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403 IJames Church Road Lot 16"� s ;a`ti;•, o`,'�w,»°v.� a�.F�t:�'� 3 -,f � r,;.':w'i;r t�..�f a�tt ;� f s� �' .. y - � �� �� .�1� 'i"v�C) AU'I`I-I6RIZATi6N NO: DAVIE COUNTY HEALTH DEPARTMENT � LJ Environmental Health Section PROPERTY INFORMATION Pernvttee's ;�t j P.O. Box 848 Name: LY UA' �u Q r1t'1'' Mocicsville, NC 27028 Subdivision Name: O R 3'N / Phone #: 704-634-8760 Directions to property: C�Ui Section: Lot: dK�-13'9P AUTHORIZATION FOR A -- �` WASTEWATER Tax Office PIN:. SYSTEM CONSTRUCTION r Road Name..>� • Ip _i **NOTE**. 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. (In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) (� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �`. J / IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST 1,y.DATE ISSUED' LF[,? �# tt r �,a 4"f: 4 N'(,:3. 4 i ,� ti.'� ..T.. i R •:t int' . .Y -. 'L Y'kVi 1: L' .r.. yP 3. i'. +"tit 7• •.41 it }+ <'�}' �' i -t �'• DAVIE COUNTY HEALTH DEPARTMENT t. `""" �► .' . IMPROVEMENT AND OPERATION PERMITS' PROPERTY INFORMATION Names 'u�1 0 Subdivision Name: N Directions to property:11€ `" � ��! �.�, �- Section: Lot: IMPROVEMENT {„ :R�t� i k a !--, PERMIT Tax Office PIN:z - _, Road Name ^' ip. **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AnA 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 6 va # BEDROOMS -3— # BATHS # OCCUPANTS GARBAGE; DISPOSAL: Yes o NV COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE I OD' k � TYPE WATER SUPPLY' „E . DESIGN WASTEWATER FLOW (GPD) � NEW SITE � REPAIR SITE 3 i 1 �b ' SYSTEM SPECIFICATIONS: TANK SIZE L OU 0 GAL. PUMP T K_ GAL. TRENCH WIDTH ROCK DEPTH LINEAR OTHER 6 ✓ / REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT-4.AYOUT '� " L !rr JS Wz "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: S' a AUTHORIZATION NO. OPERATION PERMIT BY: C% 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 05/96 (Revised) '- APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Dl5 V 15 Environmental Health Section P.O. Box 848 OCT 131997 Mocksville, NC 27028 (704) 634-8760 ****I THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed v Contact Person �� U'; Mailing Address ` � t) "� IlHome Phone City/State/Zip w� S N c� �, Business Phone f l0 q ( -7 Z 2. Name on Permit/ATC if Different than Above 0 6 1q* -J0' 1 `N Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation) Improvement Permit & ATC [ ] Both 4. System to Serve: [ ] House K Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms_ # Bathrooms a boishwasher [ ] Garbage Disposal ?';P-,Vashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: X] County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes If yes, what type? �No t EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***,� OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: // WRITE DIIRrECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #6 ao_ - /' Property Address: Road Dame S .Lr] A-" e.5 Y41 l IAn City/Zip VV 10��� 4-1, 0 If in Subdivision provide information, as follows: a2-7 yJ Name: 1 c 0 ,f' C11— Y -c1 c Section: �ot #: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. 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 DATE i SIGNATURE Revised DCHD (06-96) all testi procedures as necessary to determine the site suitability. e r� n w THIS A. EA A1AJ 15E USED FOR DRAWING YOUR SITE PLAN: APPLICATION FOR SITE EVALUATION/IMPROVEMENTSi�IUf 'PE�I ^ ,_ ��; Davie County Health Department J ; + Environmental Health Section P. O. Box 665 ! 17 I ' -'5 J i Mocksville, NC 27028 _J I OAVIE COUNT' 1. Application/Permit Requested By �> V,\ m N Mailing Address f Home Phone �'� �'� Business Phone 2. Name on Permit if Different than Above _ �• 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: House t— O Mobile Home 0 Place of Public Assembly ❑ Business O Indust j� O Oth r O Unknown ft5. if house, mobile home: Subdivision r �C d 4 Section _ Lot # ❑ Basement/Plumbing . No. of People O Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions O Garbage Disposal 6. It 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: M/ Public O Private 8. Property Dimensions _ -Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If vRa what tvnp? O No '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 Pr�o/perty: T j�C c NcasC__ aCl 1 b, t-�.4"r444V PA" C_��C�ec� w �, 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 In urred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PQOPERTY Land ECK ONE: ❑ 1. 1 OWN the property. 2. I DO NOT OWN the property. cked Box #2, the rest of this form My Lqj be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by `� , �� • �<i fes. _) `: 0 r 1 t' all testing procedures as necessary to determine said site' suitability for a ground absorption sewage treatment al system. D TE S!aKATURE DCHD (12.90) �t. DAVIE COUNTY HEALTH DEPARTMENT �ot -6/4Environmental Health Section R Soil/Site Evaluation NAME IJ• - N� �� � DATE EVALUATED ADDRESS a PROPERTY SIZE l oU , PROPOSED FACIILTY V\ LOCATION OF SITE \� • \�� Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit '_� Cut FACTORS 1 2 3 4 Landscape position -5 Sloe Z d FS 8' HORIZON I DEPTH a v 1a I. Texture groupL Consistence 1= I= - Structure k;" Mineralogy `. ltk HORIZON II DEPTH .3 t' '` Texture group Consistence - Structure 16 V,�A 8 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON - -- SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: \� - �> • EVALUATED BY: LONG-TERM ACCEPTANCE RATE: ' OTHER(S) PRESENT: ,y O9 - REMARKS: `A'` -S,& 'a'- '�r VV LEGEND Landscave 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 :lay 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 -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 Iforizon 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 I ■■■■■■■■■■■■■■■■■■■■■■c■u/c■NEE■�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■/■/■■■■■■/■■■■■/■/■/■■■■■■ NONE■/■./■■■■■■■■ ■■■■■/■■■■/■■■ ■■■■■■■■■■■■■■■■■■■■■■■■/■■ ■■■■■■■■■■■■■■■■■■■�■■■ NEON�■NEEM■■■ ■■■■■■■■/■■■/■/■■■■■■■■■■■■ ■M■■■/EE■EEE■■■MEM■ ■■ME MMME ME■■MMM■ ■■■■■■E■■EMMMMMEM■■EEE■■MEEEEE■■■MMMMM■/NEHMEN ■M■■■■■■im■ME■■■M■■ ■■■■E■■■■E■MEEMM■■■■■■■■■ME■■■■NSEEM■■■M�■■■��MINOR ■NNE■■!�■■ ■■EMMMMEEEM■MMMME■EEEEEEMEEMEESEEEMEEEM■ MME ■ ■M■ MEM■■■n ■■ ■ME■■M■NMN■MOM■MMMME■■MME■■■■MNEME■EMM■■■■■M■■■■■ ■■■■■■■■■■■■■■■■ ■■■M■■■■■MMM■■■■■■■■■M■■■■■■■■N�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■MEMMMSMEEE/MEMMM■■MEMS■■EMEME■ ■ME■■MMNMMMMMMEMEMEMMMMME■MEM■■ ■E/EE//SE■EE■■E■■■■■/EE■■EEME■■EE■■MEMME■EMH■■ ■ ■ M■■/NEEMM■MEM ■■ME■EE■■■■■■■■■M■■■■■■■■E■■■■SEE■■MEEEMMMM■EEMMM:�MMOE■■MM■■EMM■■ ■■M■■/■■■■■/■■■■■■■■■■//E■■■■■■■MME■ ■H■■■ MEM■■■ ■OM■■ EEEE■■MM ■■■MMEMMMMEMM■■EEEMEMEMMMMMEMEM■■■�■:■MME■■MMMMHMMM■MM■mMMEME■■�: ■/■MMEMM■■EMMMMME■EMMEEMMEN/EE■■■■ ■MSM■M■MM■N■■■■MO■MME■ NONE■ ■■MEMS■MME/EMMMN■EMEEEEMMEEEEEMESEMMEEMMMEEMMMn■■EM MEM■MEMS■ ME ■■■EEEMH■■MNMEEM■EE■■SMME/E■ESE�MMEEMMMN�■■NMN■M■■MMM■E■■M:MME ■■■■■■■■■■■■■■■■■■■■■H■■■■■■■■■■■■p■■■■■■■■E/ ■■■■ NONE E■■■■ES ........HEENE■N■MME■E/■M■■E■■EE■EEMMEEEESMEHM . 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