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377 Madison Road Lot 2AUTHORIZATION NO. OPERATION PERMIT BY: -ATE: - I "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIB B VE 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 WB.L FUNCTION SATISFACTORILY FOR ANY.GIYEN PERIOD OF TIME. DCHD 05196 (Revised) - - - -- APPUCAUON FOR SIZE EVALUAitON/IMPROVEMENT pE IMfi do ATC Davie County Health Deparhnent Envitonmenta/Hea/th$eXVOjl P.O. Box 848/210 Hospital Street Hockaville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �I ,Ci ©%7! (i p contact Person Nailing Address s _ 1��Q�p/� {-���'�1LV - �{ Bae Phone _ .� 3QO-( I City/state/ZIP ly O�/�y 6V L W C11 Business Phone a. Name on Permit/ATC If Different than Above Mailing Address Clty/state/Zip 3.. Application For: Site Evaluation J3 Improvement Permit/ATC ❑ Both 4• system to service: 3<House ❑ Mobile Rome ❑ Business 0 Industry ❑ Other S. If Residence: / People / Bedrooms ���h1-t Bathrooms Dishwasher D aatbage Disposal >Aashing, Machine 0 Basement/pin bing' 0 Basesnli/No plumbing 6. If Business/Industry/other: specify type i! People /amts a commodes / showers t Urinals !! Nater Coolers IF FOODSERVICE: tl Seats Estimated water Usage (gallons per day) 7. type of water supply:County/City ❑ well ❑ Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve! ❑ Yes ❑ No If yes, what type! ***IMPORTANT'**CLIENTS AIUSTCOMPLEIETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: _ ' i () () X 116L 00 WRITE DIRECITONS (from Mocknille) to PROPERTY: Tax Office PIN: # J 2 lci 2 j — 4.2 i" J / QQ�)��� Property Address: Road Name /_I`l [ G� �) G h OU q (12-A P City/Zip �-ffXil.�IJu m, -i �C/ If in a Subdivision provide information, as follows: Name: Section: Block• lAt: 1;Z_ Date Properly Flagged: 9—.-30 — ql? 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 mile plans or intended use change, or if the information submitted in this application is falsified or changed. I, dw, understand that I am responsih/e for aU charges incurred frons this appUcadom I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the siie adi ab�ihflih . , DATE (o-1— 1 2 SIGNATURE 4Ar✓/1 , THIS AREA MAY BE USED FOR DRAWING YOUR SITE PW (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No �2 Q JCJ Invoice No. ---0114� FUTURE SECTI NS PARCEL 103.03 TAX MAP H -4 /1 GISELA FAAK I D. B. 147- P. 666 1 Total 198.35' 1 j 07°-02 - 50 E- 1N 3 98.05 100 116.97 3 control 100 3 w _ 3 -� 'tn PARCEL 103.01' Z5`� v eonea`r m�� � N to _O I ?TAX MAP H-4 1 a -N _ o9Jl _ — O— in 2 m m JIMMY L. JOLLYM p 3 M O o 4 o o' N ° a) N o D. 8.148-P.050 20,055 SO.OD N M _ o N 3-,�a -N QD 20.055SQ.F7 NOD 40 b.I.z co ao 21,697 SO.FT.z 20.000SQ. 102.55 100 16 3. 12 100' 100 M -- S 07°_02'-50 W S070 -10'-25"W "' 60 !—S 06'-27 W Total 102.55 _15 Toi DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name _v \ o1� Date 3 -7 9 Address S- Lot Size FACTORS AREA 1 AREA 2 AREA 3 APPA e 1) Topography/ Landscape Position 6) 8) 9) S �. S PS U SPS/ PS U PS U 2) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) 4; S PS P S PS U U U 3) Soil Structure (12-36 in.) Clayey Soils S PS) S U S PS U U 4) Soil Depth (inches) S PSS � S PS U U U U i) Soil Drainage: Internal S ® S S -ZTP U S PS U U External PS, t PS S PS U U U U Restrictive Horizons )Available Space 5� S S PS Other (Specify) S PS S PS S PS S PS U U U U Site Classification . S, v T '5� U—UNSUITABLE Recom men dations / Comments: S—SUITABLE PS—Provisionally Suitable . Described by d'C Title oar• Date SITE DIAGRAM 7L 0Z 91 fou (6-82) 43 010