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378 Michaels Road Lot 13AUTHORI.ATION NO: DAVIE COUNTY HEALTH DEPARTMENT N ", 13 j u Environmental Health Section PROPERTY INFORMATION 5/.�1' �g PermitteeIs r P.O. Box 848 Name: G91� v- X' 1 t t..Y1&A Mocksville, NC 27028 Subdivision Name: Ilie- e- 4CiZ90 2 09-, ap Directions to property: Phone #: 704-634-8760 Section: Lot: d J�Q /� AUTHORIZATION FOR i✓ (< 1L^i t i ,. WASTEWATER Tax Office PIN:# 7'%%<_' F SYSTEM CONSTRUCTION 4 Road Name: 11^ sIGS� Zip: 77��� **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) ,�..-.a..� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIROf4NJE,NTAL HEALTH SPECIAGS'h DATE ISSUED ik 1tJ f_F'j �� r1v r ./�.+: f ., fig ii.1r.) r `i f^ •'f..k... . .. - v �� ,__ ...'Y. A HO_ RIZATION NO: 1578 DAVIE COUNTY HEALTH DEPARTMENT 'Environmental Health Section 'Environmental PROPERTY INFORMATION . Permitt8e's . ,. P.O. Box 848 hi;-r=+'� Name: Mocksville, NC 27028 Subdivision Name: ""lL. -� a i / Phone # 336-751-8760 Directions to property: f r : �� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#, i''11�- 0 - SYSTEM CONSTRUCTION RiadName: **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) ' f %! �- " NLJIIUE'*'IHlJAUIHUK1LAI1UNPUKWAJIEWAIUKCUNNTKUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED rT. FlfO:^:.s�""f': ,;J.._.. r7^._� � �y.n....V"M•eKSy�N_���.._-.,r.-,.-J� ,r�•,,,,,,,,� .K n.n,,. F ._ -_. __��"'..-� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Z.1.1 N =ect LmA� Subdivision Name: eo 1 E'_ vvo �0 vQ14PTQPgrtY: �' 1 .� '�''� 13 5 � � ^� �'�` � � Section: � Lot: "�►.,.. IMPROVEMENT (: ^3 C �,1 r PERMIT Tax Office PIN:# S 74&- Road 4&Road Name: M44we, Zip: "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 j construction/installation of a system or the issuance of a building permit (In coinoklim with Article 11 of G . Chapter 130A, Wastewater Systems, Section'. 1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE Id ~: %f PIANS OR THE INTENDED USE CHANGE„ VOi3k WASTEWATER ENVIR AL TH r: DATE ISSUED SYSI'E O CONTRACTOR MUST SEE THIS P�IIT BEFORE INSfAI,'I, G THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 4A H # BEDROOMS 02"�— # BATHS —,?— # OCCUPANTS GARBAGE DISPOSAL: Yes oQdo COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT` # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLLLfJW DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE I C)OOGAL. PUMP TANK GAL. TRENCH WIDTH t' ROCK DEPTH Zt LINEAR Fr.� / oTIIER � 1715TP.��,m � 5 t REQUIRED SITE MODIFICATIONS/CONDITIONS: P,�'e�'T�L L rtar.� e—c.-rAnoe tk"P S cfr K40~—, 14a4 --P l p i /Ot:C PQaP Lw� "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) 6348760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION N0. t S� OPERATION PERMIT DATE: T !"THE.ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T SYST=EM ABOVE HAS BEEN INSTALLED INCOMPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TMENT AND DISPOSAL SYSTEMS", BUT SHALL IN No BE TAKEN AS A GUARANTEE THAT THE SYSTEMVILL FUNCTION SATISFACTORELY FOR ANY GIVEN PERIOD OF IBM V' y.. Fa w„ APPLICATION FOR SITE EVALUATIONAMPROVEMENT-PERMIT & ATC ` Davie County Health Department Environmental Health Section2 0 1998 P.O. Box 848 „F Mocksville, NC 27028 (704) 634-8760e ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Contact Person Mailing Address Home Phone City/State/Zi Business Phone 2. Name on Permit/ C if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC [oth 4. System to Serve: [ ] House [ UZobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms 3 # Bathrooms 2-1 [ ishwasher [ ] Garbage Disposal [qzhing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 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 [ V--' If yes, what type? tL-111b t A FLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***.XAcE=l OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: "Dor x l 0c), WRITE DIRECTION (from Mocksville) TO PR �ERTY: Tax Office PIN: #5%� - 10 `Yo ( U Property Address: Road Dame ( � City/Zilp Ma ASv cllz A9 0-0 UOU If in Subdivision provide information, as follows: Name: &ai Section: Lot #: 3 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 o�unnty-He_alth Department to enter upon above described property located in Davie County and owned by ,,KtJ Q l.�CiyY�Q�✓ t onduct all testi rKdes as necessary to determine the site suitability. DATE t --P - qg SIGNATURE Revised DCHD (06-96) THIS AREA MAY 13E USED FOR DRAWINC7 YOUR SITE PLAN: T. ItsI CrN .s•:rr ' )w��L .,sspr° A - '' t '7 LA ` 1 _ 1f"(' r ' 'rt C r- Cry t1• _ - - pLu'i �,��-_ .p r�� /+ u' All � � U tom' [ G 'av Soy Lius 41 a yt� CD z i s, 1 t t �r!F" t� `� 0} cO.Ls' -% 7J [TO p9 ctl 3,SO,t� 1 6 �I fi 3 L£ ��—'sa ^' _ti nd3 _--- ;a �0 iL '< �-- 10 IU00 jr1ol— s5'G L£ f—__--- - p 1 Dd 04.46u I I IJ spooD so jai cibo£' ate:• Moog ,old ui pep:Daa, DU0 8V .7 9t �cfi XD1 .. uoVlD,lcl�o, sol P41113 go 7. �� f vi r .qye �ee.c.TW'rloge *n$ JO QWD1S 1 1p8S cru, 04u nu uD1,0,seltSol 'o,nlD to 'j��i - IDes puD ,,,,,do, so► {d �1,:�i'. •e` •g •D 4!I■ eauvp:oaao ul S �_—aCcd - # -- a uauD sD Q£—Lir o ellD, eyi ,Dq, ,+1 y a o :+, sseGliM P F ao ,d 1 e,a pe Le A,n: so ualel ,00Va —( _ ,Duitil' ,D,tt :OW.0j /1 S. De,ot^auoaWo,l uwo,p so Gotoa VPu �.r� Moo6 us Fe'.,o^-e, �� -0�5 ci47 luno, no uol,ocu,oi t eSod 1 L'• sl�,edns A-Prr7 !°�� topO ui e , loos .(10410) ('a!o en,nc Ion, aD ui ;uI not - sou cel,ODuno9 4 Lw ,eGun eP l,eyoa oD,o00 `1 �:•-z Frt, uo ew ,-+0te0 .-�caJ uolsin,edns L yea •ouo,S c DR , D I D 1 1 1 1c—.a�—ss_-r�=..:t.z uol, dl ,>soP Peep) un u:o,D d e14, , 4 xlrnc ptm4 F•• d:u ,ep i ?= (1 � s' � c-cn ai0 G>t-+ D"D �.�,c�.,...•� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI Q 5 Davie County Health Department ✓ i, ' Environmental Health Section JUL 2 1 1995- f P. O. Box 665 !!! Mocksville, NC 27028 EAl1N 1. Application/Permit Requested By r oh 'o -avyn Ser-'I"z— C• Nrtoc man Mailing Address __ [ _-�._ _ 4� 19 33 . �' Home Phone _ A 0,�S , y %/!� Business Phone ' k 7 sZ 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 s vf-�IS 5. If house, mobile home: Subdivision" �6,0 Section Lot # IT ,_ "? ❑ Basement/Plumbing No. of People No. of Bedrooms No. of Bathrooms (+- Dwelling Dimensions �1p0 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 , d O dC7-7'— �siZOO ©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? ❑ Basement/No Plumbing ❑ Washing Machine El Dishwasher ❑ .Garbage Disposal ❑ Yes "0 ❑ 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: DO �/— ew 1 � -S y^•�S �a s This is to certify that the information provided is correct to the best of my knowledge, incurrd f m this a�plication.� DATE I understand I am responsible for all charges SIGNATURE h' 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 Dawe Co my Health �artment to enter upon above described property located in Davie County and owned by n ii 5 c, FoNnr 2d v;'c Lehi• 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 _07 =� Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE U PROPOSED FACIILTY usr' LOCATION OF SITE a _ Water Supply: On -Site Well _ Community Public 4--" Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % �- HORIZON I DEPTH Texture grouP Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence l Structure ! 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: 0/ EVALUATED BY: _4 Y.a. G/ LONG-TERM ACCEPTANCE RATE: — OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R -Ridge S7Shoulder 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 DCHD(01-901 Davie County Health Department -off 6ft� Environmental Health Section . R P.O. Box 848 210 Hospital Street! Courier #: 09-40-06 c Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 -SITE WASTE TER CERTIFICATION (Check epla cement Remodeling Reconnection c` `-��� Name: S � � �� l •��- Phone Number � Q (Home) Mailing Address: .} C LM vct G f (Work) Email Address: Detailed Directions To Site: 15 C 1q111e-0e5 [01-111-8 Please Fill In The Following Information About The EXISTING Facility: Ll q Name System Installed Under: Lq 0 Type Of Facility: 11nH Date System Installed (Month/Date/Year): Is The Facility Currently V Any Known Problems? Y No `` umber Of Bedrooms: Number Of People: If Yes, For How Long?. No /If Yes, Explain: Please Fill In The -Following Information About The NEW Facility: Type Of Facility: RAO Vr old Number Of Bedrooms: Number of People �ool Size:. age Size: Other: � Requested By: f Date Requested: d �ature) For Environmental Health Office Use Only Approved isapproved omments: Environmental Health Specialist Date: /b/ q / / (k *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken a§ a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order #. Amount:$ Paid By: Received By:_ Account #: Invoice #: NV s Printed:Oct 07, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. 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