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228 Arrowhead Rd 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 6.5. Chapter 138A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME PROPERTY ADDRESS f-g 0CO-CL AQL,- °� 0DAaTEr -I - • LOCATION ISS SUBDIVISION NAME LOT NUMBER SEC./BLOC{ NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS __�_ # BATHS J # OCCUPANTS 5 GARBAGE DISPOSAL: Yes No COMMERCIAL SPECIFICATION: FACILITY TYPE ''• # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: ,41INg, LOT SIZE U c TYPE WATER Y Ulm ,yDESI6N WASTEWATER FLO�'(GPD) C6.0 FEW SITE,• . REPAIR SIT SYSTEM SPECIFICATIONS: TANK,SIZE 6AL PUMP TANK 6AL. TRENCH WIDTH 3 L ROCK DEPTH I2LINEAR FT. -; OTHER4 U,o ,. 'y'o L�'1IAty 4. REQUIRED SITE MODIFICATIONS/CONDITIONS: t. ' ***THIS PERMIT IS SU6ECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. rx 3.. 74 , V !P (15 pv _ mull P\U13 -75 100 IMPROVEMENT PEW. BY **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:00-1:38 6.-M. ON THE DAY OF INSTALLATION. TELEPHONE i IS (704) 634-8768. OPERATION PERMIT - SYSTEM INSTALLED BY AUTHORIZATION NO. �� OPERATION PERMIT BY DATE **THE ISSUANCE OF THIS OPERATI PE INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 1 , .1900 "SEWAGE TREATMENT AND DISPOSAL. SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL TION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 Davie County Health Department ENVIRONMENTAL HEALTH SECTION �~ P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of B.S. Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environsfnt�l 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.,*** + q AUTHORIZATION NUMBER NAME I-I �-.. 4 Q. DATE l��1 - 1� N2 �3 NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION Q u w h--, p c, R COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS HORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. Cls ENVIRMWAL HEALrIH.SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department Environmental Health Section �. P. O. Box 665 DEC " 5 M Mocksville, NC 27028 (� -i 9' Logi 1. Application/Permit Requested By �'L• M B I �� Mailing Address 4"�Z� COUNS-N 2';N� G � C�Q�r^ Home Phone r76fi --0'73 t.. Ci,1L/Y1�t k5 ni_s NAL 2,r1a1 Z Business Phone 3) to 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation la Septic Tank Installation Permit _ 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision SectionLot # QI/BasemenUPlumbing No. of People ❑❑�Basement/No Plumbing No. of Bedrooms .4 O-Washing Machine No. of Bathrooms 3 Z fd Dishwasher Dwelling Dimensions SZ X �� N) ❑ Garbage Disposal (.. 6. If business, industry, place of public assembly, other: Specify type I•. No. of People Served No. of Sinks P {. No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers ` No. of Showers Water Usage Figures 7. Type supply: ❑ Public yp of waterPrivate ❑ Community }: 8. Property Dimensions Sewage Disposal ContractorV-Qh�MoQ/ftA4E:rW . Se P�c co 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ YesNo i If yes, what type? 4 *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. 1 PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Office PIN # 861 ry" Road Name AUOW Lt•eAD r-1 — SP��Lm4�1 ZOA4 Box # (if available) !.. �— q PROW tle,4� City �f�P�Ty be�' 0I C1 ye l 10'i t i { 4: M This is to certify that the information provided is correct to the best o my knowledge, and I understand I am responsible for all charges C incurred from this application. l2— q� CIZ - s DATE SIGN URE d f A CONSENT FOR SITE EVA ATION TO BE DONE ON ABOVE DESCRIBED PROPERTY 4 MUST CHECK ONE: 1. I 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 f the Davie County Health Department to enter upon above described property located in Davie County and owned by - L 1W C%fc- S to conduct all testing procedures as necessary to determine sai site's suitability for a ground absorption sewage treatment and disposal system. P iZ— 3 P DATE SIGNATURE x DCHD(1193) r"; y DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section Soil/Site Evaluation NAME LDATE EVALUATED ADDRESS PROPERTY SIZE t� PROPOSED FACIILTY �c o v sF LOCATION OF SITE t-1 2Q Q w hey Qty Water Supply: On-Site Well _ Community Public Evaluation By:CSL-- Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position S S Sloe HORIZON I DEPTH Texture group C C (!'L- Consistence 7FE >� 1 Structure MineralogyLSI HORIZON II DEPTH Texture group Consistence V"'A. U}--\ Structure .� Mineralogy 41� HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS SS RESTRICTIVE HORIZON — — — — SAPROLITE S CLASSIFICATION ,S S ,S LONG-TERM ACCEPTANCE RATE " , 1 SITE CLASSIFICATION: - EVALUATED BY: \ 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 slay 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 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 DCHD(01-901 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■ OE■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ on 0 ENO mmomomm No ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ............................... ■■EM■MOMOm■Om■■...........■■■■.. 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