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112 Rick Way Lot 17f�XO AUTMIU I-ATION NO- 15- 6'I DA' OUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's! l P.O. Box 848"' Name: Mocksville, NC 27028 Subdivision Name: ' Phone # 336-751-8760 / Directions to property: �.;" " :� ✓'� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office SYSTEM CONSTRUCTION Q _ s Road Name: Zip: `� C�t��'y > **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 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) -) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r,.�.-.s•v. T V 1- Vr.y.•. -l.. Jv.w. v.-�,..Y�[...� �,�...- ...,�,., ....��J�IV �T•il Y`yTn ..[•f n'.'b•t T. �'- M $ 6 DAME OUNTY HEALTH DEPARTMENT + f IMPROVEMENT AND<<OPERATION• PERMITS PROPERTY INFORMATION Subdivision Name. ::. ,�lrecgons to Property. '!" '� Section. J Lot l n PER ., •Tax Office t Road Nan e: Zip: **NOTE**. This -Improvement Permit -DOES NOT authorize the construction or installation of a septic tank'system or any wastewater system An - AU'IiORIZt1TION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the consttuetion/installation of a system or the issuance of a building permit (In complianoewith'Att cle 11 of G.S.;Chapter tVA, Wastewater. System's; Section .1900 Sewage Treatment and Disposal Systems) r !�'*NOTICE'�"�'" TEAS PERMIT IS SUBJECT TO REVOCATION IF SITE } *,�, y PLANS OR THE INTENDED USE -CHANGE YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ' INSTALLING THE.SYSTEX. i + RESIDENTIAL SPECIFICATION: BUILDING TYPE' # BEDROOMS # BATHS_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or, No LOT SIZE. �•6D TYPE WATER SUPPLY �,,e •DESIGN WASTEWATER FLOW .(GPD) JW NEW SIZE REPAIR SITE ' y j SYSTEM•SMCIFICATIONS: TANK SIJ�GAL. PUMP TANK " GAL. TRENCH WIDTH f /! ROCK DEPTHLINEAR FP7 OTHER REQUIRED STTE'MODIR'CAk' ONS/CONDTTIONS ` **.CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINALiNsoECTION OF.THIS, SYSTEM BETWEEN 8:30 = 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.'. i APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT T 0 M R Davie County Health Department V l5 Environmental Health Section P. O. Box 848 JUL 17 1998 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE ALL THE �REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed kw �wr " Contact Person v ' Mailing Address � V 84% — Home Phone �7 PP City/State/Zip oa l w a& / t`� J-7014 Business Phone ��'7 l/ 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. IIf Residence: "ishwasher 6. If Business/Other: # Commodes If Foodservice: Cl Site Evaluation ❑ House [9'/Mobile Home # People ❑ Garbage Disposal Specify type _ # Showers # Seats 1Ciitty/State/Zip LY Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms 13 ❑ Both ❑ Other # Bathrooms (Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: ❑/County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes B No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE 3 SUBMITTED WITH THIS APPLICATION. Property Dimensions: qq Y `3 DD 1 WRITE DIRECTIONS (from 57,74 _ I _ ��58 I Mocksville) TO PROPERTY. Tax Office PIN: # 1 /'„ D I (' Property Address: Road Name -h4 � 4 oG l/l� d-704 �C�fJ City/Zip 1 b O 1 If in Subdivision provide information, as follows: 1 Name: k6b 1 Section: Lot #: 7 1 1 1 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 determine the site DATE —7 J �" Revised DCHD (06-96) SIGNATURE all testing procedures JUL 2 1 1995 - f P. O. Box 665 Mocksville, NC 27028 F_ EALTH 1. Application/Permit Requested By ( off 'D '_agrm_Serd"e— C• Ri Ja r t ki CK - Mailing Address � �r ? 1 AVY-d—Y !� Tri Home Phone (o 2`f 3g 33 Business Phone ak 7 ;Z `J I 2. Name on Permit if Different than Above 3. Application for: �/ General Evaluation C3 Septic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision —`'� sT �(3� Section _ Z Lot # _ i No. of People No. of Bedrooms -� No. of Bathrooms ��- Dwelling Dimensions , T , //00 7v 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine Ig04 S ! _l— El Dishwasher ❑ .Garbage Disposal No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ? ❑ Private 8. Property Dimensions ,// O DG7y s% 7 Q©� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? M ❑ Community '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 Property: �©/ This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. DATE / I understand I am responsible for all charges SIGNATURE ;' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY 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 representativ of the Dewe Co my Healthartment to enter upon above described property located in Davie County and owned by tnni 5 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. c DATE DCHD (1193) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI �i Davie County Health Department Environmental Heaith Section JUL 2 1 1995 - f P. O. Box 665 Mocksville, NC 27028 F_ EALTH 1. Application/Permit Requested By ( off 'D '_agrm_Serd"e— C• Ri Ja r t ki CK - Mailing Address � �r ? 1 AVY-d—Y !� Tri Home Phone (o 2`f 3g 33 Business Phone ak 7 ;Z `J I 2. Name on Permit if Different than Above 3. Application for: �/ General Evaluation C3 Septic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision —`'� sT �(3� Section _ Z Lot # _ i No. of People No. of Bedrooms -� No. of Bathrooms ��- Dwelling Dimensions , T , //00 7v 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine Ig04 S ! _l— El Dishwasher ❑ .Garbage Disposal No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ? ❑ Private 8. Property Dimensions ,// O DG7y s% 7 Q©� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? M ❑ Community '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 Property: �©/ This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. DATE / I understand I am responsible for all charges SIGNATURE ;' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY 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 representativ of the Dewe Co my Healthartment to enter upon above described property located in Davie County and owned by tnni 5 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. c DATE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY A17 DATE EVALUATED PROPERTY SIZE Ci1D.Y30ti LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L -i J_ Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH f Texture group Consistence Structure is S 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: �s / EVALUATED BY: LONG-TERM ACCEPTANCE RATE: i 1` 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- Vf---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 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(01-90)