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383 Cornwallis Drive Lot 18 44 a 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) Nay ' esus a1-��,cz ems: �D� �^ PROPERTY ADDRESS 0_0 r- tyed 1 ,e. ��" DTE 1� LOCATION i 1 SUBDIVISION NAME di r✓� /y)� /? tom' LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE to # BEDROOMS # BATHS _-,�— # OCCUPANTS _4_ GARBAGE DISPOSAL:O/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE .� TYPE WATER SUPPLY �, DESIGN WASTEWATER FLOW (GPD) -/ D NEW SITE ,Z REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE.,e!2W GAL. PUMP TANK GAL. TRENCH WIDTH �?( ROCK DEPTH A?� LINEAR FT. 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 (704) 634-8760. i OPERATION PERMIT SYSTEM INSTALLED BY /vo AUTHORIZATION NO. P3/5� OPERATION PERMIT BY %Y 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 DavieCountyhIHealtheparteent + ENV IRONM(ENTRL HEALTA SECTION P.O..Box,h65 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) r **-This Authorization For Wastewater System Construction oust be issued by the Davie County Environmental Health Section prior to r _ issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.***; NAME �`pAUTHORIZATION NUD3ER .S' .. DATE —_ S'4' i 1_ 0 � : 5 NAME ON IMPROVEMENT PERMIT (If different above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM *#WICE*f* THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL WATH SPECIALIST DATE ' DCHD 10/95 Y APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERa Davie County Health Department Environmental Health Section P. O. Box 665 ARR 3 0 19-193) Mocksville, NC 27028 1. Application/Permit Requested By Z/411 ��l���/ ��1411 Mailing Address--� ''� 3 u i(/G f/f�N Home Phone - /1/J J(,H.�; t)t I/ /+i, G/,_ 7 0 .? T Business Phone 2. Name on Permit if Different than Above d -!5-ti nlz"!:y Aa z 3. Application for: ❑General Evaluation 51 Septic Tank Installation Permit 4. System to Serve: W House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision G A6<eSection Lot # .X Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms En Washing Machine No. of Bathrooms `� I-Dishwasher Dwelling Dimensions 3 X © 5 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 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? 'NOTE: Improvements Permits shall be vali from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTIJ IN ORMATION REQUIRED: Directions to Property: Tax Off i c PIN: # .5-g1/f—/--G-- /I/� PROPERTY ADDRESS, as foil/ows: Road Name: City: ///l—Arl'S U,F��e I p SUBMIT A PLAT WITH THIS APPLICATION. ff Revisions Ale " ' Y ions a ective 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 SIGN TURE CONSENT FOR 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,H �D�epartment to enter upon above described property located in Davie County and owned by ll�� to conduct all testing procedures as necessary to deter ne said site's suitability for a ground absorption sewage treatment and disposal system. , DATE SIGNA URE DCHD(1/93) •' '', y 1� J •pO Dz a,� oil sI E low '. 00 �� � gyp► P� oo E � e 3AB 01* y i V6�� to'��l dvea l A�5 X01 v 22 2g6oo 1� �, Z 1 • �'t5 O. 00, / � Cb i, .00, °• 1 OZz c��• �� � jos �O, • ' , %a. « « « 19G2 N a �tEP' ego. o � P+ .o `3gg,8 CQ` ° � IbL s ISO 1' 19' S oNOG to p� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation f NAME DATE EVALUATED ADDRESS PROPERTY SIZE C � � PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit L_ Cut FACTORS 1 2 3 4 Lands-cape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH /0 P 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 RATEI EEE SITE CLASSIFICATION: EVALUATED BY: /// LONG-TERM ACCEPTANCE RAT OTHERS PRESENT: REMARKS: �� e 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-Ve-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 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 watef 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