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369 Woodlee Dr,., . , . - ,,.. , ::�� _ , , .,, >, ; , . ., ..- . � . , .�.. .� a�-t : . .-.,.., . . ,.:ti )`. F: . 7 .Ys , �XO `'�� --�° `i Q � �� �c > . � � � z �UTHORI�:�i'ION NO: DAVIE COUNTY HEALTH DEPARTMENT `A � Environmental Health Section PROPERTY INFORMATION Permitte 's , P.O. Box 848 Name: ��S�'� N' ��`�S' Mocksville, NC 27028 Subdivision Name: `-----'' Phone #: 704-634-8760 Directions to property: �� E T= `�a �G� �� Section: Lot: �'''�' �1 c3•�'�s. �` .�, A�WASTEWATER �R ��� �,-`t`;"-� �'— c." C;;�'�..., Tax Office PIN:#�� -� � SYSTEM CONSTRUCTION � - ,'�-�,,,,c> �:�2,�' Road Name: RQ 0 "` Zip: � D�� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie Counry 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) , �,. -, �.�� � � � ^� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' ��� �`�'`�r' '"�^J�� �.,.)Ci '� / IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - , . - - •,. � : ..... , '., " , . ., ,, .. . , . . , � ' �. � ,F,�+ � . � « � .,::.�,� .;.f'' ` � � � 1�C:c1. 4 •v} „�,,.,t/�� d - ,.. �; � DAVIE COUNTY HEALTH DEPARTMENT ,�" `�.�— : r IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitfee's � ' „� -Name a�E �'��.`��'� � tw �'..����:- Subdivision Name: ---' D'uections to property: { � � i, �� ` �� L � ' '- `�' : Section: Lot: � Il�IPROVEMENT �\ � . ti'�` � .5...�` . . PERMIT Tax Office PIN:#ti���� � - -�:� � -�?���� . ; ` ,} l""l"' � � ry �5 4 _ . ;�h, "?� Road Name: �� iG C�� 1�� �� "� Zip: �;e � �7 **NOTE** This Improvement Permit DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained frc�m this Department prior to the construction/'installa6on of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) � •- "`**NOTICE**� THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE � . .'� , ti r '::� � > � * r y � •:�;: `; ' ' � ""` ' � : 1 ` 1 PLANS OR THE IlVTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TfIIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICAT'ION: BUILDING TYPE ��V= �# BEDROOMS �_ # BATHS n, # OCCUPANTS � GARBAGE DISPOSAL: Yes o No � COMMERCIAL SPECIFTCATION: FACILTI'Y TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or Na LOT SIZE,�� Z: TYPE WATER SUPPLY ,� DESIGN WASTEWATER FLOW (GPD) <�S?q NEW SITE � REPAIR SITE , ,� i SYSTEM SPECIFICATIONS: TANK SIZE ��� GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH _� LINEAR FI'. ���� OTHER � " REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � � ' . � **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. I OPERATION PERMIT SYSTEM INSTALLED BY: p. � ,i� AUTHORIZATION NO. � OPERATION PERMTT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTTH 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 OS/96 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 l�'��iJ�� SEP 3 0 i9�7 ,/ 1%i �.�c.,'t-�t-o/ t Application/Permit Requested By � Mailing Address ����-s'�-� � Home Phone pT/ Z�' ��,�� / ! 3S ���-�+�Q �j _�. �,� � � �P Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation Septic Tank Installation Permit 4. System to Serve: Td'House ❑ Mobile Home O Place of Public Assembly ❑ Business ❑ Industry �,,, .,� � ❑ Other ❑ Unknown i�j� 5. If house, mobile home: Subdivision � ��0� �e- Section Lot # ❑ BasemenUPlumbing No. of People � ❑ BasemenVNo Plumbing No. of Bedrooms � "� No. of Bathrooms �` Dwelling Dimensions � � � � � 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures �Washing Machine ,�Dishwasher � Garbage Disposal 7. Type of water supply: '� Public t,a �9�e,��s ❑ Private ❑ Communiry 8. �roperty Dimensions �� i1 3�� Sewage Disposal Contractor ��� 9. Do yoU anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes B�o If yes, what type? '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: �� ' ,��. �-��/�-� �� .� � ) ��/ l� /�� �,� ��� �'`-' ` (�C�" ,� .��� �`� �� " � " �.,,,Q�. �� �L Tax Office PZN: # ��( '��la/- �oo'Z 9'!� PROPEItTJ AbbRESS, as follows: (j�' 1Zoad Name: D/� C i t y: C� �/G?�—C�Q_ SU$MIT A pLttZ WZTH THZS ,4PPLICttTION. Revisions effeetive October 1� 1995. 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. ,. ��` ��" � � DATE � SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Y�''1. I OWN the property. ❑ 2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be compieted by the owner or a person authorized by the owner: I hereby give consent to the authorized representative o�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 said site's suitability for a ground absorption sewage treatment and disposal system. 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION i.oT SoiUSite Evaluation __,..�,.—r—•.,.r���� APPLICANT'S NAME `�1� b�`' e� �`\`-� PROPOSED FACILITY �c���� SUBDIVISION � � � .�j .� �� --.,d.�--�- �_----'_ �-- DATE EVALUATED � � � � - �� PROPERTY SIZE � , v 9 �lN'� ROAD NAME � �Z�`�� � ►`� `� V� Sr / Water Supply: On-Site Well Comm nity Public Evaluation By: Auger Boring V Pit Cut_ FACTORS 1 2 3 4 5 Slo e % ' -15° HORIZON I DEPTH ID `' Texture rou CL Consistence 'j= -�- Structure C �2 HORIZON II DEPTH Texture group Consistence Structure . HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Texture eroun Structure SOIL WETNESS SS S` RESTRICTIVE HORIZON " — SAPROLITE — -- CLASSIFICATION LONG-TERM ACCEPTANCE RATE � SITE CLASSIFICATION: � , .� • LONG-TERM ACCEPTANCE RATE: �� REMARKS: �\�.•� � �� 'k DCHD (01-90) 6 I 7 EVALUATION BY: \�S�-� �r-���-�` OTHER(S) PRESENT: Q�� �� ----�_ ��.. �, �`1��. aw�,�_MTf�' - �z n v tiLEGENI���,_ Landscane Position ��"�' R- Ridge S- Shoulder L- Lineaz 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - Very plastic Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angulaz blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 - gaUday/ft2 ■■ ■��■■�■ ■�■■��■ ■�■■■�■ ■�■�■�■ ■�����■ ■�■�■�■ ■�■■■�■ ■■■■■�■ ■■■�■�■ �■���■ ■���■ ■��■■■■ ■■■■■■■ ■■����■ ■�����■ ■��■■■■ ■■�■■■■ ■��■�■■ ■�■■■■■ ■�■■��■ ■��■��■ ■�����■ ■�■��■���■������■��■����■�■■���■ ■�■■�■■�■■■■■■■■■■■■■�■�����■�■■ ■�■�����■■�■���■■��■�����������■ ■■■■■■■�■■■■���■■��■��■�����■■■■ ■■■��■��■������■������■����■��■■ ■�■��■��■■����■■■■■■���■����■■■■ ■���■�■■■■■■■■�■�■■■■■■■■■��■�■ ■�■����������■ ■��■�����������■ ■���■�■����■���■���■��■���■����■ ■��■■��■■�■■■�■■■■■■■■■■■■■�■■■■ ■■■■■���������■■■��������������■ ■■■■■■�■���■��■■■����■������■��■ ■■■■■■■■■■■■■■■�■■■�■■■�■�■�■�■■ ■�■��������■�■■�■��■��■■�■��■��■ ■■�■��������������■��������� ■■�■���■■�■��■���■■�■���■■■■���■ ■■■■■■■■■■■�■■■A�■■�■���■�■■���■ ■�■■�■■■�■�!i�����■■�■■■■■■■■■■■■ ■�■■■��:r�■�■����1■����■�■�■■■�■■ ■�Gi�r■�/�L'���'._'���:C�������������■■ I�■■■��!!�i���■■■■■■■■■■■■■�■�■■■■ ■�Giiii■�■■■■■■�■��■�������■��■■ ■����r��������■■ ■��■■��■�■■■■■�■ ■����i�■��■■������■■■■■■■■■■■■■■�■ ■����������■■�����a���������������■ ��■�,�■ ����....,�...�.==�..���+■■�■■■■ i�■r�■���■��■ii��i��■��i��������■�■ ■■■ ■�■ ■�■ ■�■ ■�■ �ii ■■■ ■ ■■■��■�■■ ■■■■�■�■■ ■�■��■�■■ ■�������■ ■��■����■ ■��■■■��■ ■��■■■■■■ ■■�■■�■�■ ■���■■■■■ ■��■■■■■■ ■■�■■■■■■ ■��■■■■■■ ■■■■■■■■■ ■�■■■■�■■ ■■■■�■�■■ ■■■■�■��■ ■■■■�■��■ ■■■��■�■■ ■■■��■�■■ ■■���■�■■ ■■■■■■■■■ ■������■■ ■■■■■■■■■ ■����■■■■ ■�■■■■■■■