214 Clayton Dr DAVIE COMITY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NDTE** 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 B.S. Chapter INA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
WRAFk�s �c,, ��o�S.n PROPERTY ADDRESS CI4 `D,,.. .2 70 2 y DATE �S
LOCATION LSO I N '\w,— \\ Q ��
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE �oy ras. t BEDROOMS O BATHS + # OCCIIPAtJTS GARBAGE DISPOSAL: Ye No
COMMERCIAL SPECIFICATION: F�ACILITY-TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes' No
LOT SIZE (�.3 JrOc PE WATER SUPPLY U3"WATER DESIGN WASTEWATER FLOW (GPD) (o(). FEW SITE .REPAIR SITE
SYSTEM SPECIFICATIONS: TANK 5IIE)b00 GAL. F4Amp'TRNK GAL. TRENCH WIDTH iii—DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/COr1DITIDNS: � � �- mac`. O nd Q Ok-� b�
s ,
***THIS PERMIT IS SUBJECT`TO REVOCATION IF SITE PLANS,;OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. {
:r
Z'7o L/n1c% Cc�GTN
RAIU GV
�Nc�P
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS kTEM BETWEEN;
8:30-9:30 A.M. OR 1:00-1:30 Q.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760 ..y
OPERATION PERMIT SYSTEM INSTALLED,BY
AUTHORIZATION NO. C4UL) OPERATION PERMIT BY 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 10/95
' R
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION '
is
' P.O. Box 665
Mocksville, N.C. 27028
4� : r /00. 00 .
.-„RUMIZATION'FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issued by the Dave County Environmental Health Section prior to
issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie Countyfkilding Inspections
Office when applying for Building Permits.***
AUMIZATION NJ.9ER
NAME `,` n # l�spa rw.. W 0. DATE $ 9 4° N2 0460
NAME ON IMPROVEMENT PERMIT (If different than above! ”
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. \
9
TT//��LIIT
1 ( ENVIRMWffAL HEALTH SPECIALIST. :, - DATE, t
.DCHD `.10/.75 r
t t,:
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' E " APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental Health Section W
P.O. Box 848
Mocksville,NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed t_!3� y Qe n ( ,c+'a f-e Contact Person 1 3 uQ P"-
Mailing Address U 2 s4 R' U,S. 1-1,x., 1'S12 Home Phone n1 q� ''Z�
City/State/Zip ad,f ,4 _o Jtil. 0 c'C)G, Business Phone 4I U
2. Name on Permit/ATC if Different than Above M i k A, 1]v _w6„g Wk+ s
Mailing Address_5.2Aj�g 0•.s, Lf.,,w, (S-h- City/State/Zip A �ye Are P Ab(2. -2-� 06h
3. Application For: VSite Evaluation i [Improvement Permit&ATC [ ]Both
4. System to Serve: P(rHouse [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People a #Bedrooms 3 #Bathrooms +2- [k]'Dishwasher[ ]Garbage Disposal
[ ]Washing Machine OBasement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: [ ]County/City K Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes eNo
If yes,what type?
PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 1 WRIT/E�DIRECTIONS(from M/ocksville)TO PROPERTY:
Tax Office PIN: #S06- - -2 - - s� -c (9 s-+ D /�a' F h 7 C'��y �rr{�'
Property Address: Road Name OVA v-L a D r j y P
city/zip .e t I(ep-. t)6 3 -'r ; d v I Lv �. o
If in Subdivision provide information,as follows: lJe✓-� W o N t" :"P 4-/-
Name:
Section: Lot#:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Re tative of the Davie County Health Department to enter upon above described property located in Davie County and owned
�l•'K.r,w��5"
bytiN conduct all testin rocedures as necessary to determine the site suitability.
DATE C SIGNATURE
Revised DCHD(06-96)
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation q
NAME 1`tADATE EVALUATED - 1
ADDRESS A to n PROPERTY SIZE g• C�CSyp
PROPOSED FACIILTY o s -���0 LOCATION OF SITE
Water Supply: On-Site Well Vol _ Community Public
Evaluation By:QZL. Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position 5 S
Sloe Z TO -17
HORIZON I DEPTH
Texture group C'L_
Consistence F:
Structure C CR C
Mineralogy
HORIZON II DEPTH `'
Texture group C. C
Consistence -'Y =Z
Structure
If-
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS SS
RESTRICTIVE HORIZON —
SAPROLITE
CLASSIFICATION ,
LONG-TERM ACCEPTANCE RATE 1
SITE CLASSIFICATION: —a S• 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 <;lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vr-.cy 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
3C--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
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