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361 Hobson Drive Lot 8... .-ori.. _ ktTTHbRI7�ATION NO: "n R $ i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pernfittee' `.-', P.O. Box 848 Name: n='vim= •�• - �.�.Rcgai•-0'm '� Mocksville, NC 27028 Subdivision Name: �;� Phone #: 704-634-8760 { Directions to property: V Section: Lot: AUTHORIZATION FOR ri Q0 »� WASTEWATER Tax Office PIN:#� t4J - L SYSTEM CONSTRUCTION ` Road Name: c.�r` Zip: h1 U1 **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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED R �.. � '<.3-•;. ,..., ' "•_..'a ..� ,.: -' j _... h 1 ,� R -ter '.:: /.� r( , , - �,_ � .. ... -. � .. �1�0 DAVIE COUNTY HEALTH DEPARTMENT -1� IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORM TION Pe�tixtCee'� -. Natrie:' _ , �'ti, .^ -Y`;�. '_-� csR1T 1 x , ; � Subdivision s_ �'ti � S •visio Name: (� '• ' ' ,'i Directions to property: Section: Lot: t 1% IMPROVEMENT PERMIT Tax Office PIN:#..-:� Road Name: `'•.. r �. }'` "' 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 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 ,,"� s .? " �•� M PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPAL BEDROOMS # BATHS 'Z # OCCUPANTSL-- GARBAGE DISPOSAL: Yes.Q COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �5;�1 TYPE WATER SUPPLY \0 n� DESIGN WASTEWATER FLOW (GPD) ,1C) NEW SITE REPAIR SITE r SYSTEM SPECIFICATIONS: TANK SIZE I D 0lD GAL. PUMP TANK b GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 0 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT i� I�1ai **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: _ 6 i AUTHORIZATION NO. OPERATION PERMIT BY: I 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. DCHD 05/96 (Revised) # APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department E� C� E i Jij Environmental Health Section - s I I ? j P.O. Box 848 31A; 91997 � ' Mocksville, NC 27028 ' M (704) 634-8760 c l ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed / Rri Contact Person Mailing Aiddress o Home Phone y 7 2 D `o g City/State/Zip ,& - 2 d �zr Business Phone 2: Name on 1'ermit/ATC if Different than Above Mailing Address City/State/Zip e 3. ,Applicat: n For: [ ] Site Evaluation [ J Improvement Permit &.ATC [ ] Both 4. System to Serve: [ J House [k Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Reside:.ce: # People_ # Bedrooms_ # Bathrooms__ [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers f i, If Foodservice: # Seats Estimated ater Usage (gallons per day) i 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 [ ] No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** XZLVa(OF THE PROPERTY MUST BE v SUBMITTED WITHr,APPLICATION. Property Dimensions: ��� /f �WRITE DIRECTIONS (fromksville) TO PROPERTY: 1 Tax Office PIN: # - - u � �:�� o �x l �C dm' A' 7j B 11 Property Address: Road Nam�r e -0 6� rq �I , a60 s 4 City/Zip �jd46y1Al/e a7d �' 3 , gsbjain� /14 If in Subuivision provide information, as follows: Name: Section, .. _ Lot _i This is to'cfitify that the information provided is correct to the best of: my knowledge. I understand that any permit(s) issuedA' after are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is .-sified 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 Davi. County Health Department to enter upon above described properly located in Davie County, and owned by to conduct 11 testi proced s as necessary to determine the site suitability. DATE '�%� 27 SIGNATURE 4 Revised DCHD (06-96) THIS AREA MAY 13E USED FOR DRAWINC7 YOUR SITE PLAN: .SG 3 Cdk a r '� ♦ l ©' � 341 © 61.1c " Of f e e A O s Z _� 17 � I � o •,�'aX 3� 5t) iA Da S M0 (deed deecriptbw �---• nz `' 117 A •ure as ealeutate,Jjb� t X M M u` r v VIV Seat this 1-3—dry of 0 V s S M0 (deed deecriptbw `' •ure as ealeutate,Jjb� broken tines {.horm tK ook .. __. PaSe:_ r. • . rdance wtM G. S. 47,M Seat this 1-3—dry of 0 V DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME � S ` Ns�_S� PROPOSED FACILITjY SUBDIVISION Water Supply: On -Site Well V Community Evaluation By: Auger Boring Pit DATE EVALUATED SECTION LOT 1 � PROPERTY SIZE ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % r> _�60 U HORIZON I DEPTH 1, Texture group C_ L L Consistence�– Structure C Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS $ RESTRICTIVE HORIZON — SAPROLITE -- i CLASSIFICATION LONG-TERM ACCEPTANCE RATE 0 SITE CLASSIFICATION: Q S - EVALUATION BY: LONG-TERM ACCEPTANCE RATE: •A OTHER(S) PRESENT: REMARKS: <\"� N\� \ a- � DCHD (O1-90) 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 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 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 ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ 1111.. ■IR■■I.■ RENEE ■.■■■.■■■■Ree■■■■■■'.Rr:�;i■Mr��■■l�i� 1111 .� ■■■■IS■ISM■■Nee■■■IS■■■■■:■..iii■e!�IS.■■ ■.■■■.■.■....■■.■■■.■■■■.■■■.■■■■ISM■ ■■M■■M■■■■■IS■■Nee■■IS■■.■■■.■■■■IS..■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ....................... ....................... ....................... ....................... 1111■■ MEMO MEMO SEEM ■■ NONE NONE MEMO ■NNIS