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301 Michaels Road Lot 31Vx° Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 SO, 00 t AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***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 BuiTding�lnspections Office when applying for Building Permits.*** M Q AUTHORIZATION NUMBER NAMEP�Z.es�1 DATE �+ \3 ct `G. NAME ON IMPROVEMENT PERMIT (If different than above) I ( \ SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.' j ENVIRONENTAL HEALTH SPECIALIST DATE DCHD 10/95 AX 0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMIPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic 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 permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME J�ax9_ ' PROPERTY ADDRESS _%fI/L�f1.g�.�S� _ DATE 3 3 -c b LOCATION U I') SUBDIVISION NAME SLOT NUMBER SEC./BLOCK NUMBER � c RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ! BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes J�o COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE JOU X 3M� TYPE WATER SUPPLY CA DESIGN WASTEWATER FLOW (GPD) NEW SITE ✓ REPAIR SITE BOG SYSTEM SPECIFICATIONS: TANK SIIE A06 GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH LINEAR FT.� OTHER REQUIRED SITE MIODIFICATIONS/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. 1 vc1' IMPROVEMENT PERMIT BY **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 RA`*"\t%4 AUTHORIZATION NO. 0�kA(5-0 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, 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. DOHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE _ Davie County Health Department Environmental Health Section P. O. Box 665 MAR " 7 1996 Mocksville, NC 27028 . A I 1. Application/Permit Requested By a + /1,a rr e r Q(o �j r esA / Mailing Address 7 % -�' L ct� r'!:11 -1G' e C+ Home Phone 6 -';� �— �IF-35 y cj S L_/ i � /V G oz 7 8 Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation ASeptic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown / 5. If house, mobile home: Subdivision SG �c �e S Section Lot # �— ❑ Basement/Plumbing No. of People — ❑ Basement/No Plumbing No. of Bedrooms Washing Machine No. of Bathrooms Dishwasher Dwelling Dimensions g A, ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: 4 Public ❑ Private 8. Property Dimensions 10d k 300' Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes I No If yes, what type? ❑ Community 'NOTE: Improvements Permits shall be valid 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 incurred from this appli tion. 3` r -2p DATE PROPERTY INFORMATION REQUIRED: Tax Office PIN: # PROPERTY AbbRESS, as follows: Road Name: city: SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. the best of my knowledge, and I n r i rowSo 6A, PtG6 I am responsible for all charges C - CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 5/1'. 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 representative of the Davie Count Healtrg r hent to enter upon above described property located in Davie County and owned by t`G/VS8 el, M j 6 / C E //V C to conduct all testing procedures as necessary to determine said site s swtability for a ground absorption sewage treatment and disposal system('�, J—b,Gr'� DATE SIGNATURE DCHD (1193) .. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI f �+ Davie County Health Department t I / H Ith Section � nvironmen a ea JUL 2 1 1995- r P. O. Box 665 J Mocksville, NC 27028 Ema=. 1. Application/Permit Requested By--- C• o" �i Z 1A Mailing Address r `i_ g,r' �. fi l a l Home Phone AT0 Z Business Phone '. k T s2 ✓-S 2. Name on Permit if Different than Above 3. Application for: /� General Evaluation 0 Septic Tank Installation Permit 4. System to Serve: V House ❑ Mobile Home ❑ Place of Public Assembly J_. ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision —`' e 4` �Q� Section Lot #�_ 17 ❑ Basement/Plumbing No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions //00 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories 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.. PE y �� Q©� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/No Plumbing ❑ Washing Machine ❑Dishwasher ❑ .Garbage Disposal ❑ Yes &40 ❑ 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: � 0/ S°•A V JV/ -8 +5 �I This is to certify that the information provided is correct to the best of my knowledge{ incurred from thi 2picaltion. "- DATE I understand I am responsible for all charges SIGNATURE 'Al CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED ftPERTY 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 County Health De artment to enter upon above described property located in Davie County and owned by it t v f-od 2ew; tem i� . to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. Zyp -�, s DATE DCHD'(1/93) • , DAVIE COUNTY HEALTH DEPARTMENTS f r Environmental Health Section Soil/Site Evaluation NAME ,��'/Yl�^� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTYLOCATION OF SITE G! Water Supply: On -Site Well Evaluation By: Auger Boring Community Public C� Pit Cut FACTORS 1 2 3 4 Landscape position 4 - Slope -1. HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH (- Texture groupL Consistence Structure P - 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: 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 -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 Ilorizon 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