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873 Gladstone Road Lot 11"*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 N 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 e/ -.'J." �l0 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTHIPECIALIST DATE ISSUED REsrDEtmALSPEcrPCATION: BUILDING TYPE H_"#BEDROOMS,IY #BATHS 1 #OCCUPANTS_GARBAGE DISPOSAL: Yes or No -- COMMERCIAL SPECIFICATION: FACILITY TYPE - #PEOPLE_#PEOPLEISHIFT_ #SEATS_INDUSTRIAL WASTE: Ya or No �LDTSIZE _ TYPE WATER SUPPLY" _ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE -_GAL. PUMPTANK_GAL. TRENCHWIDTH_ ROCKDEPPH_ LINEARFI'. _ REQUIRED SITE MODIFICATIONS/CONDITTONS: **CONTACTA REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECITON 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) 6348760. PERMIT gob X-� �ISy AUTHORIZATION NO. I7/ OPERATIONPERhITBY: L /�� DATE:,/ �V **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATETHAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SEC ION.I900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OFTAIE. DCHD0396 (Revised) U AUTH�ORIj,ATToxlVo: 1816 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pennine's/ ,f�l:S'/ �/ Name: 4b` ,/,/ gC�- P.O. Box 848 Mocksville, NC 27028 S(k71Y) D !� Subdivision Name: I Directions topropeny: Phoneii: 704-634-8760 - J' Section: Lot: FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#�J.S3` se" -� G'72 le "*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 N 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 e/ -.'J." �l0 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTHIPECIALIST DATE ISSUED REsrDEtmALSPEcrPCATION: BUILDING TYPE H_"#BEDROOMS,IY #BATHS 1 #OCCUPANTS_GARBAGE DISPOSAL: Yes or No -- COMMERCIAL SPECIFICATION: FACILITY TYPE - #PEOPLE_#PEOPLEISHIFT_ #SEATS_INDUSTRIAL WASTE: Ya or No �LDTSIZE _ TYPE WATER SUPPLY" _ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE -_GAL. PUMPTANK_GAL. TRENCHWIDTH_ ROCKDEPPH_ LINEARFI'. _ REQUIRED SITE MODIFICATIONS/CONDITTONS: **CONTACTA REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECITON 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) 6348760. PERMIT gob X-� �ISy AUTHORIZATION NO. I7/ OPERATIONPERhITBY: L /�� DATE:,/ �V **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATETHAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SEC ION.I900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OFTAIE. DCHD0396 (Revised) .t AT1.^%l1D i'xA TMXT Mn.•: �TTATTV VLA A T Mi "T"A"Mxffrwim' **NOTE**':This Authorization for Wastewater System Construcfion 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 l l of G.S. Chapter 130A,Wastewater Systems, Secnon 1400 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - 1j IS VALID FOR A PERIOD OF FIVE YEARS 'IRONMENTAL HEALTH SPECIALIST DATE ISSUED �'F/s.wa i,�s z%F n ' �„'.. ., "'rrN . .. K -•v-.e.- i„r'T— sa• ?,"w'�.`.ti+'rfa'"�rya^rre yY•„,wW. ti„_.p y,.. •...y ... •-. *� 13 16 DAVIE COUNTY HEALTH DEPARTMENT �,e IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permtttee s Narrle. t�/awl f'ii7 (/E�i SubdoNan:S!0 5 Directions toproperty: Section: Lot: Il IMPROVEMENT Q �a PERMIT Tax Office PIN:#��_45 g9/ - -120 Roada e: e^/ - Zin: cx �i 0,2 **NOTE** This Improvement Perrni6OES NOT authorize the construction or installation; of a septic tank system or any wastewater system. An AUTHORIZ ATION FO WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation f a system or the issuance of a building permit. (In compliance with Article 11 of G. Chapter 130A, Wastewater§ystems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT N SUBJECT TO REVOCATION W 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 # BEDROOMS # BATHS V_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No, I COMMERCIAL SPECIFICATION:FACILITY TYPE # PEOPLE _ # PEOPLEISHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No LOT SIZE / TYPE WATER SUPPLY - DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: PERMIT LAYOUT .F **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) 6348760. OPERATION PERMIT SYSTEM INSTALLED BY: r AUTHORIZATION NO. �I OPERATION PERMIT BY: 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, SECIION .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 (Revisal) t Y APPLICATION FOR SITE EVALUATION/IMPROVE .� elI & R Davie County Health Department y L5 Environmental Health Section -9 P. O. Box 848 IYIILI A —8 im Mocksville, NC 27028 ( t-8XXX NLroNEIENTAI HEALTH (336)751-8760 ERAW COO ****IMPORTANT**** THIS APPLICATION CANNOT B ALL THE REQUIRED INFORMATION IS PROVIDED. / 1. Name to be Billed (� '�I 0 0 ��X7 4� Contact Person Mailing Address 0/ �/� �OI .�`� Home Phone City/State/Zip ✓//F�C�hTS )/ I'l/i� r,, oZ 7D a Business Phone e / 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms L� # Bathrooms O'Dishwasher ❑ Garbage Disposal pushing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: 7. Type of water supply: # Seats a County/ Estimated Water Usage (gallons per day) 8. Do you anticipate additions or expansions of the facility this If yes, what type? *** IMPORTANT Property Dimensions: ❑ Well ❑ Community is intended to serve? ❑ Yes lB-14, SUBMITTED WITH THIS APPLICATION. Tax Office PIN: # 0736- 1 Property Address: Road Name 1 1 city/zip _A7-y1kV;11z` A �7D'Z8 I If in Subdivision provide information, a follows: 1 ; l ) Name: Q 17 »nYI G-' Cy C 1 1 Section: Lot #: �� 1 1 WRITE DIRECTIONS (from Mocksville) TO PROPERT 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 as necessary to d temune the site suitability. DATE SIGNATURE Revised HD (06-96) conduct all testing procedures YOU MAY USE THE $ACK OF THIS .FORM FOR DRAWING YOUR SITE PLAN. Home Phone " Business Phone 1�,0*0 �i,-d [if rent thari Above No. of Sinks ❑ General Evaluation 13 Septic Tank No. of Urinals EQ House 0 Mobile Home of. I S13-1; No. of Water Coolers -iO Industry ie',SubdIvIsIon'LL5 0 Other V busine , ss, Industry, place of public assembly, other: Specify type M 0 Place of'Pub ilc El Unknown ry Sectioni�*�7 ir- �' Lot #F 0 Baserriiint/016mbln 0 Basement/No Plury D Washing Machine; li Pishwasherli 0 Garbagei :D-ispiosal of Peopid:Served No. of Sinks No. of Urinals Lavato % of. I S13-1; No. of Water Coolers of Showers' Water Usage Figures pe.of-water supply: Public 0 Private D -C op&ty.Dimbnsibns- Sewage Disposal Contractor you: anticipate AfditionslexpaAsion of the facility this sytem-is Intended to serve? 0 Yes 0 No fes, what type? VOTE ,,.,'Improveme s' Permits shall be valid for a period of 5 years from date Issued. Improvements Permits are sUbic .4— revocatio'n,11site plans or the intended use chanbeEffective October 1, 1989. Ylt: rections to. Property: ro 0 tiv 10 ns to,certify 'thatth6 Information provided Is correct to the bet of 6a from thl'6a I[ I best 1 -11 . F c V. '171- /. W, and I understand I am responsible for.al NTE,1. SIGNATURE_ CONSENT SITE EVALUATION 10 BE DONE 9N ABOVE DESCRIBED TY is NE 0 1. 1 OWN the.property. 02. 1o k6foWN the p Dx , oi,,the rest of this form MUST be completed by the owner or a person authorized by the owner: wnen sent 26lhe auth6nzed repr6sentative of th'&Davie County Health Department to enter upon -above dc n 'Davie County and owned by ling -procedures as necessary to determine said site's suitability fpr a ground absofption sewago:tt( am. : - DAVIE COUNTY HEALTH DEPARTMENT i/ '} Environmental Health Section Soil/Site Evaluation f NAME _ l�/ f!� DATE EVALUATED-/?���G� ADDRESS PROPERTY SIZE l/ S PROPOSED FACIILTY LOCATION OF SITE (0�9 Si�wr Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit 9/ - Publicy - Cut Slope R HORIZON I DEPTH FACTORS 1 2 3 1 4 Landscape position Slope R HORIZON I DEPTH Texture -group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG' 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: Y EVALUATED BY: 'Ila LONG-TERM ACCEPTANCE RATE: / 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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic - Mineralogy 1:1, 2:i, 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