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136 Parkway Ct Lot 25 , ;fie ry -:+ t' .::1'. �✓- ' �c '. o +,r Nr a ASCI')tQ3tL2 ATION NO `DAVIE COUNTY.HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pei-mittee's P.O.Box$48 Name: �" Mocksville,NC 27028 . Subdivision Name: 1 Phone#: 704-634-8760 ?��.�► Directions to property: y Section:_ Lot: oC.� AUTHORIZATION FOR WASTEWATER Tax Office PIN:#' - =tit SYSTEM CONSTRUCTION , Roj11 Name **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/Authonza6on Number should be presented to the Davie County.Building Inspections Office when applying for Building Permits. (In compliance with Articled l 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 OFTIVE YEARS. ENVIRONME14TAL HEA H SPECIALIST DTE ISS D 1025 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name: FYI Name: �� �1 j +<: Directions to property, -- !.>.f ;�`,�''� ,r` Section: Lot: v \! EMPROVEMENT r PERMIT Tay Office PIN:#�+ - Ira 4; Road Name:,'- "f`..� 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 I I of G.S.Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems) y ***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 #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE/:. #PEOPLE #PEOPLE/SHIFT #SEATS IN USTRIAL WASTE:Yes or No LOT SIZE , f TYPE WATER SUPPLY t a DESIGN WASTEWATER FLOW GPD NEW SITE � REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �O(�,GAL. .PUMP TANK GAL. TRENCH WIDTH, ROCK DEPTH .? LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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: OPERATION PERMIT S TEM INSTALLED BY: %7K EXT, Ir AUTHORIZATION NO. OPERATION PERMIT BY: DATE: ��1 G "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) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 M (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. w rlilemv 1. NametobeBilled Contact Person Mailing Address # Home Phone 2 City/State/Zip v 1/ 27/70 Business Phone "�0 2. Name on Permit/ATC if Different than Above CLO Al Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation VfImprovement Permit&ATC [ ]Both 4. System to Serve: [/]"House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #People---& #Bedrooms_, #Bathrooms [ ]Dishwasher[,KGarbage Disposal [,'Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply: [/County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes L,?No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***XAXAVOF THE PROPERTY MUST BE y SUBMITTED WITH T APPLICATION. Property Dimensions: 1 �C WRITE DIRECTIONS(from Tim TO PROPERTY: , Tax Office PIN: # 6: - ��Z(� ; �' Property Addres : �iO�Road Name ' City/Zip mAdk6diawe ; If in Subdivisionpr vide information,as follows: Name: d Q ZX :Z 000 ' , , # 5' ' , Section: Lot#• , , 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 Represen t1v7 jof�the/Davie C unty Health Depart nt to enter upon above described property located in Davie County and owned by "�r a onduct all ng pr ed s as necessary to determine the site suitability. DATE 2-t — SIGNATURE Revised DCHD(06-96) THIS AREA MAY BE USED Fol? DRAWINC7 yoU1{ ITE PLAN: Pa Lt 5 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM U Davie County Health Department Environmental Health Section SEP { 8 19M P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL f 41218 DAVI 1. Application/Permit Requested By Mailing Address c C Home Phone !29,3#7 2 Business Phone" 2. Name on Permit if Different than Above 3. Application/Permit for: ("General Evaluation ❑ Septic Tank Installation 4. System to Serve: [R/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry Other P��❑ Unknown It 5. If house, mobile home:Subdivision NOvRDatSection 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 a 12-,6,0e( , G J9,CeIZ42 Sewage Disposal Contractor .4 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: a j QjJti (� avyL aVC,, J. 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. 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) In `t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME � a1�-=; s���r��'" DATE EVALUATED J - ADDRESS S P -� PROPERTY SIZE 2'� PROPOSED FACIILTY O S4 LOCATION OF SITE 1 D t��� Q V 44 O�F— Water Supply: (� On-Site Well _ Community Public Evaluation By:v �L Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % C6- S HORIZON I DEPTH $ Texture group " Consistence Structure Mineralogy '.1 HORIZON II DEPTH Texture group Consistence IF Structure rC Mineralogyl'. HORIZON III DEPTH Texturegroup Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 5S RESTRICTIVE HORIZON SAPROLITE Y CLASSIFICATION LONG-TERM ACCEPTANCE RATEI Lk SITE CLASSIFICATION: �'�' EVALUATED BY: LANG-TERM ACCEPT NCE RATE: •� OTHER(S) PRESENT: REMARKS: _ �,N �vv� 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-Finn VFI-Very firm EFI-Extremely fine 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 ■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.....■■■■.■■■■.■Ce■■■■■.■ ■E■■■.■ ■■■■■■■■■■■■■■■■■■.■■■■.■■■■■■■.■.■n.■■Nee■■■.■■ ■..■eee■■■■■■■■■ ■■■■■■■/■■■■■■■■■.■■■■■.■■■.....■■/SSSS■■eee■■■■■■■■Ee■.■..■■■■Ee■ ■■■■■e■eeeN■.Nee■eee■■■E■N.e■■■■■■■■MMe.■..eNe.■sN■M■■■..■■.■.■■N■ .....■.....................................�........ 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