338 Frank Short Rd_ _
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" It�A0VEI�NT PERMIT
DAVIE CDUNTY HERLTH DEPARTMENT
IMPROUEMENT PERMIT and �ERATION PERMIT
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',. �+��NOTE�� This i�prove�ent per�it DDES NOT authorize the construrtion or installation of a septic tank syste� or any NasteNater
syste�. RN AUTH�RIZATIDN FOR NASTEWRTER 5Y5TEM CON5TRUCTI�1 �ust be obtained fro� this Depart�ent prior to the �
`� construction/installation of a syste� or the issuance af a building per�it.
tIn co�pliance with Article il of 6.5. Chapter 1�A, NasteNater Syste�s, 5ection .1900 Sewage Treat�ent and Disposal Syste�s)
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NAME �`�. � C� '�,�.�r, � `� � �'� PRDRERTY ADDRESS F� �"'ca � � �; ��:_7� i i: ►=- � _ I` +�-. -� "� � l)� DATE ' I � - �� -�
"= � — �'�- �:. - � � "' '�o
L�AT I ON i -, J ( � ` �--,� r„e �� _ .. ��: �-��....:..,r. �\� �.� K' ., �" �.,:�..,, � r.., �. �", . '� i ..;:.;t.-
�. . `.b,•:.�':is..r" `::-� :::.^�...'_v.. . . ..
5UBDIVI5IDM NAME LOT Nlp4BER SEC. /6LDCf( NlM1BER
RESIDENTAL SPECIFICATION: BUILDING TYPE �c�<� �>f .s�. �M BEDR�MS -a � BATNS _� � OCCt1RANT5 :� 6AREAGE DISPOSAI.: Yes�No�j
C�IERCIi� SPECIFICATIOhI: FRCILITV TYPE � �k PEDRLE �1 PEOPLE/SHIFT � 5ERT5 IMDl1STRIAt. NASTE:* Yes/No
►
LRT SIZE �`''-> k~; � TYPE WpTER SUPPLY �1 a��'� DESI6M V�STEWATER FLOW tGPD) �� �� IdEN SITE REPAIR SITE
SYSTEM 5PfCIFICRTIDNS: TRNK SIZE�i�'�:� 6AL. F�IhiP TAt�( 6AL. TRENCH WIDTH � ROCK DEPTN :-��� LII�AR FT. �"`��U ,
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIDNS:
�+�*THI5 PERMIT IS SUBJECT TO REVOCATION IF SITE F�ANS OR TFIE INTENDED US'E CFIANGE. VDUR WASTERWATER SYSTEM CONTRRCTOR MUST
SEE THIS PERMIT BEFDRE INSTALLING THE SYSTEM.
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�.,.�t �1'�y�� � ` 'b � --
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IMRRDUEMENT DERMIT BY �'4��`"<,�,�. ;u. �\� f ,``\,.,��'��.'�. ����{�
�*CONTACT A REPRESENTATIVE � THE DAVIE CIXJNTY HEALTH DEPARTI�NT FOR FINAL INSRECTION OF THIS 5Y5TEM HETWEEN
8:30-9:30 A.M. OR i:�-1:30 P.M. ON THE DAY OF INSTALLRTION. TELEPHQNE � IS t7Q4) 634-87E0.
�ERATION PERMIT SYSTEM ,INSTALLED BY �'':=��a? /����C.�v
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AUTHORIZATION N0. p�.
�
DATE % ` / —�`-�i
t�THE ISSLKNJCE � THI5 OPERATION RERPIIT SHALL INDICATE TFIAT-THE SY5TEM DESCRIBED ABOVE HAS BEEN INST�.LED IN (�MWLIANCE WITH
ARTICLE 11 � G.S. CHpPTER 130A, SECTION .19� "SE4IAGE TREATMENT AND DISPOSAL SYSTEMS°, BUT SHALL IN NO �F1Y BE TAI(EN AS A
6'URRRNTEE THAT TF� SYSTEM WILL fUNCTIDPI SRTISFACTORILY FOR RNY 6IVEN PERIOD � TIh�.
D�HD 10/95
1
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Heaith Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
Application/Permit Requested By /�� c.�� ��� �`'� dr�'-' -
Mailing Address %� Ll ,� �)( �. � _�� Home Phone ���' �%7 7.�
lJ L�C_S V j%J� f'l:� C.� Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation
4. System to Serve: House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People �
No. of Bedrooms �
No. of Bathrooms �
Dwelling Dimensions 3 � x� �
�'Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Other
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
❑ Unknown
Section Lot #
❑ BasemenUPlumbing
❑ BasemenUNo Plumbing
❑ Washing Machine
❑ Dishwasher
O Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: p Public rivate ❑ Community
i. � ��
8. Property Dimensions I��. X��� Sewage Disposal Contractor �
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes L�J'No
If yes, what type?
"NOTE: Improvements Permits sha�l be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
�}c+st,
_ _ - _ _ ^ � PROPERT� ZN�OIZMATZON REQUZIZEb:
Directions to Property: �
�Tax Of f i ce PIN: # �%,S% - ,� � - �l� ) �
PROPERTi,J Abb1ZESS, as��i lo s:
Road Name: �u.c,'�C ���,r'�' �Gt
c;.ty: %Vjn�,)csur Il�
SU$MIT tl PLAT WZTH ZHZS APPLZCtITZON.
Revisions effective October 1� 1995.
����rn°^� �'/
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.
� - � � - �'� � �.�� �'- c��'�
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: . 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. , �
3- aq- g�b � ' � �.
DATE � ~ SIGNATURE
DCHD (1/93)
,. ' `, DAVIE COUNTY HEALTH DEPARTMENT
, ' Environmental Health Section
Soil/Site Evaluation
NAME �� � b� R S^ O� \ DATE EVALUATED �� ��� ��
ADDRESS S�aK� Q PROPERTY SIZE !�� ���� F�
PROPOSED FACIILTY ��� ��S� LOCATION OF SITE FR A N k ���R� �d
Water Supply: On-Site Well V _ Community Public
Evaluation By:e,�l_ AugerBoring ✓ Pit Cut
FACTORS 1 2 3 4
Landscape position S .S 1 � � 1 -�
Slope �
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Mineraloqy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLaSS.LFICATION
LONG-TERM ACCEPTANCE RATE
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SITE CLASSIFICATION: � S �
LDNG-TERM ACCEPTANCE RATE: ° �
REMARKS: ���._.��5� " � 1� � ' �
LEG
DCHD(01-901
EVALllATED BY:
OTHER(S PRESENT:
.
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-Finn VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightiy sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
,iC--SYngle grain M-Massive CR-Crumb GR-Granular ABK-AnQular blocky
SBK-Subangvlar blocky PL-Platy PR-Prismatic
Mi neralca¢y
1:1. 2:1, Mixed
Notes
H orizon 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
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•� i�----�� � Davie County Health Depart�ent
• � ~' � ENUIRONR9ENTAL HEALTH SECTIDN
��` P.D. 9ox 6b5
, Mocksville, N.C. 27028 �
, AUT}IURIZATION FOR I�STENATER SYSTEM COM5TRUCTIa1 /' � d• 0 b
lIssued in co�pliance Hith Article 11 of
G.S. Chapter 1"sOA, Wastewater Systeis)
+�*�This Authorization Far Waste►+ater 5yste� Construction �ust be issued by the Davie County Environ�ental Health 5ection prior to
issuance of any Building Per�its. This For�/Ruthorization Nu�ber should te presented to the Davie Caunty Building Inspections
Office when applying for Building Per�its.*�+� wv ;.
`1,�, ! C, ` AllTHURIZATION I�ER
NRIE �� c�`(��''�. �i S�� F� \ DRTE �^"�' � I �— f� � � v� if. ��� ��
NRhE ON IlPROVEMENT PERMIT {If different than above)
SITE LOCATION � � ���� ��" ,
C�ENTS/C0�@ITION5 ON AUT}IORITATION T� [�NSTRUCT WA5TEWATER 5Y5TEM
. , � ^`
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�tNOTICE� THIS AUTHORIZflTIDN FOR WA5TEWRTEA SYSTEM CON5TRl�TION IS VALID FOR R F'ERIDD DF FIVE t5) YEARS.
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auiear�ura. �n� �cta�tsr na�
DCHD 10/95