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354 Michaels Road Lot 10AUTHORIZATION NO. 1117- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Perriiittee's ,. P.O. Box 848 - f Name / cu, -.'f1 — -fi I..VA AJLA L Mocksville NC 27028 Subdivision Name: A Phone Th 704-634-8760 Directions to property: 1,?Y t -Cl S 1 1--' Section: Lot: r � - :� ttii 1 c 0-r Tax Office PIN:# ?�I /0 Road Name: Ek- t`' IIAEL fi 1 Zip: '� % -Z-6 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **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 I iof G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION C 4ENVI `IS VALID FOR A PERIOD OF FIVE YEARS. , AL HEALTH SPEC ALIST DAT ISS D �DAVIE COUNTY HEALTH DEPARTMENT +. -IMPROVEMENT AND OPERATION PERMITS Peaittee,s z { r PROPERTY INFORMATION -•_ , it e Name:. wi r } r!. L.Subdivision Name. Directionsto property: '11 Y' t (, l �. f ° Section: Lot: ` IMPROVEMENT PERMIT Tax Office PIN:# Road Name: i "i : c 1 E;-,,' zip:<I **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENT AI. HEALTH SPECIALIST ISS D SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE A DA INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS 7— # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS - INDUSTRIAL WASTE: Yes or No LOT SIZE'LflX LOi TYPE WATER SUPPLY C O "' DESIGN WASTEWATER FLOW (GPD) :71,–o NEW SITE REPAIR SITE 11 t SYSTEM SPECIFICATIONS: TANK SIZE �O GALL; PUMP TANK T-, GAL. TRENCH WIDTH ROCK DEPTH 1 Z LINEAR FT.�y OTHER 1 'L `�•-iKi1[�:>l)Tlpr-') REQUIRED SITE MODIFICATIONS/CONDITIONS: W�qj\Lz_ u3 CI�tJ�jtit7 IMPROVEMENT PERMIT LAYOUT I IAA 1 a L7i v /cam c:, �0. C, **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 Riga _ SYSTEM INSTALL ' V 41 ��' r \10p \ `C)iq Nr. n aT See &F r� 1 RE- Li 3ZS str Ai c,11 0 rJ Fao"3r d AUTHORIZATION NO. 11'7 OPERATION PERMIT BY: DATE: IZ4 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 Davie County Health Department „���,�. Environmental Health Section t � vo P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 OCT 81997 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED-UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. o� 1. Name to be Billed e0q,,o � 61' 1 ' / ah Contact Person l�� Mailing Address r' 0' [3 "/" -739 Home Phone'q g 4 r —7 City/State/Zip Coo )-e e of '" `7 jy C d-704 Business Phone cD0 T — L5S 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: GYbishwasher City/State/Zip ❑ Site Evaluation Sr"Improvement Permit & ATC ❑ Both ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other # People ? # Bedrooms # Bathrooms ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: 7. Type of water supply: # Showers # Seats m County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) ❑ Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes @--No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. l Property Dimensions: / DO / X X302 1 1 WRITE DIRECTIONS (from Tax Office PIN: # 5-14-6 - 10 _ 2562 1 Mocksville) TO PROPERTY - 670 6D / �^ r Property Address: Road Name ,. +/ ,. �Ut Cit /Zi iii G�4Sy l (� 1 1 v L �`% 2g 1 Y P 1 1 If in Subdivision provide information, as follows: 1 Name: Q, 0,�, r -e -s � tt �1 Section: Lot #: 1W 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 oe and owned by p I l m h ,/� / ,qio conduct all testing procedures as necessary to determine the site suitability. DATE J SIGNATURE Revised DCHD (06-96) 1 f.� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI D Davie County Health lt, Department JUL 2 11995 , f nvironmenta eat ection Lh P. O. Box 665 Mocksville, NC 27028 FAUN mu 1. Application/Permit Requested By r ©r► o ���r1 IJtr�/j� C• f' •li 44 Mailing Address —L'.� A2-t��✓_ Y;� r_:!` Home Phone 6�g 33 �rfr�=i�•4�%� Business Phone '..k sZ 2. Name on Permit if Different than Above 3. Application for: General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: ®'House p Mobile Home ❑ Place of Public Assembly __ ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision -� ,T-� GyQ£� Section Lot # 17 ❑ Basement/Plumbing No. of People No. of Bedrooms No. of Bathrooms F h Dwelling Dimensions -7-9 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 ,Zd O F7;L- s, 7 Q© r S we age Disposal Contractoi 1-1 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 ."o ❑ 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�. -�1_r b )VI -e g This is to certify that the information provided is correct to the best of my knowledge{ incurred from thi a plication. %e, 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 De�wwe Co my Health Department to enter upon above described property located in Davie County and owned by � il s o Fo2m 5 esv; fes l 1 C . to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. U� DATE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT &'JD ` Environmental Health Section Soil/Site Evaluation NAME / i6�L DATE EVALUATED ADDRESS PROPERTY SIZE 4fl� PROPOSED FACIILTY LOCATION OF SITE d� Water Supply: On -Site Well Evaluation By: AugerBoring Community Pit 0 FACTORS 1 1 2 3 4 Landscape position L Slope % HORIZON I DEPTH Texture arouP Consistence Structure Mineralogy HORIZON II DEPTH G Texture group Consistence Structure i c 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: LONG-TERM ACCEPTANCE RATE: 7 REMARKS: DCHD (01-901 EVALUATED BY: A L l OTHER(S) PRESENT: LEGEND Public Cut 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- Vl---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