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226 Morrison Rd
a •�#•-', DAVIE COUNTY HEALTH DEPARTMENT p IMPROVEMENT PERMIT and OPERATION PERMIT I IMPROVEMENT PERMIT y `I*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) k. Y 1. 0r.r150-)` A 1 ' lti NAME � h�- J• �.?,J \ �P ' =-, ;�"��;d. '�t4��`�`,t DATE RR LOCATION SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE AVotcca # BEDROOMS # BATHS i # OCCUPANTS GARBAGE DISPOSAL.: Yesivo COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY W DESIGN WASTEWATER FLOW (GPD) �:�7D NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 660 ► �: , GAL. PUMP TANK 6A1.. TRENCH WIDTH ROCK DEPTH �-� , . LINEAR FT. 00 . OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: r ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEWCONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. F f f Oy 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:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE #.IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY i, • `3r AUTHORIZATION NO. 0 © OPERATION PERMIT BY �� 'a�..2_ DATE �- r **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICAlt-THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPL.IANCE WITH ARTICLE 11 OF G.S. CHAPTER 136A, SECTION .1900 'SEWAGE TREATMENT AND DISPOSAL SYSTEM', 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 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 � �• v Nocksville, N.C. 27028 AUTHDRIZATIO! FOR WASTEWATER SYSTEM CONSTRUCTIO (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) 4 tea. ***This Authorization For Wastewater System Construction oust 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 Inspectionst Office when applying for Building Permits.*** NAME G W\` \ `c�S DATE 1 D ' 0 — R lj� AUTHORIZATION MAER =J015 NAME ON IMPRDVEMEMT PERMIT (If different than above) „~ SITE LOCATION o N a CWWS/CO DITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **+NOTICE+*+ THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. _ ENVIR S&UALTH SPECIALIST L HEALIST '':DATE ' DCHD 10/;95 RR , APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM D 8 Davie County Health Departme Environmental Health Section SEP 2 1 P. O. Box 665 J)1 ` Mocksville, NC 27028 h 0 C3 ENVIRUAVIE COMM 1. Application/Permit Requested By Z S L (iOLRx: 1 l Mailing Address� � R�rJla�- R�• d Home Phon (704 94Q,- 2-3 L 3 Business Phone 2. Name on Permit if Different than Above -- JJ 3. Application for: El General Evaluation @rS(eptic Tank Installation Permit 4. System to Serve: ❑ House VMobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision 12 c-1 J Cy Ca, av�� Section Lot # ❑ Basement/Plumbing No. of People ❑❑ Basement/No Plumbing No. of Bedrooms 3 (?'gashing Machine No. of Bathrooms v ❑ Dishwasher Dwelling Dimensions to S+ r �Z� ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public L�Private ❑ Community 8. Property Dimensions r at c T'e- Sewage Disposal Contractor 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: tJest io R j e� AciJ o A J e 4 ( 5 on �o�'tt'fso►� �a fr�vw e .0 10 a \ + vv- "J wI to 4k-'t- e-r-A 1 1 O'� 0;ti� b a, ;,n t fie C o W 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 this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Ltd 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 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(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section \ , , Soil/Site Evaluation NAME S W DATE EVALUATED ADDRESS �A'R'�p PROPERTY SIZE PROPOSED FACULTY �� ���`�� LOCATION OF SITE, Water Supply: On-Site Well _ Community Public Evaluation B�M� Auger Boring Pit Cyt FACTORS 1 2 3 4 Landscape position Sloe _1b HORIZON I DEPTH Texture group e L kZ,L Consistence Structure - MineralogX ' \ HORIZON II DEPTH 1 Texture group l Consistence Z Structure F3 Mineralogy ! HORIZON III DEPTH Texture rou Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S RESTRICTIVE HORIZON ---s SAPROLITE CLASSIFICATION ,S ,S . LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ,'- EVALUATED BY: Sia LONG-TERM ACCEPTANCE RATE: o •� 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-V----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 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(01-901 j Mi.■....■ ■....■.■■■....■.■■....■MM■■..■ MOSS■ ■....■M.MOMO■■M.SMSM■■■...■ ■..■.■.■ ■MH■■.■.■.■■.■.■ ■■■O.E.■■■■...■t■..■■..l�l: ■..H...■.....t■■■■..............■SOME■.■ MMMEMM■MEMEMEMM■MCM■■■.. ■■.......■..OMMI�.�rM...■ ■..■.■■M...�!iA1M.SO..M■■■■MOM■■■■S■■■ moommoommoss ■■■.■.M■■■ ....■■■MIM ■...t-• .--------- ..■O...M.../��iA\'�.�L`■■t■M...O■■MOMMMtMOS■ ■■■■■■■Mt.■■■t1■Mt.■■OHE..■��.t1►MEE..t■E ■t■■..■Il■.■�E'A/.��I.E■.M.M.■M.■MMM..MEMM.M■M■ ■■■■■■■OM■ ■.O�O.monsoon OC%G■OSI.■ �!i1■.■ ILIO■O■.O..I�.....,Si!!'/�.....ME.t....■M.MM..MM.M■ ■ENEM.M;Mm ■■l ■■.■■■■■/%.■■■Oil.■ // .../i�lr7!!! !■■tl�...■/i��.t.t...■■■..OMMEMIRNEMEME■■ ■...M■■■ ■■■■■ ■O.■■■■/�%■■.■O■�! ■ ■ // OJ9li■f%LI101■OI���.��0!\�.��iii�� 7 %c�lil=Mimi ■.■■.■..ME■■■.■�M.■■O�E■n■■■■■!�■�■ ■�.■.O..M..E.i..� 1■/u!C---- ............... ........... ....... ■■■■■■....■.E....iir.MO■...M.OM..�itV�l',I I!i'f.�l\JO.■tM■ ,ter ■OE.M.E.■ ■..■11/x..■■.■.■ ■■/1RRENINE MUN. ��iie�iiiii�ii�%#������.�����������%1®�1% li�lLl����SMO■ ■EMES.■■ ■E■C / � %■■■ ■.NONE�C .■ ■■E.■■■■■i+���omm ■M.■.■.■■..M■M■■MME►/M1IM'EME.%MMEMEME■ .■OEM■E.C./MOOD■O .■■M■■�G■ME■li ■OE■■■.■l� M■■E■�......■.M.■MMM....MM.11�lM��.EMM..OM■ ■M.■..M■GaEt■■■■■■.■■■R%G■■MEN ■ ■.■.■■■Mu.M.M■■■■.■.■■■■.M■■E■■■■.//.O/IMMi�■■■■■.■MM■ ■.■ ►. ■■■ %■!.O!'!t►.��0■■/I■.■■■■O.i■ ■O■■■.■OO.S.■.O■...■■■■■.0O.O■■■M■r1■MIIM■MM■■M■t■■MM■ ■■■■■►■E■111111!!]■■r\S■►a.O.E■O■.■■■�O■■■■■■.■.E■■■..■ ■■■■■ ■■■■M■M■M.MM.UMM■■M■M■M■t■■■ ■O.OM.EE.II�s1u MEMS■%■■ Oman O..■ ■M■n■■■■■OE■MEM■. ■■.O■ .M■/■■MOMMO■.IA"MME■MEMEMM■M■ /M- ■ %MEEM■MME.■■omE.■■mi■■■■■■■- 0 ■No ONES iMOE � M■■.Et...■//MM■■■■ ■..■.■■ ■ M.■ ■ ■ .MESON M.■t.t.EME:�/IMM/S�IMl1/HMSMM■S■MMOME■ ■.■■M■M..■.EO/O■Et.■.■■.■.■.■■■■■M M■■■in ■ ■■........0/!'�c�1MEMM►�/■■rl.i9■EMM■.■■■.MM■ ■■■■■.■ME...Ci ■■■ ■■■ ■.■■■.■■■.■�■.■■■■.■■�■■.......■MMI!?�.■!E//11/,MOMS'/■MEMO.MOMt■.SM■ ■OM■.■■■■.pOO.�■EMESE■�■■■.■■■■■.■ ONE....■■■.■■■■..■.■'/I:lFARM`momaJ■l,..Ht■SEms O..SO■ ■■.■■■■OO/./■■■■.■■■■.■■ ■■■■■■■n■�OMEN■..■......■■■■■■■JIB■�/°�..//rJ.■//.Mt..S.■M■MOSMO■ ■EM■..EMGMMM.■ONSENSE■■ ■O■.■■■.■MO■i■■■■tO■O..■■■t■..M►l..a a MII■C7.IMEMMMMMOMMEMEME■ ■O..■./■■Ems.O■■EM■SES ■■.■E■■■.■.■ Nunn■t■■■.■.■..■OMi�O�%O.ESM.■/�■■t■■MMEMEMEMME.■ ■■.■/.%■■t■■ ■■■ ■■.■.�HM■loin■O.M■■■■■■.■M■ ■■NE.■■■MMMMMESON ■wMMM■■■■■EMMMME■M■ EMEMM■ ■�■.� .MEMO . 0 ■HSE■ ■am M■�M..t..�M.ME0. 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