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118 Western Dr Permittee's ,� 7 / ��"'/�"'" DAVIE COUNTY HEALTH DEPARTMENT � �dame: ��"p`!��' J ti✓�� �'��'�' Environmental Health Section PROPERTY INFORMATI N f��Q 'r;-' ,�.`!'�-�,% �r, P.O. Box 848 �, ���� Directions to property:�''��? �'�'�' ` 1 �� �'' Mocksville,NC 27028 Subdivision Name: � ,•, ` , 's' � �"' Phone#: 336-751-8760 ��,:;�� t'',t' c.� r,`�.�� �..- ,./'� � �. r Section: Lot: AUTHORI7,ATION FOR WASTEWATER Tax Office PIN:#�7�? -1�S� � ��� SYSTF,M CONSTRUCTION ��� ll� I�Ps fP�ry, 15�2. /v�4�6GSVrl AUTHORIZATION NO: Q�� v� � -.j 1� Road Name: Z�p: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior ro issuance of any Building Permits.This Form/Authorization I�Iumber should be presented to the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Article 1] of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) i , ,' �i � ,.✓ r " ' ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION w--�"�: ,�i r 1 4 � ""'�r<r--,�f f"�% ,.��I �-��'�� IS VALID FOR A PERIOD OF FIVE YF,ARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE�_ #BEDROOMS�#BATHS '� #OCCUPANTS ✓�� GARBAGE DISPOSAL:Yes or No � COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No 1 Y ";-�,�'`� �J LOT SIZE��./�� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) `�-a��' NEW SITE REPAIR SITE �/ SYSTEM SPECIFICATIONS: TANK SIZE Lr'�� GAL. PUMP TANK GAL. TRENCH WIDTH�� ROCK DEPfF�, j✓ LINEAR FT.�'�-'�� OTHER , �! /"� (,%�' f%� �' ./}r°'�� f � • REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT t � ��, ! FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#TS(336)751-8760. OPERATION PERMIT `�� �� I `',� K( �� „ Z.$ �JJ' SYSTEM INSTALLED BY:�r`n'� `-a'kt\ � I �L►,"t- -z.a-�""6`' �y� �,� G �(��v l � S�c�a,.lr,� K z z�t' 4�p„�b I s1�.F�(�� � l �k � (� � �ti' � ��- `,��` � I �ST � � �. �.c,� 1 a o ' � I 3s, �' r Z�•G � � `�r � �S� C� w ( ( �� AUTHORIZATION NO. 2�0 9 OPERATION PERMIT • — DATE: � b `.z 3�n �O .� � � ^ _ '"*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 0?l02(Revised) �/�/j'�� ��(�l �O�j�D ri? �v'� v��� . a,�,. c� {V / � , . : . , , . � DAVIE COUNTY HEALTH DEPARTMENT,. � PermiUe�'s /,.--. / '�""/"� R I+Tame;^�.r�f�' �r I , �✓�"'� �"�' Environmental Health Section PROPERTY INFORI�IATI N' � rl�// % � �� / P.O. Box 848 } A "�r '���'" Directions to property: �`'f f' ` `���' J �` �� 1�1ocksville,NC?7028 ' Subdivision Name: ��� �t/ ` ` Phone#: 336-751-8760� • � : . ,�;-�f , + ' Section: Lot: ' ' AUTHORI7,ATION FOR WASTEWATER Tax Office PIN:#� ��� - IS -3 y�� � '�„ SYSTF,M CONSTRUCTION ��� ` , AUTHORIZATION NO: ������� 1� RU�d Namv�T P(��� • �Z°e Ks�� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permit�.This Fonn/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building Permits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) ! f ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION `1 � ; � c=- �:-�r � i ,/�.I � �x�f IS VALID FOR A PERIOD OF FIVE YEARS. �,.:;' ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE_� #BEllROOMS_�#BATHS��#OCCUPANTS J GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No r �-, LOT SIZE r',1�� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) � �r�NEW SITE REPAIR SITE� SYSTEM SPECIFICATIONS: TANK SIZE ��J� GAL. PUMP TANK GAL. TRENCH WIDTH•-�<' ROCK DEPT �r LINEAR FT.✓�"'}r �... � `f�->i OTHER ''1)!( ` �f (-�lr'j '�l .,'� /'°l� � REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT . ...- S'.{i [' FOR FINAL INSPECfION OF THIS SYST'EM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT _ 2.`� ��`�"'���- ���}J" SXSTEM INSTALLED BY:����`•� �-c` k''\ ►.�.c M l \,.,.,-P , 1 HZ ���C _2a- c1,c...b�- � ����� 1�� �'s �p,,� I 5�,n c��.,k�..- � �L*c K,,1 z z�t' �1�c�hbc,.� ( ;,h��F ��� �\��L� . " I�� _ �� A� �ti� � �` Su- � � �N�W�•,c1�`L � !'� �n�S� / ` / � � � �� , �� ` � + � ��,� -3�, � ~ �4° � �.G,,� i � Ct � br�s�� �,. �, � � � � - � � 4 i AUTHORIZATION NO. 2-�'�9� OPERATION PERMIT • ^DATE: � � ' 2 3 ' O �' .�- .... � _.— — — "�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 02/02(Revised) ��L1/ �L/- �O��UO�0� _ �-/`+�•� �1J/�� 7' . . DAVIE COUNTY HEALTH DEPARTMENT � `� Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION (� � �"r'�— �„� s�z�- ��=3y� l l � I�!ti�� `�' y1,�,,1,� �,2�'-D� Water Supply: On-Site Well Community Public G1fP/✓ Evaluation By: Auger Boring Pit__�/ Cut FACI'ORS 1 2 3 4 5 6 7 Landsca e osition Slope % HORIZON I DEPTH �y a Texture rou C,G Consistence ✓� Structure /` Mineralo .' HORIZON II DEPTH �, ' Texture rou Consistence +" Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo �` SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFiCATION �" LONG-TERM ACCEPTANCE RATE � SITE CLASSIFICATION: � �� EVALUATION BY:� LONG-TERM ACCEPTANCE RATE: ��`Y OTHER(S)PRESENT: REMARKS: LEGEND T,�ndscaAe 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 Tex�.ur� 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 ON I T+.N . NIQiS� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � 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-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed LY� Horizon depth-In inches Depth of�11-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-gaUday/ft2 DCHD OS/OS(Revised) ■■���■��■■■������■�■■�■■■■■■�����■�d���■■■■■�■■■■■■■■���■���■■��■■ ■■■�■��■■■■■■■���■��■■■■�■��■�■�����■■�■�■■■��■■■■��■���■■■�■■�■■ ■��■■■■���■�����■�■■��■■�������■ ■�■■��i■�■■■�■�■■■�■���■■■■���■■ ■■��■■■��■■■■���■■■■■■■■�■■�■��■�����■�oOY���■��■�■■������■■■■■�■■ 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■■■��■��■■�■�■���■����■�■��■■�■■■■�■■��■�■■■■■■��■�■■�■■■■�■�■�■■■ ■■■■■■��■■�■■��■�■�■■■■■■��■�■■�■�■■�■�����■�■��■■��■■�■■���■■�■�■ ■■■■■■■��■���������■■■���\�■��■■■■■■■■■■■�����■■■■■�■■�■■■��■■■■■■ ■■■■�■��■����■���■��■■■�■■���■■■�■�■■����■■��■■■■■■��■��■�����■�■■ ■■�■����■��■■�■■�■��■�■■��■■■■■����������■■■��■��■��■�■■■■��■���■ ■■■��■��■■��■������■■■■���■����■ ■�■��■�����■■■�■■■��■/���■�■�■�■ ■■�■■■��■��■�■�■■�■■■�■��■��■�■■■�■��■■■��■■■■■�■���■�■��■�■���■■■ ■��■■■■���■■���■��■����■���■■■��■�■■■■■�■����■■■■���■�■�■■■�■�■■■■ ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME :���° � �tr� PHONE NUMBER '�/Y�����(o ADDRESS ��� ����P�'� ��/� SUBDIVISION NAME i���C`'i�� �<G`" �C� LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED ! NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED G o�J� Pf INFORMATION TAKEN BY �,e�-// This is to oertiiy that the information provided is eoned to the best of my knowledge,an that i understand I m res onsible for all charpes incurte is application. SIGNATURE OF OWNER OR AUTHORIZED AGENT "� Hev.1/93