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136 Northbrook Dr Lot 31 �•.E; "' -s,14.3 '�t d"ltT .a r{w y..7aYMi?"7T'w'.t#�'�`"aq"�.r{ � ,.y"- .tj, 3{f' �` _�' 71t ja`v»+.y �,,+�;., !-.oe i,g. '?�.l'.: ti?.her>>. AUTHORIZATIOIfd NO. j 8'nA DAVIE COUNTY HEALTH DEPARTMENT, Environmental Health Section PROPERTY IyNFORMATION PerrnitteeP.O:Box 848 1 ' -Name: wti Mocksville,NC 27028 ' Subdivision Name: Phone# 336-7M-8760 Directions to property: 401A �$ " Section: Lot:' 'AUTHORIZATION FOR �~,� WASTEWATER , SYSTEM CONSTRUCTION Tax Office PIN:# - —- Road Name: Zip:e < , **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. (1n compliance with Articled 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 FIVEYEARS). E O ME AL ALTH SPECIALIST DATE ISSUED a OA DAVIE COUNTY HEALTH,DEPARTMENT " "`' IMPROVEMENT AND OPERATION PERMIT PROPERTY INFORMATION P11 errmi Name:__" ,`" f l"Ira—/V .fi�[''�, r'.p- Subdivision Name: r:�"f r 1 1't ..� - 1 Directions to property: rz"'/ �~ . = Section: Lot: �a f I114PROVEMENT PERMIT Tax Office PIN15 �. Road'Name: r":,� Zip: e- **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.- constructionrnstallation 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 of ;` J:;• .,, f.,� `"j; " > '^ PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE E IRONME AL ALTH SPECIALIST DATE ISSUED f /�• . INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS C-Y #OCCUPANTS GA GE DISPOSAL&,or No r ✓ COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZ V TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITZ; SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH r ROCK DEPTH i�;/ LINEAR FT.2M OTHER &U4 0 REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER•*.*RISER(S) IF S" ELd FINISHED GRRDE* t5r �.7 *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(VAj(4f-Q'3¢Q.x OPERATION PERMIT SYSTEM INSTALLED BY: UAL o tP r �g AUTHORIZATION NO. OPERATION PERMIT BY: 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 NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) ;� APPUCATION FOR SITE EVAUlAT10N/IMPROVEMEW PERMIT Davie County Health Department Environmenfal Mealffi Se+ctfon y P.O. Box 848/210 Hospital street Q -Qpr, Mockaville, NC 27028 ``��✓ 1336)751-8760�FAI y U ***IPWORTANT*** THIS APPLICATION CUMM BE PROCESSED UNLESS ALL THE REQU INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. i. same to be Billed S.4yIPr 'eggpp-',''&7u Contact Person bigdfO�lnt Mailing Address Iola .5 "Ix-`P"P4 Boaoe Phone Y90? -9VV T- City/state/ZIPBusiness Phone y�-7D2Z mob:/ 2. name on Permit/ATC if Different than Above Mailing Address City/state/zip 3. Application For: U Site Evaluation e1mprovement Permit/ATC 0 Both 4. system to service: House ❑ Mobile Home 0 Business 0 Industry 0 Other a. If Residence: # People # Bedrooms / Bathrooms —2- 5 a Dishwasher ti'Oarbage Disposal lashing machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. if Business/Industry/other: Specify type # People # sinks # Coaomodes # shovers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: &-County/City 0 Well 0 Conoaunity s. Do you anticipate additions or expansions of the facility this system Is Intended to serve! 0 Yes 0 No U yes,what type. ***IMF0RTANT*** CUENTSAIUSTCWPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: -5're Ake,4el ^,,' 3 f WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Otiice PIN: # ",;?a -- 3/- �0�d200 �O/ ,(/or4? Z;*m-s Property Address: Road Name ,j/d,�filj�o� U• o� /f' hl- City/Zip 107E C/e•�� �� �Pi ,i P�s� /.s� If In a Subdivision provide information,as rollows: iP Name: _&Z/V�b�� ' Section: e 2 Block: Lot: Date Property Flagged: 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 rrsponsib/efor all charges Incurred from this appUcadon. 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 1'a "'?e -aV4 to conduct all testing procedures as necessary to determine the site suitability. DATE 5-/`�- ` SIGNATURE Aa'' � Jax THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. _ Revised DCHD(07/98) Invoice No. LOT . 1 J (, `AC•) r ' LOT X40 }. In (5.5AC.) „': . `» 19 r ' o 3 SS a yR v �-Z5 `2g 1 L3�' L32 �oL�35'- 0 _OT #42 ,,.,' 5.425 A^) LOT #18 'l v \ \ \ \ � LOT #19 LOT.X17LO \\ � - -- - 4<6• \ �_� \\ LOT #16 \ J \ \ \ LOT #14 \ LOT X15 LOT #32 \ LOT #21 / LOT #23 LOT #22 LOT #13 \\ // <� /yon , oEr .,r�, �, IN Q � y33 �h' ate ... _% LOT #30 / -146+ 1 LOT #12 F %� , / / T — '� ... A.•.) n� , / - ., �; Y / LOT X29 LOT #28 LOT #27 I LOT #26 cti ca N j 1 /,+ LOT J31 � % LOT #11 B3 65.00 48 38' E r T - . z kot �,,'- j.vt '�18co ^ 1 asp. N o w ti I l TMS SURWEY CREATES A -SUBDMSION OF LAND MRtI•ItN THE AREA OF A r_ COtJPtIY 1* YPA!!TY WT I LA71:`,5 m PARCELS OF LAND. sty'L. t,''' 1 ttt� ' r '.F ( ZY6i a.. r= . F s ¢. �.x„ y.. ✓ r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM U Davie County Health Department SEP 1 8 19Z Environmental Health Section P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL DAVI 1. Application/Permit Requested By ✓y�A Mailing Address Ifa Home Phone !29,3 # 1 7 Business Phone' 2. Name on Permit if Different than Above 3. Application/Permit for: VYGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: W/ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ In Other R as PPO Unknown 5. If house, mobile home: Subdivision Ott v� Section --Z Lot# ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No.of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ 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 T. ❑ Private ❑ Community 8. Property Dimensions I�"&g 49AJz, G aezu fy 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: (� n�, � 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. � 9 DAT SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. 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 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(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation q NAME DATE EVALUATED ADDRESS c� ¢' _ PROPERTY SIZE rl\V) PROPOSED FACIILTY d V Ste- LOCATION OF SITE `"C) Water Supply: On-Site Well _ Communi y Public Evaluation By��)' Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S Sloe Z O - HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy1" HORIZON II DEPTH u Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION . X LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: <a • EVALUATED BY: LONG-TERM ACCEPTANCE RATE: \A OTHER(S) PRESENT: pt h)Q 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 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 M ..............................■...■....■■..■.■■■..■.■■■... .■■.... .......................................... ........ ■■■■■.■■■■.■■ ■.■..■..■■■■.....■..■■.■■......■i!'E■■■■■..■E.■.■■.■■■■■E■■E■..■■■ ...........................C■..................�...._■■.■.■■..■■.. ■.........■■■..■■■■.aMMMM..E.MM■■M.M■....■■�ass=Ii�'=ONE='E■iiiii■ on MMMMMMNMNMMMMMMM EMMEMMEM elMEOME��%�E�� MENE_M�� ��������■����o�������������������MEMEMEN�E�No MMMMMMMMMM-■i � ��� ................■■...MH.■■■■E■■O■M.■■■■E■...... 0 MEN ME.■.E'� ........N....................................... 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