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244 Ijames Church Rd Lot 7,.y,•rn(:r'rN....>,,,...... .•a.�;-,a u.''„%�1 y •.;jrr;t,rte- '�?, Y i r rar c i ,. `' r... DAVIE COUNTY HEALTH DEPARTMENT AP, ' — IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT _ 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) 7aa NAME AN t�� V�`f\\�'A�@ Q. PROPERTY ADDRESS -1:t 0,YY1 e.S l.-{'1V L12l A / • DATE LOCATION SUBDIVISION NAME O LOT NUMBER 1 SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING`TYPE # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: YesQ COMMERCIAL`SPECIFICATION:`1sACILITY TYPE`,•:.`. # PEOPLE # PEOPLE%SHIFT # SEATS INDUSTRIAL WASTE: Y'es/yo LOT SIZE TAPE WATER SUPPLY CADESIGN WASTEWATER FLOW(GPD) NEW�� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK WEI DW),�GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH � LINEAR.,!PT. OTHER - . - .d - L REQUIRED SITE MODIFICATIfWS/CONDITIONS: r_- _. ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANSOR THE INTENDED USE CHANGE. ; YOUR WASJERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ,. 4. 6 IMPROVEMENT PERMIT BY *CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPAPR FOR'FINAt"INSPECTION THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATTELEPHONE # IS (704) 634-8760. ry ' OPERATION PERMIT SYSTEM INSTBY 1. p AUTHORIZATION N0. OPERATION PERMIT BY 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 .1908 "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 10/95k �p� .y, � rCpN,•,w"r'k�. f -Davie County*Health:Department . ENVIRONMENTAL HEALTH SECTION , P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIDfi (Issued in compliance with Article 11 of G.S. Chapter INA, Wastewater Systems) ***This Authorization For_Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to i issuanceof any Building Permits. This Form/Authorization Number should be presented.,to the Davie County Building Inspections ,} Office when'applying for Building Permits.*** \ q / b ` UTHORIZATIDN Nl1P'.BER NAME W �.\ '(�� P�Q DATE — l }r✓ S? a 3 7 4 NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION, f COMMENTS/CONDITIaG ON AUTHORIZATION TO TO CONSTRUCT WASTEWATER SYSTEM + ***NOTICE*** THIS,,AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A-PERIOD OF FIVE 6) YEARS. • ENVIRONMENTAL HEALTH SPECIALIST DCHD 10/95 yrr �n r, '� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ?k3 Davie County Health Department x ;� c Environmental Health Section 1� f. P.O. Box 665 + ,>� Mocksville, NC 27028 - ) Application/Permit Requested By PT l Mailing Address r P Gc c/n A �f; Home Phone , Business Phone f i � 2. Name on Permit it Different than Above 1 . ! V it 3 `Application for:. ❑General Evaluation Septic Tank Installation Permit }, System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly Business ❑ Industry ❑ Other p Unknown M= z t house, mobile home:Subdivision � h�/��� Section Lot# ❑ Basement/Pitimbing 1 uu 1 No of People ❑ Basement/No Plumbing J af7 2/Was � l of Bedrooms JJ C�'washing•Machine 4 No of Bathrooms °2- Dishwasher Dwelling Dimensions 3 U©.�11 , ❑ Garbage Disposal �> 6: If business, industry, place of public assembly, other: Specify type x a r No of People.Served =No. of Sinks I,C No of Commodes No. of Urinals 4 of Lavatories No. of Water Coolers ^z No.of Showers / Water Usage Figures 7":T of water supply: Public ❑ Private ❑ Community 8. Property Dimensions ' .' ' Sewage Disposal Contractor • , 9: Do you anticipate additions/expansion of the facility thitis intended to serve? ❑ Yes 3 No If yes,what type?. s syem, _ f "NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to t` revocation, if,site plans or the intended use change-Effective October 1,,1989, z PROPERTY INFORMATION REQUIRED:.. ri Directions to Property Tax Office PIN # PROPERTfJ ADDRESS, as.fo l lows ; +. Road Name: cit `` alA, ,}� SUBMIT A PLAT WITH THIS APPLICATION.:: Revisions effective October" 1 1995. 1� S ry 1 + M �TfY'S rl z r ' 1 of L •1'T"' .•,. , .. ...., .. : •. ,• } This isao certify that the information provided is correct to the best of my knowledge,and I understand,I am responsible for;all charges `,J ,incurred from this application. :. Ay DATE SIGNATURE " CONSENT FOR SITE EV�ALLUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Cl3 �. I OWN the property. ❑ 2. I 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 ,Q,-'to,conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment low isposal system. / _ ��• f' GATE SIGNATURE HO i • APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT O Davie County Health Department JUL I I Ii Environniental Health Section P. O. Box 655 Mocksville, NO 27028 ENVIRONMENTAL HEALTH DAVIE COUNTY ` 1. Application/Permit Requested By Mailing Address Home Phone 9/D- 9 9 SI ff 7-1-713, -2 7Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 22.16eneral Evaluation ❑ Septic Tank Installation 4. System to Serve: fSY1-Icuse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision <' Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions - 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 ❑ Private ❑ Community 8. Property DimensionsI`, �jf 629 aZAZ� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? P— es ❑ 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: � ' i / 01' 1V ,6 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. U G7 DATE ;> SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. I 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 representati a of the Davie Cou Health Depa ment to enter upon ab ve d s ib property located in Davie County and owned by to conduct all testing procedures as necessary to d e mine said site's suitability f ground absorption 96wage treatment and disposal system. G�3 —� 1/; f! 7� ATE SIGNATURE DCHD(12-90) rr ! =* DAVIE COUNTY HEALTH DEPARTMENT h a� Environmental Health Sectionr - Soil/Site Evaluation NAME DATE EVALUATED ADDRESS S`A�� PROPERTY SIZE PROPOSED FACIILTY d 4- LOCATION OF SITE MU Water Supply: ��aa� ,�On-Site Well _ Commun}ty Public Evaluation By:�� Auger Boring Pith ✓ Cut FACTORS 1 1 2 3 4 Landscape position 15 1 S Sloe Z HORIZON I DEPTH I Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH a �` Texture group Consistence Structure 6� Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS Ss S RESTRICTIVE HORIZON SAPROLITE -, CLASSIFICATION .S. .S LONG-TERM ACCEPTANCE RATE c y SITE CLASSIFICATION: S' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: t `c OTHER(S) PRESENT: O N� REMARKS: `_ \`A C � -�.y 4�ba, A 4 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 5C-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 • ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■..w��■.■..■■...■■..■■.■■...■.......■■■■■■■ SENSE= ■■■e■.■■.■■.■■ ■...■■..■ln�l.L....■.........■■... 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