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109 Canton Rd Lot 11, Sec 2�0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT A, **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) NAME 0j ( f//ll tIllIn0l PROPERTY ADDRESS L�IY101� E /� - %d 6 ATE l LOCATION SUBDIVISION NAME / *e //lam LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE 11,,1wj- # BEDROOMS ? # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY / D DESIGN WASTEWATER FLOW (GPD)NEW SITE REPAIR SITE ZZ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK /�I_ GAL. TRENCH WIDTH _�� ROCK DEPTH , LINEAR FT. �d OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***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. 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 (700634-8760. OPERATION PERMIT la Nd Dry11 lrvlt% pied SYSTEM INSTALLED BY d cl yAr AUTHORIZATION NO. OPERATION PERMIT BY�C YWII 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 DAVIE COUNTY HEALTH DEPARTMENT _ IMPRDVEMENT PERMIT and OPERATION PERMIT 'Ii iNPROVt -f l - PERMIT ` , e / 'tCr7.t'/ f 1 .LAX yS — �� **NATE**`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 constructonhnstallation of a system or the issuance of a building permit. (In compliance'with'Article 11 of 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME �' : i�` : ? l�1'�C PROPERTY ADDRESS /0/1 7/'fll f� iL= J -yfi `f G G �a DATE LOCATION SUBDIVISIDN NAME t LOT NUMBER // SEC./BLOCK NUMBER ( RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ? # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/N—�:), COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No / +r LOT SIZE .•l/C TYPE WATER SUPPLY r.' DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK,��� GAL. TRENCH WIDTH 'L ROCK DEPTH LINEAR FT. OTHERl " REQUIRED SITE MODIFICATIONS/CONDITIONS: M ***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. �+�swwwrrr 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 r /• i l F. �L�' "�' 1, Nil SYSTEM INSTALLED BY ,�'� AUTHORIZATION N0. ,% i '�S' � OPERATION PERMIT BY � ' rwJ'`�� 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. J DCHD 10/95 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. 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 NUKAR NAME A'1 !r"1r�ll me �n �' DATE ,S ` ° ;'. W a 0 v 3 J NAME ON IMPROVEMENT PER MIT .� RMIT (If different than above) SITE LOCATION Yallect/ G COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **{NOTICE*}* THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIROMM)EMJTAL HEALTH SPECIALIST DATE DCHD 10/95 Davie County Health Department ` c ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 - b AUTHORIZATION FOR WASTEWATER SYSTEM CWTRUCTION (Issued in compliance with Article II of S.S. Chapter 130A, Wastewater Systems) 04"—. ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Sebtion 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.*** s AUTHORIZATION N XBER NAME► c \C �r� O eR S c, N �o N�' :.N c. DATE I 0 D J 9 Jr � � J NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION NO A•� o �� o W _ �C��� t COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. k EWIRDIM NTAL HEALTH SPECIALIST DATE DCHD 10/95 DAVIE COUNTY HEALTH DEPARTMENT - 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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME 0 Zb PROPERTY ADDRESS F��' ' i)�D�C.�. , 0 06 DATE R) �23 - • LOCATION lB A tU - �� a �+ �3� 4.� wkwr '11, � + SUBDIVISION NAME QNjt CA �Z, W LOT NUMBER ' _ SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: &No A COMMERCIAL SPECIFICATION: FACILITY TYPE.,. # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: yews/No LOT SIZE Orso yTYPE. WATER SUPPL.Y,, %bl"'j DESIGN, WASTEWATER FLOW (GPD) ''NEW SITE REPAIR SITE . a SYSTEM SPECIFICATIONS: TANK SIZE, 00o Gk. ` PUMP TANK GAL. TRENCH WIDTH s ROCK DEPTH LINEAR FT. 30D� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***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 §YSTEM. is r e i 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 o<.riv-sti F q l�/ b►/ AUTHORIZATION NO. 0 C) B 1,0 OPAAT) **THE ISSUANCE OF THIS OPERATION PERMIT Sac I DICA ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .19 -sq GUARANTEE THAT THE SYSTEM WILL FLNCTION SATISFACTO DCHD 10/95 P' PERMIT r DATE �. 1:1 _9 THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH E TREATMENT AND DISPOSAL. SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A Y FOR ANY GIVEN PERIOD OF TIME. Lbt # 11 APPLICATION FOR SITE EVALUATION IMPROVEMENTS P MLT_..._........- .-•- �����, Davie County Health Department l ✓ � Environmental Health Section 5 i� P. O. Box 665 O� Mocksvilie, NC 27028 1. Application/Permit Requested By I D(Q;G �iy �a 8r2k1 I D•U S ;r7 _ZZ(-, _ Mailing Address F 50 x 7 1Y170c-sV/Ct---- _ &. C 70.E 9- Home Phone 7s 7`1 Business Phone ! !%k - 7--;� 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: louse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision gcJA IL J-�b ce-o CJ Section Lot # No. of People No. of Bedrooms No. of Bathrooms =2 7-0 -P Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes a No. of Sinks No. of Urinals No. of Lavatories C=-- No. of Water Coolers _ No. of Showers Water Usage Figures . 7. Type of water supply: OKPublic ❑ Private 8. Property Dimensions % A Gem 1.0 7--b Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing Cn�Washing Machine Dishwasher Cii'Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes UKNo If yes, what type? ❑ Community '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: This is to certify that the information provided is correct to the best incurred from this application. 3 /,o - ys - - (5 DATE knowledge, and I understand I am responsible for all charges SIGNATURE CONSENT FQR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 .OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE ' DAVIE COUNTY HEALTH DEPARTMENT I I Environmental Health Section Soil/Site Evaluation NAME _ -�� �, N t` �'L S n DATE EVALUATED t. L. ADDRESS PROPERTY SIZE PROPOSED FACIILTY V\ o u s Q LOCATION OF SITE Structure Water Supply: On -Site Well Community Public Evaluation By: C C I- Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position t. L. Sloe % HORIZON I DEPTH Texture groupG Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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: �-� r/ EVALUATED BY: LONG-TERM ACCEPTANCE RATE: r OTHER(S) PRESENT: REMARKS: LEGEND 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 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(01-901 ■N■