330 Juney Beauchamp Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
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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 /� f/ ROPERTY ADDRESS ,d 1P . eya D •��,�OG J,
+ '" IrH �7 lt1>'I, DATE
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F LOCATION t�11 i' err. ..�,,. . ✓
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ) # BEDROOMS ..S # BATHS # OCCUPANTS _r1 GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE / TYPE WATER SUPPLY G��// DESII7J WASTEWATER FLOW (GPD) `�/ r NEW SITE Z--'REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE„ GAL. PUMP TANK GAL. TRENCH WIDTH .__s ' ROCK DEPTH -,?• LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
e**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.
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:38 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
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OPERATIC( PERMIT SYSTEM INSTALLED BY
AUTHORIZATION NO. �" 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 138A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEM", 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
a APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM
Davie County Health Department
Environmental Health Section _
5 1996
P. O. Box 665
Mocksville, NC 27028
IFl:ri�� T11 Pum
/ W.Int txW iim
1. Application/Permit Requested By a-a Lc� lye lli;Qd T2
'Mailing Address j _12�oM24/ lya- 4eu,sv:I/, A/C.arlo..Z3 Home Phone 010) 5i�5
Business Phone 91,0 f7P? e./0 2/
2. Name on Permit if Different than Above
j 3. Application for. ❑General Evaluation 4 Septic Tank Installation Permit
4. System to Serve: Z House 9 Mobile Home ❑, Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
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5. If house, mobile home:Subdivision Section Lot #
-� ❑ Basement/Plumbing„
No. of People / ❑ Basement/No Plumbing
No. of Bedrooms 2 Washing Machine
No. of Bathrooms �Z UU-Dishwasher e
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 Water Usage Figures
7. Type of water supply: ❑ Public C3'Private ❑ Community
} 8. Property Dimensions ! Rc Acs Sewage Disposal Contractor '�G�F" btu— Allo v
91 Do you anticipate additions/expansion of the facility this'sytem is intended o serve? Yes Colo
If yes, what type? )70J Ci A(O 62 .G /1
.._ / R>v oL/kzt�e-d rDDyh5
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*NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
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revocation; if siteplans or the intended use change. Effective October 1, 1989.
"IPROPERT11 INFORMATION REQUIRED:
Directions to Property: . Tax Office PIN:
J viri`� ,�o�✓G/ji P / PROPERTY ADDRESS, as .follows:
Td Road Name:
1 City: e
SU$MZT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
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This is to certify that the information provided is correct to the best of my knowledge, and 1.understand I am responsible for all charges'
z incurred from this application. / r
DATE SIGNAT E
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: F0 1. 1 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
t to conduct all testing procedures as necessary to determine said ite's suitability formgrs absorption sewage treatment
and disposal system. •
DATE SIGNATURE
y DCHD(1199)
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
-71 si(4"
i PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut /
FACTORS 1 2 3 4
Landscape position
Sloe % -�
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II •DEPTH pt 4
Texture groupC
Consistence ✓- r i
Structure
'
Mineralogy /= -
:j HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
i HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
1 RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: _ EVALUATED BY:
L
LANG-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-V,-,ry 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
Stricture
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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Davie County Health Department
"+. ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27026
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article it of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issuedbythe 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 NUM..BER
NAME ��i°(/ /Zj, /lJr(� DATE h .('— No 0405
NAME ON IMPROVEMENT PERMIT (If different than above) p /
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FOR W TEWATER SYSTEM CONSTRUCTION IS VALID FO P IOD OF FIVE(5) YEARS.
ENVI AL HEALTH. CIALIST DATE:
DCHD 10/95