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446 Michaels Road Lot 21a DAVIE 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 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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME /1 J % ✓ PROPERTY ADDRESS LS IR1 - °2 70A T DATE LOCATION SUBDIVISION NAME /�/( LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS —'2- GARBAGE DISPOSAL: Yes/No CRCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE., TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE !%REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE A00 GAL. PUMP TANK OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: GAL. TRENCH WIDTH ?V ROCK DEPTH-)" LINEAR FT. IM26 ***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. IF IMPROVEMENT PERMIT BY / ! �Z **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 AUTHORIZATION NO. fJ.�D,2 OPERATION PERMIT BY �aC/ DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMIPL.IANCE 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 FUNCTIONSATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 Davie County Health Department " ' * ENVIRONMENTAL HEALTH SECTION y P.O. Box 665 Mocksville, N.C. 27028 - - AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of ' G.S. Chapter 130A, Wastewater Systems) ***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 Office when applying for Building Permits.*** ` ��/ AUTHORIZATION NU�ER NAME / ,% DATE /. 7/ fz �a �' d 3 G. F' NAME ON IMPROVEMENT PERRM"I'T (If different %than above) 9 SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **fNOTICE*** THIS AUTHORIZATION FOR A ATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. � 4/"A4? ENVIRONMENTAL HEATH SPECIALIST DATE .DCHD 10/95 i APPLICATION FOR SiTE EVALUATION/IMPROVEMENTS PER 1D h Davie County Health Department ` Environmental Health Section ASR P. O. Box 665 'i Mocksville, NC 27028 t. r 1. Application/Permit Requested By t7ae�c" � Q� i Imran Mailing Addressb • K r] 3g PP rnc°,^ �Ci Home Phon ) 2. Nnmo on Permit 11 Oilloront thnn Abovo .�. a, Applicnflon for: Q Onnornl Fvnlunfinn t[.1 Soptl(-,Tank Instnllation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Put Assembly i ❑ Business Cl Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision '-5a1bc. A- -es Section '-ot # No. of People a No. of Bedrooms 3 No. of Bathrooms 7 Dwelling Dimensions J' rl �4 )4 X D 9 6. It business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals ❑ Basement/Plumbing ❑ Basement/No Plumbing Washing M: '.-gine ❑ Dishwasher ❑ Garbage Di :posal No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions 1 n(0 )( 3 00 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? ❑ Community i 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. improvements Permi" are subject to revocation, it site plans or the intended use change. Effective October 1, 1989. PROPERTY INFORMATION REQU 1::D : Directions to Property: Tax Office PIN 47 t? (V - Road Name Bo:: #(if available) City 0 This is to certify that the information provided is correct to inciirri'd from IhiS ai/�lPiin�tinnAA of my knowlp(dg6, anroyynderatnnd I nm rnspnn ihlu her iill chim1wi .. fh 1.x.1 1Y1.1�-••� CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DES---CRIBEED' PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 0 2. 100 NOT OWN the property. It 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 Co n Health D en o -enter upon above de,-,cribed property located in Davie County and owned by r- "/ ,SO '11 9 W 1 (_ -//I, Lto conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system, c t 0 1 , d" DATE SIGNATURE f` 4 P. O. Box 665 MW f' Mocksville, NC 27028 I � 111 � N �IdTA EALTH 1. Application/Permit Requested By (Ji©h 'O 6ryn Se e-- C• 9,, r e yi ce, So Mailing Address �L 1 _ i:�• t! f Home Phone TT �. ��,�,� Business Phone K7 ;Z `JS� 2. Name on Permit if Different than Above 3. Application for: General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: 9 -House ❑ Mobile Home ❑ Place of Public Assembly] ❑ Business ❑ Industry ❑ Other ❑ Unknown n vf-�iS 5. If house, mobile home: Subdivision -� –"-' ''T o 4' �B� Section _ Lot # APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Davie County Health Department Environmental Health Section D JUL 2 1 1995 - ,7 ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms / fA- s ❑ Dishwasher Dwelling Dimensions - '' %,100 7—iP Boo ❑ .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: ublic ❑ Private ❑ Community 8. Property Dimensions /LJ O F/– All. F Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes "o 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: �0/ Sa.A r 4 , � 411 t P CI,�.Is � V JVLD IS �� This is to certify that the information provided is correct to the best of my knowledge{ incurred from thi application. %011 DATE I understand I am responsible for all charges SIGNATURE` CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED &OPERTY 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 County Health De artment to enter upon above described property located in Davie County and owned by ii5 e-� kg&z Cemce,c. to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 2 �5�.-�, s DATE DCHD (1 193) r' DAVIE COUNTY HEALTH DEPARTMENT�� Environmental Health Section Soil/Site Evaluation NAMED DATE EVALUATED�,�� ADDRESS / PROPERTY SIZE PROPOSED FACIILTY % i9/l� P LOCATION OF SITE 4WXX1de 1_f1 Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH .� Texture group 0 Consistence ,- 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: _4er— EVALUATED BY: ,A 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 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/f12 DCHD(01-901