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109 Dublin Road Lot 1'!i.'H,p rti,5,ea.,,y(v, "Y`�4 v�f4-�`* rc q,}y.•i iYx d':�%.i;11 v'Nr'':L,aNt ry 'r.i.:,$T..y�,aApY��,y f.:�[ I{i „�5;pry:'n .� �.5y'n ywp 'i � I�ksay f� y��Y • J' AVIE COUNTY HEALTH DEPARTMENT / /a MOVEMENT a k" 41VIJOVEMENT AND OPERATION PERMITS PROPERTY INFORMATI( PehA'I ee sl Su) dMsion Name: ^,0A,,j Dir_o_n;-tmproperty:+ L{L] fe3_ICrJ Section:/ Lot: . IMPROVEMENT .. ��y� PERMIT' Tait Office PIN•�teL!_ o Road Name: J �� jip: �2 i **NOTE** This Improvement Pernlit DOES NOT authorize the constriction or installation of aseptic 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 pemrit, (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 . -41 ;., �J_ , % ' . 1 j' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTHSPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. .)LK RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS ,�� # BATHS Z # OCCUPANTS GARBAGE DISPOSAL Ya or N6 COMMERCIAL SPECIFICATION: FACILITY TYPE//ff # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY 6 DESIGN WASTEWATER FLOW (GPD)C f // NEW SrrE__Le_-' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 20t GAL. PUMP TANK - GAL. TRENCH WIDTH cf -v�ROCK DEPTH LINEAR FT. JfO6 OTHER - REQUIRED SITE MODIFICATIONS/CONDITIONS: **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. N � I CP� �1– F rm Q � .DATE: AUTHORIZATION NO. Q ' I— OPERATION PERMIT **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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 PE � Davie County Health Department JW EnvironmentaCHealth Section P.O. B'ox 848 APR - 81997 Mocksville, NC 27028 (704)634-8760 I I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed B030, I� / r .+ L44421 Contact Person l� i I be -4 /J o� 6 y Mailing Address i!5 -24k US l7wy /11�y Home Phone 998'' 7i3 S- City/State/Zip A 4 VA ti C e /t1, C• a7c b b Business Phone 9 9$ 3 3 2. Name on Permit/ATC if Different than Above C 0 2 G `\ v' I c e - S Mailing Address cS✓F /-I e- ' City/State/Zip tS9 m 3. Application For: [ ] Site Evaluation WImprovement Permit & ATC [ ] Both 4. System to Serve: WHouse [ ] Mobile Home [ ] Business [ ] Industry[ "] 'Otther t 5. If Residence: # People --3L # Bedrooms # Bathrooms a4 il Dishwasher [ ] Garbage Disposal [,j ashing Machine [ ] Basement/Plumbing [ ] Basement/N6 Plumbing 6. If Business/Other: Specify type IF People #Sinks # Commodes # Showers-qg # Urinals- # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [y f°ounty/City [ ] Well [ ] Community) 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ I If yes, what type? ] Yes (i]'I10 EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:*** IMPORTANT *** AVMCPOF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: I A 0 yl l 1 6 X 2"76 Y '02 tee ; WRITE DIRECTIONS (from Iocksvdle) TO PROPERTY: Tax Office PIN: #S`! r Property Address: Road Name LO -4I fJubl!N .P J- i City/Zip ,;A � JA N c e c. i If in Subdivision provide information, as foilows: Name: L S ;l fl,r h e ,l` A Section: Lot#: (� This is to certify that the information provided is correct to the best f 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 1 A �I A b /t-( #1v R- to ndu't all to ng ocedures as necessary to determine the site suitability. DATE !� - 97 SIGNATURE_��� Revised DCHD (06-96) THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: J ' \ w. r„ �V • /� � ,�. - � �1�opv 7z°�vy�E\ / o`e'kz hi.�s a / Q ' ,e��� rte•_ ~ JD. p9 SHAMROCK ACRES`"° oMxfes�aR•FioPvue I - \S W. - `_ DUW M. 0711�RA: Jrf� M .�� MA°i,� . - ldC�O1dR0 - . reswtesrfr�ex e•,.n - - _, _ - Q - ADVANC& W. (910) 240-506 qq `�Q,_ �• p t4C• OLRVA b X7 �{ jdo Ar F I Q Y DAVIE COUNTY HEALTH DEPARTMENT` Environmental Health Section // Soil/Site Evaluation /� / NAME dew/? 4dode1� DATE EVALUATED `�7/�� lS ADDRESS ha- PROPERTY SIZE PROPOSED FACULTY LOCATION OF SITE Water Supply: On -Site Well - Community Public Evaluation By: Auger Boring Pit f - Cut FACTORS 1 2 3 4 Landscape position Slo e Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH F F Texture group Consistence Structure k S Mineralogy HORIZON III DEPTH Texture group Consistence Structure t. Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 'EVALUATED BY: �F/ OTHER(S) PRESENT: 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 :lay loam, - SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay 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 '1PR-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 Saprolile - 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 \ \,k�.-...m.s ...... a � „�-n� ..-ym::rv'n f•+i i'v.yy'^raH tiko•7.�'?"+-^...,ns:�rn Ec. ".Y'�'•.Ta- .�`iy`l i'n.[1+,rtr ..� -. _.•,• ��O �4MI [jIZAT N N( % 9 PAVIE COUNTY HEALTH DEPARTMENT �C-n �'�s+'��S Environmental Health Section PROPERTY INFORMATION' -a Pzrnn ee's : P.O. Box 848 /} Name r G.. Mocksville; NC 27028 Subdivision Name: runaz "t / •� Phone #: 704-634-8760 . Directions to property ;hl /, ewTt Section:_ Lot AUTHORIZATION FOR WASTEWATER Office SYSTEM CONSTRUCTION : Tax PIN:.16 ' Road Name: / ip: ©�p **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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal; Systems) , ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION Ai 619,/, it 1. 1�- fi aJ7 IS VALID FOR A PERIOD OF FIVE YEARS ENVIRONMENTALHEALTHSPECIALIST'. DATEISSUED