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691 Richie Rd rJ -• .;.:::v f...i:t`,: ;•r:-:•.�, -is.':•. C rte_'" ... a r'). d ..�.5"n %.r-. r A e) y ) .. v �-- ,...,p- I DAVIE COUNTY HEALTH DEPARTMENT ' IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT If **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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME Row 0 PROPERTY ADDRESS /1 1 DATE 11— It- ci5 LOCATION LO 1 N ' R` ar 1 c-�12 �o ca "1 b o� a S� M, SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE Dasa. # BEDROOMS 3 # BATHS # OCCUPANTS rJ• GARBAGE DISPOSAL: Yes&oN COMMERCIAL SPECIFICATION: FACILITY TYPE l' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Y s/No P r - / LOT SIZE � - TYPE'WATER SI�PI�( Q�t ,DESIGN WASTEWATER FLOW4(GPD) 3 © NEW SITE V REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 0 oay-. "PUFF TANK 6AL. TRENCH WIDTH ROCK DEPH LINEAR FT. QO OTHERS REQUIRED SITE MODIFICATIONS/CONDITIDNS; ***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. 001 I a , c3�yv PIMRRDVEMENT REKNIT 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 aojlAwda 4 eke AUTHORIZATION NO. &7p OPERATION PERMIT BY DATE d TAI" **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 - Z Or 4. Davie County Health Department ENVIRONMENTAL HEALTH 5ECTION P.O. Box 665 J (�0 Mocksville, N.C. 21028 0 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of B.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.*** A 7\ Q ' AUTHORIZATION NUMBER NAME S Q"\� p,N N C�t2 o v+ N DATE 1 1 I r �J l� �� No 7 0 N2 1 NATE ON IMPROYMIT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON.AUTHbRIZATION TO CONSTRUCT"WASTEWATER SYSTEM •"N' #*00TICE"* THIS;;AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ` ENVIRONIENTAL HEALTH SPECIALIST., DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI 10. Davie County Health Department _ Environmental Health Section 3 P. O. Box 665 M1 Mocksville, NC 27028 ENYIRO IDAE COU 1•. Application/Permit Requested By /'cif�' �'•/f'�N e ���� Mailing Address +1 D Home Phone 01" 'Z-7,o 2BusinessPhone SAO 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation eptic Tank Installation Permit 4. System to Serve: CtAiouse ❑ Mobileome ❑ Place of Public Assembly ❑ Business /❑ Industry. / ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision /y D Section Lot # { ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms 2- ❑ Dishwasher 4 Dwelli imensions ❑ Garbage Disposal �• 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 E; k No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public P rivate ❑ Community ' 8. Property Dimensions t �• Sewage Disposal Contractor 1 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No i. If yes,what type? l r '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. PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Office PIN # �$$� -Z7 y Road Name Box 4/ (if available) �. cityl o c&-y l le— I. i L e- C,� r E This is to certify th t he information provided is correct to St of knowledge, a I understand I am responsible for all charges incurred rom this application. DATE SIGNATURE r CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY [and ECK ONE: I OWN the property. ❑ 2. 1 DO NOT OWN the property. cked Box#2, the rest of this f rm MUST be completed by the owner or a person authorized by.the owner: ive consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by t all testing procedures as necessary to determ• sad ;e sui abili r a ground absorption sewage treatment sal system. DATE SIGNATURE DCHD(1193) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ���ZX k X111 Y,r3 t3 DATE EVALUATED I " ADDRESS S 'P 'Cc"� PROPERTY SIZE pU \ A PROPOSED FACIILTY �DugQ LOCATION OF SITE ?\X c C\\'Q \�t"Ax Water Supply: On-Site Well _ Community Public Evaluation By:(_* Auger Boring V Pit Cut FACTORSW1_ 2 3 4 Landscape position Slope R HORIZON I DEPTH Texture rou L Consistence Structure e C Mineralogy HORIZON II DEPTH Texture groupC Consistence Structure Mineralogy 'I HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S s S s RESTRICTIVE HORIZON -- SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE Q If c SITE CLASSIFICATION: . S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 14 OTHER(S) PRESENT: REMARKS: LEG D 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-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mi neraloiry 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 ■■■■.■■■■....■...............■..■.........■.....■....■.■.■ E■■.e.■ ..........■......................................... ■E!.■■■■.■■■■ ...........................�.................■.0■■■■ ■■■■■■!■■■■■■ ........................... 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