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142 Pardue Loop (2)tx a ,1; s � � Davie County Health Department K ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27029 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***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.*** AUTHORIZATION NUMBER NAME ri( u'!(y1r�/`7 DATE �'- N127) 1 NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION/�,yr°r �r�'��/ir.�� CII/ l%'u C r%rJy ? / T V COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FO ,1 5 EWATER SYSTEM CONSTRUCTION I5 VALID FOR A PERIOD OF FIVE (5) YEARS. r ENVIRONMENTAL WATH SPECIALIST DATE DCHD 10/95 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **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) NAMEC CPROPERTY ADDRESS LOCATION . I // rl/_ /91 P/,.%/t ,%7 e`<"/J / .I LJ,r// r ,° A- � ra DATE SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ' # BATHS p� # OCCUPANTS �, GARBAGE DISPOSAL: YesV COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE fI/' TYPE WATER SUPPLY f DESIGN WASTEWATER FLOW (GPD) NEW SITE f�-REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/i GAL. PUMP TAW GAL. TRENCH WIDTH..?C ROCK DEPTH LINEAR FT._c�'t%l OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 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 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY l/U i r1D v 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 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 10/95 �r DAVIE COUNTY HEALTH DEPARTMENT t . --� ' IMPROVEMENT PERMIT and OPERATION PERMIT i IMPROVEMENT PERMITi **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 it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME PROPERTY ADDRESS !'i/,( �D %� `" 1 DATE LOCATION r'l „f0 ;ii 1/%if ' , , <"� ,� /t ,✓ -1 SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE r i / # BEDROOMS. # BATHS V t OCCUPANTS /GARBAGE -DISPOSAL: Yes o COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE aril TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) _ / NEW SITE i_.--' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/"',-,? SAL. PUMP TANK GAL. TRENCH WIDTH '',c' ROCK DEPTH LINEAR FT. r OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BYi?� **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 SYSTEM INSTALLED BY l/►��„�,;�/(�. u r7B AUTHORIZATION NO. 0/6—/ OPERATION PERMIT BY �C!+ i 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. i DOHD 10/95 WOW AM DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED����� ADDRESS PROPOSED FACIILTY PROPERTY SIZE 49.0-G LOCATION OF SITE =7Z&5Ze_-V Water Supply: On -Site Well _ Community Public [� Evaluation By: Auger Boring i/ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ov Texture group' Consistence / Structure �C Mineralogy( y HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION J LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY:i'/ LONG-TERM ACCEPTANCE RATE: 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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Anirular 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 �r. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 JAN 2 4 1996 1. Application/Permit Requested By Mailing Address To 7Ardue,—lU6 p Home Phone 2607 &AIAImC& _( L, 2!7D0L Business Phone 716 700-7957 2. Name on Permit if Different than Above 3. Application for: 4. System to Serve ❑ Business ❑ General Evaluation & eptic Tank Installation Permit ❑ House 9 Mobile Home ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People No. of Bedrooms No. of Bathrooms 19— Dwelling Dimensions 6 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers �1 Water Usage Figures _ 7. Type of water supply: ST Public ro �Ij on Of ❑ Private 8. Property Dimensions a -c -;u Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Yes ❑ Basement/Plumbing ❑ Basement/No Plumbing 04ashing Machine 1I?'5ishwasher ❑ Garbage Disposal VIN"o ❑ Community 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: G�/JS ow AJaVey (i�GUCAore9 �f?J ,6 PS! /C' 51/0 d `C_5- lh' a Kke c :t.e. , & & a�oNf iv/i-es fuz� LeF�- /,I4), pard o e /0410 Coo Oe h;&4 14as-e— Gil Gr�e�.J Tiurn , f'rc per �v w l ( b e 51 a C- o r re t-1 C- I �a n C o This is to certify that the information provided is correct to the best of incurred from thispli at'on.M DAIE Tax Office PIN: # 5�(4/-0 -00(07 ,E? poo GD 0c)PROPERTI/ ADDRESS, as follows: Road Name: City: 11e1t1,qyre- Jj . G SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. knowledge, and I understand I am responsible for all charges IGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1:11. 1 OWN the property. M2. 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 Count galth Department to enter upon abpve described property located in Davie County and owned by S L( V. A ,1 �-C, =e ti Cl a1q- �1 to conduct all testing procedures as necessary to determine s ' site's suitability for a ground absorption sewage treatment and disposal, system. 1.2 l (0 DATE SIGNATURE DCHD (1/93) ■■�■�■■���������■���■���������������■��■ ����\�� �������■ ������■ ■■���■���������■�■��■�N�����������nr�■ �������� �■■������������■ ■■■���■����■ ��������■������������������■ ■�����■����■���■����■�■ ■�■■��■■�����■����■������������� ■��■■��������■��■�������������■■ ■�■■�■����■■���������������������������� ■ �������■����������■�■ ■��■��■�■■��■�■■�����\����■■����■���������■�������������■��������■ ■■������■�����■■�■���■��■��������■��������■�����������������■��■�■ ■�■�\E��■��■■���■����������\����■��■������� ������� ���■���■��■�■ ■������■���■���■■�■■����������■�i�■�■�\�������■���� ����■�������■ ■�■����■��������.�o���������■�������■�����������■�■ ��������■����■ ■�����■������������■�������������N���■���■�■����������■■��■����■ ■�������■�■�■������■�■������■��■ ���■��������� ■�� ���■��■�����■■ ■���������■�■���■��■��������■����������\■��■��■������■�������■�■■■ ■�����■��������■■���������� ■���������■�������■ �■�■ ���� �■���■�� ■���■����■�����■��■��\�■�����■���������������� ������N �������■■ ■�■�������������������■�������■������o�����■_����=iii��iiiiin�ii�■ ■�■������������������■��������������■��■ ��� ■ � ■■ ■�■■������■�����■�■�■������■�������■������������� �■�■�■ �■■�■■��� ■��■■������������������■��■���■��■■���������■���������_��������■ ■��������■■�■��■������������■�� ■������N��■������������������■■ ■■■�����������������o���■�������■■��■■■����N���==■�����■��v■����� ■����������■�������■�������������■�■��■��■�■��■ _���■���■����■�� ■�■���������■■�������■�����������■�■■��■t���=�����■ ■���■_�����■��� ■■����■■■����■■�■�����■�����■■���■ ■ �■��� ���u��■���■ ■ �■��� ■������■����������■■��H■�■���■��■�����■�����n���=■�■���■�■�����\ ■�■■��■■�������■��������������■������■����■���n�� ■ �������� ��� ■������n��■���■���■���h�■������■��■�Nv����u�������■������ ■■■�������■��������■■���■�■����� ����N�■ ■ N�����■���■�����■ ■■�■■■����������■■���N�����■��■���M■�����■�■���■������������ � ............................�..................■ .. ...�......� ■■■■■�■�N���■■����■����■���I.!�■��■��■����■��N��� �■�� ����■� ...........................«�................. �. .........0 .........................................�.....�C .�.:�.._....... ■����H■■�������■����������������������■ ����■� �� ■���� ����■�� ■i■��������������������������������� ������ ������� ■������� ■�H�■■�������■■������■�e�■����� �i■�N�/���� ��N���� ■���■�� ■■����������H�����■��■�■�■■�����������N�����M�h���������� ■��� ���■�■�������■��������■��������r� �������� ■ �� ■ ��■�■�� ■�������������������■��■�������u ■ �■�� ■ ■ �����■■■��� ■������������������■���������■���! �������� ��■ ������ ■■■■��������■���■ ■��� Nh■���� ■ _... 1���, �■� ���■� ■�������■�� ����■■���■��I��=:Gii11���■��■ �►��� �■■� ■ ������� ���■��■�������������� �����■������ �I■�1,� �����■���■ . ��■■�� ��■■�� ������ ����� � ���� � ■ ��� ■■���■ ■��������■N����������u 1�������■����� � �������■��� ■■�■��������������■�����11��■■■■■■■��■� �N��� ■■��■��� ■��0����■����o■��������Il���������u �� ��■����� ■������������n���■�����11■� ���� ■ ■ ■ �� �N�� �� ■■■■■�■■���■■h�■�■/����I������5�■ ■ �� ��■����■ ■�■�■ ■�■���v��■��� ����_�� _�"��'-� �� ■���� ����������■u����■������.:���� ■ ����������� ■■�■�■■■�������■���������������� �■�■u ■ ��� �������■����■�uu���������■� ■� ���� �N�■���� ■���■■■�����■■���N��m�u ��N� �■ h� N�■■■� ■�������■��■■■���u���.■.������� N . \� n���■�� C:CC:CCC:::::::::C:�::::_::::�: :_ �'::::: ..............................■. .. . ..............:::.::::�:::_�. �.. ......■..... ........ .... ............ ..._... �':C�::::::�:.:=�:�.0 : '::�_'.�: ... ... ..........�........................ . . ... ..... ■����������■��\��������■���■�������■N ■�� �� ■������/�����������■������■����� ��� �����N� ■�■�v�����■�■■��u■������■����������� ■ ■ ���N�■����■■ ■■�������■�����������■�������■� �� ���■��■�■� ■���������■������������■������ ����� u����H���� �� ■�����CC�■NCC:C��C����:�C�C���=�� ■ ���� ����� '::::: .... ... ......C......... . . ..:::_:�:::::::. .. ... .. :=...�i. .............. .. ... _. ................ s... ..�.......C........... . .�.. ......:'�.................. ...............................�...._..._....................... ......................................�.. ....................... .......... ........................... .......................... .................................................................. .................................................................. ........................... ...................................... ....�......................5..........._■......................._. .,... ...........................�::C�:::::�::C::CC:C:::::C.: 1.............................. ..... .............................. . . ■.....................