) 6 ? if NEW SITE REPAIR SITE - L111- SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHL?(, ROCK DEPTH LINEAR Fr 9 �•.5 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT s k 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 SYSTEM INSTALLED BY: 64 4 E : AUTHORIZATION NO. C'. • OPERATION PERMIT BY: % / f 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 02/02 (Revised) 41 Permictee= ; .' i� �DAVIE COUNTY HEALTH DEPARTMENT y Name: ` Environmental Health Section PROPERTY INFORM�•I�10 P.O. Box 848 I Directions _tii`propeity:,., i hlocksville, NC 17028 Subdivision Name: Phone #: 336-751-8760 �'�' • '" AUTHORIZATION FOR Section: Lot: WASTEWATER Tax Office PIN:# M SYSTEM CONSTRUCTION- - ^ AUTHORIZATION NO: 0 0 2 5 A Road Name: 9 %�' f1(r Vr �(p; 210& **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) f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION t rX ' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _4 # BEDROOMS # BATHS ? # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT f # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY,_ [F /)SIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH t_ 1 ROCK DEPTH ,, /) LINEAR FT. . OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: " IMPROVEMENT PERMIT LAYOUT f s k� i 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 f Ij SYSTEM INSTALLED BY: `#tel .1 1( AUTHORIZATION NO OPERATION PERMIT BY: / i' DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 07/02 (Revised) — — APPLICANT INFORMATION Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Community PROPERTY INFORMATION Public Evaluation By: Auger Boring • Pit 1/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure MincralogX HORIZON II DEPTH Texture group Consistence Structure MineralogX HORIZON III DEPTH Texture group Consistence Structure MineralogX HORIZON IV DEPTH Texture group Consistence Structure MineralogX SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: I OTHER(S) PRESENT: REMARKS: ate` 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 .w NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VI3 - Very plastic ' r ct re 'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prisipatic 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 DCHP 05/99 (Revised) .� . ...�..�.................�_.....................�...�.... ... .. ................. ............................. ■�������������������■ ■�������e��������������������■ �. ��:�:::C:::::::::::::�:�:::C::::::::C::C::::::::CC:::: .. � .�.�.................................................... .6 .. . .................................................... .. .......................................................... .. � ��CC...................................................... ... ...................................................... ... ...................... . ........................o..... ��� ■�■ �������������������������i���������eo������������������■ ■■ ■ ■�����������������������i����������������������������� ��■ ■■ ■ ■■ ■����������������t����������������t��t����������������■ . .. .C..�......................�............................. � . .... ...................................�................ ........................................ ................ . ............ .......................... .......�...... �C�■.........■■C.........�...............�■.........�..■ ■ ■ ...■....■.■......... ....■................... . ... . .■.C.........■........■.......■■■...■■..■..■ ■■..■�■.■■■ _�'�:: :'::::::::::::::::::::::::::C::::::::::�::::::::':: .C...�.0.......................... ............ ......��.. . ::C'�C:::::::::CC:::C::C:CC:::::CC=::CC::CCC:::SCC:CC::::: ..�C.....................�...................... ........ 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SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193