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279 Michaels Road Lot 34DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORIIATION 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) NAME .4�01- PROPERTY ADDRESS f/{/CHIT E' S A /J- / 0,�?&TE Z��' LOCATION�'i SUBDIVISION NAME ) �' /P C--�'/��i`'S LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS -V # BATHS A # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE tl-**' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE e�L GAL. PUMP TANK GAL. TRENCH WIDTH ?/, ROCK DEPTHLINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 0 IMPROVEMENT PERMIT BY Zk a **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 �sDJ.n Q IQ ire t Uri) o pH �_►--- F -VAN P c i _ AUTHORIZATION NO. O 1 �� OPERATION PERMIT BY �v DATE b -I **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 136A, 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 10/95 Davie County. Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION j.p (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) oxo ***This Authorization For Wastewater System Construction oust 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 Officewhen plying for Building Peroits.+*+� / /� / AUTHORIZATION NUVBER NAME �J ," ✓ DATE ��/�/ !1C-� 0 ey JV NAME ON IMPROVEMENT PPEERRMIT (If different than above) � SITE LOCATION '!//,1, la"/`� ttL� V li�l 4 — COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIIATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER LS @ R a V Davie County Health Department Environmental Health Section P. O. Box 665 Juil 1 9 1996 Mocksville, NC 27028 1. Application/Permit Re ested B �/ Mailing Address . / Home Phone '" /�`�► �-�� 55 2. Business Phone 9N �' 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation 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 Section Lot # 7 ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms N ❑ Washing Machine No. of Bathrooms 1/ ❑ Dishwasher � Dwelling Dimensions 'Iw �a� A0 ❑ Garbage Disposal 6. If 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: j Vf�u`blic ❑ Private ❑ Community 8. Property Dimensions L3 6 2.Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? '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: P .OPERTY INFOMiATIO' REQUIRED: Tax Office PIN #_4 /7 Road Na;ae Box ,f (if avt;.ilable) City ZI I This is to certify that the information provided is correct to the of my knowledge, llu incurred from this application. DATE N/ I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. I 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 representa i of the Davie Count Health DeWment to enter upon above described property located in Davie County and owned by IGY)s-u tiQED L Ps UJC�.. anG. to conduct all testing procedures as necessary to determine said site's suitability for a gro nd absorption sewage treatment and disposal system. g DATE ZiGNATURE DCHD'(1193) APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMI U Davie County Health Department 95- Environmental Health Section • 2 (9 / r P. O. Box 665 1 I Mocksville, NC 27028 EALTH 1. Application/Permit Requesteed� By r©h 'o✓rri7 C•ejar-tyice- 1 Mailing Address " ` ,t iyI f;�`�" � ��:�' J i : Home Phone 6 � � 3g 33 �0 Ks, I iT//� Business Phone ;Z 2. Name on Permit if Different than Above 3. Application for: General Evaluation a Septic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly) D Business ❑ Industry ❑ Other ❑ Unknown j 5. If house, mobile home: Subdivision '� -`' 'T tea` �Q� Section Lot # 17 ❑ Basement/Plumbing No. of People No. of Bedrooms No. of Bathrooms fa - Dwelling Dimensions jp0 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ Basement/No Plumbing ❑ Washing Machine IgQQ s �� ❑ Dishwasher i ❑ .Garbage Disposal No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: rubric ❑ Private 8. Property Dimensions iQO PV�is/* Q©F S we age Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes &4o ❑ 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: �,9/ So: 9— Y., -h 97-V � /-, 6) +5 This is to certify that the information provided is correct to the best of my knowledge{ incurred from thia plicatioonn. DATE I understand I am responsible for all charges SIGNATURE *' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED FYROPERTY 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 Da�wwe Co my Health �artment to enter upon above described property located in Davie County and owned by � iy c, � o�js, ed v; 6a khc . to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE DCHD (1/93) • �� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section •' Soil/Site Evaluation ) NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY L�l��T��� LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope Al 116 HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture gr022 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATEJ_V I H. EE SITE CLASSIFICATION: P-5 EVALUATED BY: 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 ;lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V+2 -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(01-901