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975 Point Rd DAVIE COUNTY HEALTH DEPARTMENT t - 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) NAMEPROPERTY ADDRESS _ 'o l�1 "- �.• DATE LOCATION SUBDIVISION NAME LOT NUMBER SEC./BLOC( NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE !1 / # BEDROOMS',—? # BATHS # OCCUPANTS -:W" GARM DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY — L DESIGN WASTEWATER FLOW (GPD) ?1d FEW SITE ----REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEWv4 GAL. PUMP TANK GAL. TRENCH WIDTH :n6 / ROCK DEPTH 9" LINEAR FT. / OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS 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 1 U S NoT'Con,.Pt C3 AUTHORIZATION NO. Q5 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 1 Davie County`Health+ p 'De artment � V r ENVIRONMENTAL HEALTH SECTION P.D. Box 665 •/`_ Mocksville, N.C. 27028 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 NLVBER HAS DATE �S" /6 -9� N2 0355 NATE ON IMPROVEMENT PERMIT (If different than above) ' SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM t**NDTICE*** THIS AUTHORIZATION F WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE• DCHD 10/95 _._. _. .., .. ..... P_ .. n,.,,..3t.F:u r. __ t :. .�, Y _€_t ,i rx'e i"u)y.. _ 91 ..Y t v .. ] _ a✓.t...,,t. r G ` b n q APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER e c Davie County Health Department Environmental Health Section j v P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address R-r- ,9/0 w, 1u RJ Home Phone y:�� /U Business Phone 2. Name on Permit if Different than Above 3. Application for: eneral Evaluation El Septic Tank Installation Permit 4. System to Serve: ouse ❑ 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 2-- ❑ 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 rivate ❑ Community 8. Property Dimensions I� La l Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 14 o 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: 30 mI ISS Man oR rman No }- hc�uP-- rnr sQl S(lA) L P 7e-s� 10o -1 pc- o 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. -q5 s DATE SIGNA RE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. I DO NOT O]dibed If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by th I hereby give consent to the authorized representative of th Davie unty Heal Dep rt e,nt to enter upon property located in Davie County and owned byAMeIC to conduct all testing procedures as necessary to determi said site's suitability fora ground absorption s and disposal system. �2 - GS J S DATE SAGNATURE DCHD(1193) . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �/'GVGr�s DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position L 4-- Slope Sloe Z 1 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure /Z /l / Mineralogy • / ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure MineralogX SOIL WETNESS RESTRICTIVE HORIZON - SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: _- �� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge &-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 Aay 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-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 ■■■■■■■■■■■■.■■■■■■■■■■■■■.■■.■■■■.■■■■■■■■.■■■■■■■..■■■■■■■■■■■ON MEMO MEMO monsoons ■■■■■■.■■■■■■E.■EEE■.E..M■sE.■■■E■■■.■■M ■■■ ■ ■■ M■■■■■u on KNOWMEENEM M MMMEMM■MMMIMMi ■.■EMEENE....E.O..E..■N...■■.■ .■■E.M.N M.M■HN■■■E■M■■/■ ■■m ■.■.■.■■■■.■e.■.■■■■■.e■■■..e■..e.■.....s...■■i=.■..■ ■e■■e■■.... ■■■.■.■■■■■■■.■■■E.M.ENEM■EE■EE/■E■Ea■■■■■■■■■u ■■i■■MC■■■■■■ii iiii�i■iiiiii■C ■CCCE ■Ciii.i=iiiiiiii ■�����■iiiiiiiiiiiiiiiiiiiiiiiiii�■iii■�����■�■�■MMEMO 0 NONNI uii�ON IMMMMEC ■■■.■...■.■.■....■....■M.......N ■� .■.. ■ ■ MEN�MEM■EEC ��������iiiiiiiiiiiiiii•NiiNONE e �� ����� iiimimom ■■■■■■■■■■■ .■■■■■.■■■.■■■■■■■■ ■■■ Ee u ■■ ■ MEM■ON ■■M■ME ■�■■.■ MMMMM■ MMMMMi NEEM ■ ■.■...■.■■.■■.■..■...■eE■■�.■■Ee■■■■■■ ■■ ■N ■■■■■. ■■.■■■■■■■■■.■e■■■■■■■■■u■■■■■■■■■■■■ ■■-MM ■■■MEMO■ Cii��iiiiiivii�■iiiii�Oiiii=CiiiiiWE ■ MEMMEMEM ME MENEM No iC:iCiCCCCCCCC:CCiiiCCiiCCIUMME . 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' �-"'�w^srJ'•,� F ., .y�' 'eSr„�,n-t� �9 a,Wt L 1ov�. �'e- �7 a -�t� vaY Yi ;'a"r''i I P'.... .� •s Y� .�'';'L'"• fir. yI�Ig '�r ,`1wgCL�`r ��k°,j„C ,SQri.•� �. �. ,� + 'O!�j"��.?.3 ��• 1�+C. ;, 'fir !,` 7'�p � k -yi. y .sir ►h' w �r ,:rte s" �e ti •y � . t ' h r .i t�f►r �•r'y � •ga '� li� 'y���JL � a x L. rYF" •�1,y�, .r.. V' •r �Y v' rz i _rA ter.; y �.it�3. � � 6'�'{�9..a ` •i 'ti a1�' i� ' l �.�'�}1;i �Tf,�ir •• r � }� r i, •'r r �w rl ��f�!'.T�e Le�r'�'sc.""r f+•7 'N - - - " Davie County NealK 7Sen artment and .Moine Nealt§ 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634-5985 May 17, 1995 Jimmy Stephens 597 Becktovn Rd. Mocksville, NC 27028 Re: Site Evaluation Point Road - 8. 69 Acres Dear Mr. Stephens: As requested, a representative from this office visited the aforementioned site on May 15, 1995. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr. , R.S. Environmental Health Section RH/wd Enclosure