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981 Howell Rd �,-,!ur.x'i. ...d.`y:•i:e Fir,.>-.._....�,....>:..i...._.._ ...;.,.Y.. .a-.rt .. i.,.. ,... 1 .'[ .: s'` .. .. _. '.' _. r XQ t--/ 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME 0 C r PROPERTY ADDRESS`F 7 o olg DATE LOCATION /f(itJrP�� f�I SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICRTION: BUILDING TYPE _ # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY -1V,0// DESIGN WASTEWATER FLOW (GPD) NEW SITE &I"REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE A10d GAL. PUMP TAW GAL.- TRENCH WIDTH ROCK DEPTH ��/ LINEAR FT. 1 b- OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST "4h SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 7 ie IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT nn SYSTEM INSTALLED BY ( b 1 b 1' AUTHORIZATION NO. L OPERATION PERMIT BY DATE **THE ISSUANCE OF THIS TION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF B.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 SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 Davie County Health Department ) j o ENVIRONMENTAL HEALTH SECTION * t _ P.O. Box 665 Mocksville, N.C. 27028 sr _f 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 NUV&R NAME Q �(Ci r)P/ DATE 4e N2 a 1)04 - 1 NAME ON IMPROVEMENT PERMIT (If different than above) t SITE LOCATION COMIENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FD WASTEWATER 5Y CONSTRUCTION" VALID'FOR A PERIOD OF FIVE (5) YEARS. s � ENVI AL HEALTH SPE IST DATE DCHD 10/95 ._.. .. _ ., u.l � ._) ''r3 _ •'.t r ..e r. _- ! i t•. . .. e^{ .t. .7 r .ee_S•' ..:f 1.�._ -.. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER 1 � �p P� Davie County Health Department / Environmental Health Section �a1 P. O. Box 665 Mocksville, NC 27028 AUG - 6 1593 6� Bp --------------- 1. Application/Permit Requested By y✓r92IR Mailing Address Home Phone 3 ? -{ Business Phone ll O 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: 9" House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # El"Basement/Plumbing No. of People T ❑ Basement/No Plumbing No. of Bedrooms d 01/washing /Washing Machine No.of Bathrooms '2' ❑ Dishwasher Dwelling Dimensions ❑ 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 WaterUsageFigures 7. Type of water supply: ❑ Public 2 PPivate ❑ Community 8. Property Dimensions ey Q cte Sewage Disposal Contractor // 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? I El Yes Er<0 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: i 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 thi applic tion. —/6ATEf SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY 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 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. DAT SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / NAME �tl P✓� DATE EVALUATED101 N ADDRESS PROPERTY SIZE �/�QAC' PROPOSED FACIILTY �ed�� '"LOCATION OF SITE /7� ell Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 17 /`S75 Sloe Z — — — HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH d16t 6,f f� Texture group ell, C 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: EVALUATED BY: �� LONG-TERM ACCEPTANCE TE: OTHER(S) PRESENT: REMARKS• ��.� ,o o,.. ��f _e i el e 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 Mi neraloity 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 ■■■■■.■■■■■■..■■■■■■■■■e.■■■■.a■■...■■■.■■■e■■■■.■.■■■■■■■ .■ . ..Ai■ ■■.■■■■.■■.■.■■■■■.■■■■■■■.■■■.■■■■.■■.e■■.■.■.■.■■■e■■■■■■■■eMa■■ MEN EGA ii:::iii::::::Cii:i■::::::::i''i::::C'ii::i::':o:CCiiii:Cii:ii::ii:i:: ■■■■■■■■■■■.■■■■■■.■■■.■■■■■■■■. ■■■■■.■.■■■■.a■■■■■■■.■■■■■■■■■■ ■■.■■■.■.■■.■■..■■.■■.■■■■a�■■■■■■.C■..■.■■��■.■.■.....■.■....■.■■■■ ■■.■.■.■■.■■■■.■■..■■.■■.■it■■■■. ■■.I/■■I.�'S..■■■.■■■■■■■■■■.■�■■■ ■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■.��.■■■■.■■.■■■..■■.esu■■■■■.■■■■■■ ■■■..■■..■■■■.■..■■■■.■■...■■■■.��■S■t■1t■�e�!i�■N■■N.■■N■■MNN■ :C::::::::C:::::::::t.::::::::i'.':::'t■::'�■�■:■�:::::::::■.::::MEN MMMMMMii:::�.::C:::'.::::�.iii::::::C::i:::.�:C�::C:C::::::.i::'iC:�■a::C: Uii:ii::■MI.�MMMMMN i:isii:.�i:CC::iI■�iii:::i�C:Ciii.�iiiii::.moi ■■.■■■■.■■■■■■■■■■■■.■■■■■■■■■■■.■■■■■ .■�MEMNON. ■C■■■■■.■■■■■M■■ Mimi MMOMEMI ■■■■■■■■■■■■■■■■.■■'/■O■■.■O■■■.■�.■■� ■MENIMEMNSOM SEEM ■ ■ ■■ M■.■.■ ■■ria■..■■■.N..■..u..■■■.......■...■.■::.... 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County Nealtli De artment Nealtfr Aen and .�lvme y cy 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE,N.C. 27028 PHONE:(704)634.8988 August 20, 1993 H. D. Brewer Rt. 8, Box 262-1 Mocksville, NC 27028 Re: Site Evaluation Howell Road Dear Mr. Brewer: As requested, a representative from this office visited the aforementioned site on August 18, 1993. Based upon the information provided on the application for a site evaluation and after an evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure