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110 Brookhill Court Lot 40AUTIcORIZA'I ION NOS 19 3C.,' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittees P.O. Box 848 // Name:rs'��✓�.D�i Mocksville, NC 27028 Subdivision Name: Pne h # 336-751-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - RoacName: t70 I' / yr **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 l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECI IST DATE ISSUED y 'wy`�'sr�f/�.. k its :�. . t„_�. .r N• ': ., ... _ Y, DAVIE COUNTY HEALTH DEPARTMENT iMPRO�EMENT AND OPERATION PERMITS, PROPERTY INFORMATION Pe�min`1te�'s f f � ” Name: �` _ .' — Subdivision Name: FrJ cF' Directionsao property:/ Section: , ✓` ��f r / Section: Lotti: IMPROVEMENT /'Ci �F • ©Of�i 7 PERMIT Tax Office PIN:# - - Road0/ / Name: 00 /'/ CQL11): �Wv **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) r 1 ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPEC ALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS_ GARBAGE DISPOSAL: Yes or No - COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)_ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEARFT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT **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 (336)751-8760. 00 OPERATION PERMIT r SYS' INS ALLED BY: Y) � r/ AUTHORIZATION NO. OPERATION PERMIT BY: DATE: �T- **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. DCHD 05/96 (Revised) eq- DAVIE BOUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS , PROPERTY INFORMATION Pe> mlttee's ` NSubdivision Name: Directions to'properfy:.r°` 1, ! Section: _ _ Lot: IMPROVEMENT a •Q/Jl PERMIT Tax Office PIN:# - - Road Na e: d0 , / C -z i1 **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 '-` SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL HEALTH SPECfALIST DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �[-� # BEDROOMS # BATHS --Z—# OCCUPANTS �� GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE LOT SIZE TYPE WATER SUPPLY # PEOPLE ' # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No DESIGN WASTEWATER FLOW (GPD) -Z� �) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. TANK GAL. TRENCH WIDTH � ROCK DEPTH � LINEAR FT. OTHER -5 � 'P'UMP REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT J�� `, n i � ,✓ l **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 (336)751-8760. OPERATION PERMIT SYS INS ALLED BY: T - AUTHORIZATION NO. [&V OPERATION PERMIT BY: f Y %� DATE:i`T **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 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) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) AME C2/'we � �� /( PHONE NUMBER ADDRES BDIVISION NAME '4141 - LOT # DIRECTIONS TO SITE - xO DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY - NUMBER BEDROOMS 'If NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED Z-_ g'i% INFORMATION TAKEN BY %9-z This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Gto-und Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR CONTRACTOR C ', •- I'-) - 7 k' - DATE PERMIT LOCATION 9"It 859 S.R. N6. SUBDIVISION NAME LOT NO. 47() SECTION OR BLOCK NO. HOUSE 4 MOBILE HOME U BUSINESS El NO. BEDROOMS -' NO. BATHROOMS GARBAGE DISPOSAL UNIT YES 0 NO 0 AUTO. DISHWASHER YES (:3 NO 0 AUTO. WASH. MACHINE YES ❑ NO ❑ SITE SUITABLE YES ❑ NO ❑ SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual Public ❑ IMPROVEMENTS PERMIT BY House Trailer 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal. 600 Sq. Ft. Three Bedroom Housee--90 a 900 Sq. Ft. Four Bedroom House 1200 Sq. Ft. INSTALLED BY a—k. C., - CERTIFICATE OF COMPLETION Y�� meDate Qi (8/16/73) *Construction must 6mply with all other applicable State and local regulations LOT AREA Ale" a II ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `Note: Issued in. Compliance with G.S. of North Carolina Chapter-130—Article 13c. Name >4 Date 2152 Location G:'i'.oi // ----< _ ,r-� li� - ./'.ttL': ✓ '_ r Subdivision Name' Lot No. Sec. or Block No. Lot Size �� House Mobile Home _ Business Speculation No. Bedrooms 'i No. Baths No. in Family Garbage Disposal YES i❑ © NO -'" 1( Specifications for System: Auto Dish Washer IES ❑ NO E]�!� — '/ •p7 cm Auto Wash Machine YE Q NO E]� �C c.� Type Water Supply II *This permit Void if sewage system described below is not installed within 36 months from date of issue. 177 Improvements permit by *Contact a representativell, of-fhe Davie County Health Department for final inspection of this system between 8:30- 9:30A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. ii Final Installation Diagra System Installed by li Certificate of Completion Date *The signing of this certificate shall indicate that the system described above has been Jnstalled in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily. -for any given(iperiod of time. .... a-.:;.an•�c.. ,na. ...- ILiarrYil�ia�_wrt—.. Apr DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name _ Date Location Subdivision Name Lot No. Sec. or Block No Lot Size House Mobile Home _ Business Speculation _ No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ - Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. ! f 1 yh 4 f Improvements 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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR CONTRACTOR ATV; nS DATE .5 JJR111 PERMIT LOCATION �,dlFArw.�rn,�c,,� a"� S-�� le k,�,seJ N? 1429 S. R. NO. SUBDIVISION NAME WooAle-e LOT NO. SECTION OR BLOCK NO. HOUSE P MOBILE HOME 0 BUSINESS ❑ NO. BEDROOMS ? NO. BATHROOMS House Trailer 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal. 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft. AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE YES SITE SUITABLE YES ❑ NO ❑ ❑ NO ❑ ., n� lal (�Yj SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual Public ❑ IMPROVEMENTS PERMIT BY Yin INSTALLED BY CERTIFICATE OF COMPLETIONv By Date ://k`?7 (8/16/73) *Construction must 6mply with all other applicable State and local regulations LOT AREA "S -gait -4-a'- /5'a'X3`XIfIt Jgue( APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT p Davie County Health Department Environmental Health SectionP. O. Box 665 Nd / Mocksville, NC 27028 1. Application/Permit Requested By IV\ t, -'�> NL. IV N Y lel- `, r\ K -ttMailing Address// 5 • 16-y o us/-/r2E S% ��/ t NSEALS'ALt✓M A/.0 2%/a% Home Phone lam% /9) 743-1/W Business Phone 2. Name on Permit if Different than Above n I, 3. Application/Permit for: IP� General Evaluation ❑ Septic Tank Installation 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivisionvu Section --,� Lot # No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 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: ❑ Public ❑ Private 8. Property Dimensions 3& j k fso 3 47 Ao Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ 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: V3 This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I 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 representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation a NAME Y \`4 a U e `.{� �' e.� DATE EVALUATED ADDRESS A "` PROPERTY SIZE PROPOSED FACIILTY `Xo Qj g'0- LOCATION OF SITE Water Supply: On -Site Well Community Evaluation ByttiA Auger Boring Pit Public Cut FACTORS 1 2 3 4 Landscape position S_ .S 5 S Slope % �-,b° - �;o - I HORIZON I DEPTH " a" Texture groupL L V L L C Consistence t- 'T F T -`T Structure CL V C Mineralogy l 1 ;1 ', 1'. \ 1'. HORIZON II DEPTH 2 w' ' (OLk Z Texture group C Consistence Elr Z Structure C� Mineralogy ',1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS V7 - SS S S sf RESTRICTIVE HORIZON �— SAPROLITE --- CLASSIFICATION S \ 5 q -S S LONG-TERM ACCEPTANCE RATE -:O - 4 '� SITE CLASSIFICATION: 5 - �o �EVALUATED BY: \v �cv�� -_Ba ROW S LONG-TERM ACCEPTANCE RATE: , 3>� ' �� OTHER(S) PRESENT: REMARKS: sic.y. ��� L Zz' 'zkw\ 3 (" q: t' I .Z 3 , DCHD(01-901 LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope CC -Concave slope CV -Convex slope Texture q�--�o�� e.S_ FS -Foot slope N -Nose slope T -Terrace FP -Flood plain H -Head slope S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty clay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR-Very 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 SC -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 wate►' 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