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379 Pineville Rd• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME Ir- • �/'� ^ /c, r-c-,rK PHONE NUMBER M ADDRESS r SUBDIVISION NAME M LOT # Pt � DIRECTIONS TO SITE `�� Pi /kA- y //�. -- �` ✓-� --f n r� �1tiss DATE SYSTEM INSTALLED Z ?o NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 0 ` 0 q TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 A'L!TH6R1ZATIOKNO: or DAVIE COUNTY HEALTH DEPARTMENT l Environmental Health Section PROPERTY INFORMATION Permitt e'" // Ji P.O. Box 848 . Name: r ?'; '��'fi� i;/ ti) sf �3 Mocksville, NC 27028 Subdivision Name: Directions to property: , �% i . Phone #: 704-634-8760 7 Section: Lot: AUTHORIZATION FOR /l'f l-r:r •q,"!/•/If�" �"f, ir= !� WASTEWATER Tax Office PIN: s'' ,•1' SYSTEM CONSTRUCTION r i)�'lr"._f s' - tfs.,r�, •�.!%i�,��✓ Road Name:_/°`!/l **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: (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ' �-- J r%.<n, f !� "r' _ ,%/ % ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. PCC ENVIRONMENTAL HEALTH SPEtIALIST DATE ISSUED7C- ,� '" •" i _�w •.i, ��.�.:' . _'._ .. � �, Gam- i a a- �= �-� - n RTMENTDAVIE COUNTY HEALTH DEPA - - **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE S1' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _ f' _ # BEDROOMS 4_ # BATHS _/ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 4114 ' TYPE WATER SUPPLY +mac DESIGN WASTEWATER FLOW (GPD) n NEW SITE f" REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ,, p1 GAL. PUMP TANK GAL. TRENCH WIDTH, ��' ROCK DEPTH ,42 LINEAR FT. � �J REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT `7�� C (� err' 5Av le t- P - "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 7S SYSTEM INSTALLED BY: 1' 1,5-vxjpe Q� AUTHORIZATION NO. / OPERATION PERMIT BY: DATE: D0 **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 NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) IMPROVEMENT AND OPERATION PERMITSi PROPERTY INFORMATION Permitiee's �� ? oo -.Name ;�,1} '� ^ l'�'-i u>+' Subdivision Name: Directions to property: Section: L"ot: / '' / ' - • ��/ IMPROVEMENT ," PERMIT Tax Office PIN: r} ') Road Name: r�'�'t`r` A�`�'✓` �� r_. Zip: � , �e �' z% **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE S1' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _ f' _ # BEDROOMS 4_ # BATHS _/ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 4114 ' TYPE WATER SUPPLY +mac DESIGN WASTEWATER FLOW (GPD) n NEW SITE f" REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ,, p1 GAL. PUMP TANK GAL. TRENCH WIDTH, ��' ROCK DEPTH ,42 LINEAR FT. � �J REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT `7�� C (� err' 5Av le t- P - "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 7S SYSTEM INSTALLED BY: 1' 1,5-vxjpe Q� AUTHORIZATION NO. / OPERATION PERMIT BY: DATE: D0 **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 NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION 4..:. - r 11 Permiq&'s -Names''; ''``'" ;."_ tet: -�.* 'r Subdivision Name: r `. Directions to property: �": Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:#y _ 1 Road Name >✓ -°r r _ 'i .;'. �' Zip { **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATEIb,,. ` - SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. Vii° J ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE /-j/ # BEDROOMS 9 # BATHS # OCCUPANTS _Z__ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE flldel TYPE WATER SUPPLY /­,­/ DESIGN WASTEWATER FLOW (GPD) -V -, t NEW SITE / � REPAIR SITE r `� SYSTEM SPECIFICATIONS: TANK SIZE_ �.%[,r" GAL. PUMP TANK GAL. TRENCH WIDTH � � � ROCK DEPTH � LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1 **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: .................... .- AUTHORIZATION NO. /� / J OPERATION PERMIT BY: ,�'' Y :/ DATE: 2.!/y "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 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 & Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (3 6)751-8760 I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Y 1 Y 1 A VV\. k o ` K - Contact Person _ Mailing Address 22 F'►" ", y� Home Phone City/State/Zip 10-4 s 5y' e' /l/• C • _ 2! ° 2 $ Business Phone _ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip / a9 Both 3. Application For: ❑ Site Evaluation ElImprovement Permit & ATC 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other -1# 5. If Residence: #People # Bedrooms Bathrooms El Dishwasher ❑ Garbage Disposal ff/ 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 No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PYATM THE PROPERTY MUST BE a SUBMITTED WITH THIS APPLICATION. Property Dimensions:/7 <C" WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY: Tax Office PIN: # 1 Property Address: Road Namei/ ; Lyt/'�/ 1 r� 1 V /6 1 City/Zip If in Subdivision provide information, as follows: 1 Name: 1 1 Section: Lot #: 1 1 1 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 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 the site suitability. Z -79 DATE q- - / '3 SIGNATURE Revised DCHD (06-96) YOU MAY USE THE 13ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. • �' � • i♦ a � _ ref - �'- _'" y �. Jar.✓ r°' i T � '�� ^�,` �+�`� � �� • n aK �� "eras tf ��vti?',`,,. �, �"� • • �' � ti� , — � � ,� � • Via. �"" Zr"�l �f.�.'r+� « ' ... 7�' ",'�,'� t � '� , °-��.+ .�y� +' a �. 76 / .till Ilk k r.��� L f(r�"W .. Y • '44 fit,• .� � ♦ ' �y � `IIs. • �� •� �. � , � l � t} •w _ r ,�' s +• 'i z -rf �'.�.. � � � itis. `� _ L. '- 4 4 I � • • �v. � _ 1 r - s i yi,}'J••LI wa.7rt:�, ati i �+^•k 'fit' " �1� •'.S �' � * -ti ,N:•. DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME Ad CP DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE C" SUBDIVISION Z�AI NAME �I,P Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH -{/j1 r'' r & Texture group Consistence r Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �. EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscaue 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very 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 (01-90) ■ MEMO OMEN ■EM■ ■EE■ SEEN ■M■■ ■ ■ ■■ ■■M■ ■■■■■■■ ■EMM■■■ SOMME■■ ■OMMEM■ ■M■■■M■ ■MMOMM■ ■MMEME■ ■■EMEM■ ■■■■■M■ ■■■■E■■ ■EMME■■ ■■MEM■■ ■■■■MM■ ■■ME■■■ ■■■■■E■ MONS■■■ ■E■E■E■ ■E■E■E■ ■■■■■M■ ■■■MME■ ■■MM■■■ ■■■MMM■ ■■■MMM■ ■■■■■■■ ■■MMM■■ ■■MME■■ ■■■■■■■ ■O■■O■■ ■■N■■ ■■E■■ ■ME■■ ■E■E■ ■■■■■ ■E■E■ SEMEN ■■MM■