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167 Potters Ridge Dr Lot 9 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT i **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 -Ti y^M �- �Cn+ A�\ �'. Z4 PROPERTY ADDRESS ��O`!�S 7�'I �I2-5DATE LOCATION S�� " ch. Q511-1-11 SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER Jr- RESIDENTAL SPECIFICATION: BUILDING TYPE u S A ME BEDROOMS --v— M) BATHS (i OCCUPANTS —�- GARBAGE DISPOSAL: Yes No COMMERCIAL SPECIFICATION: FiCILITY TYPE'- # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE':'-Yes/No LOT SIZE _....-1DE V51pE WATER,SUEPLY v QxW DESIGN WASTEWATER FLOW ('GPD) NEW SITE V REPAIR SITE SYSTEM SPECIFICRTIDNS: TANK SIZE Li"6AL. PtlIP TAFb( GAL. TRENCH WIDTH ROCK DEPTH LINEAR FTyJb OTHER 4 REQUIRED SITE MIODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MAST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 0 IMPROVEMENT PERMIT BY **CONTACT A`REPRESENTATIVE OF THE'DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9: CA.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE (M IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY F A AUTHORIZATION NO. 561 OPE RAT ON PERM T BY ��� DATE S 97 **THE ISSUANCE OF THIS OPERATION PERMITL INDICATE THAT SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER IRA, SECTION .1908 " TRFA T AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION TISFACTO ILY FOR GIVEN PERIOD TIME. DCHD 10/95 µ' Davie County Health Department •� _z:� ENVIRONMENTAL HEALTH SECTION R_;•- 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) i ***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.*** AUTHO RIZATION N�U�I6'ER NAME DATE 9 NAME ON IMPROVEKNT PERMIT (If different than above)) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***N[TTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5),YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE I L� �� D L/ Davie County Health Department Environmental Health Section �;�t� ��^ ' P. O. Box 665 9 �a;;J Mocksville, NC 27028 1. Application/Permit Requested By �^^- � Mailing Address ��� �-�%i s U�i t�e l r, (�--�Q Home Phone ���" ���- � (5`>{ Q,t,J�.sc�� I( z �C �--? ��-3 Business Phone ��(�-' 7� '"3��Z� 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: �House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Indust ii�� � Q r❑, Other ❑ Unknown p 5. If house, mobile home: Subdivision n'T�� 5 I�� �Xt�Z., Section 1- Lot # _1— ❑ BasemenUPlumbing No. of People 5 ❑ BasemenUNo Plumbing No. of Bedrooms � � Washing Machine IJ No. of Bathrooms � /�- �Dishwasher I � Dwelling Dimensions 32 X �� ❑ 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 /, ❑ Private ❑ Community 8. Property Dimensions �I��X 3 7��x �`����JL�•�Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes j�.No 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. PROPERT ZN ORMttTION REQUIREb: Directions to Property: Tax Office PIN: # J�.�`��- �,3- Lf I�� PROPERTtJ A�bIZESS7, has s follows: n Road Name: ��I I ri{}p,..i5�i(�.c�.C, �"� City: f'Yloc��U�11L SU$MIT A PLAT WITH THZS tIPPLIC�ITION. Revisions effective 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. G��1�-+'`�--� �- �— �� DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: � 1. I OWN the property. ❑ 2. I 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. ' �- 9- �>� DATE SIGNATURE DCHD(193) a � Iry I .a J ca!71'rof 4) IF,Jn/ :"� b 7h .W /_�.��T�-LST I`.• Mn. nON J►'/O tµ,1. h 0� "p - O /FkUM 1NE CENTLkL1NE - �' w1EkSECTION OF , gt•Jyq,• ' `� ti 1// Sk 1431 ANI, Sk 1410 I . IJa Jt'. I _ I _4 s 1aJ1'co'r Sa oe' I! O N ROAD• V D aA \ I O 5.010 c c. ;"N�. � I � 5.232 ac. e 603 IN30 868. SOLD ' PROPOSED PO-FT.RIW Os _ ^ 6t•23• ws,12j4 2 rr,!•5 86.24' a!n• 0 209.09 351E 50.00' 4 12 f �/J Jua.tr c Ih 8J tv.v nt c ® 5.010 cc. m 5.100 cc. ,r.,�. .. M I $OLD y 287.05 76-SqI $30,090 . 1 wta.r t 1 alf}.IYRYIii[ o . ntw..r rr+lc r 1111 �1W .P nd- cA(A FAX.:.0Artc. / S)2• 'Y' .ar sa r a H 69' ® 0CD 3p•4 h .. // '� ll.n oar T` s so'ai'tTW80 a, 9/T S 87•55'03'E- 302.15' a 01RC,( `tio��8 t ao•3Y t6'W 1 C \ warn+t...a/• �� N 5.00.1 cc. a o sy.,, anPF 8 � �`z7// o ,..�r,�,, n. Ati.a..thi r, u_ O r isJ*)m O %p. $29 , 500 . = en's 5:59 �r�» 0th' ,32 ° $35 370 . 5 255 cc. 3;222 5'el!; -0 w zCc, 3r 1, 0 0 0 . �c� a - 5.274 cc. - $31, 116 A16 414r0 4�w q9O F2TiJTIA d'n i ,i S 89.58.47-W 490.76' N ^� W 833.08• N 5.098 cc. N S 83.44 I N °_. p $30, 078. \\ C y pf w O – � 5.132 ac. $30, 278.. p rpunG 343.54 -- �I 1 C C4 CS ./ 471.74' - W I 1. - '•�•• 5 33.44".�� Owners:�� -�-y S 8=-44��•W �_ /T , �r Ii TEMPORARY F n �\ I I CUL-DE-SAC r— � • DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation NAME ) 'V3 . S(a\\'Itn�r �' DATE EVALUATED ADDRESS S P r"4 PROPERTY I ►J •y C1 � PROPOSED FACIILTY \ LOCATION OF SI"I'E Q Water Supply: On-Site Well _ Community Public Evaluation ByCtL Auger Boring Pit Cut FACTORS 1 2 3 4 Landsca a position S S Sloe HORIZON I DEPTH 6 Texture groupC Consistence Structure Mineralogy HORIZON II DEPTH L �' Texture group Consistence �. Structure Mineralogyil • 1;1 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 C SITE CLASSIFICATION: �� J EVALUATED BY: LONG-TERM ACCEPTANCE RATE: '� _OTHER(S) PRESENT: 1 � 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-Vc-y friable FR-Friable FI-Finn► 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 ■■.■.■■■.■■■.■■■■■■■.■■......■■..■■..■■■ ■E■E■Em ■mm■m■■■ ■■ ■■■■■■■■■■■■■■.■.■■■■..■./■■■.■■�.■■.■.■■.■.■■■■.■■.■■■■./NEON■■■ ...............■...............■...NEON■..0■...■...�...■......... .■...............................................■■_ ■■■E■■■■■■■■■ ........................... ................... ■... 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