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1402 Main Church Rd .c•,rLt+., .y.....�`':...+�ir's�ww. i .�.�f._4.': i 'ti"w'` .. .6. Y.��.i.n.b*�.,.�.,.. .-y v -. x z� ,. ,. .. .. .: ., .. .-...c.:..._..,,TT. 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 it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME dv PROPERTY ADDRESS Al/We/e 2xx . ~ DATE0�� LOCRTION �, / ,✓ .C- SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS # OCCUPANTS . GARBAGE DISPOSAL.: Yese COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZEyTYPE WATER SUPPLY �Q_ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE/ GAL. PUMP TANK GAL. TRENCH WIDTH~ ROCK'DEPTH J9 , LINEAR FT. DZ7 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***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. 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 SYSTEM INSTALLED BY JL 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 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 Alf, .; Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WAST EWR SY CONSTRUCTION (Issued in con a with Article 1 of G.S. Chapter s , Wastewater System *tithis Authorization For Wastewater System Construction must a sued by the av Coun Envira t, Health Section prior to is any Building Permits. This Form/Authorization 6er,should be pr nted to avie County Building Inspections Office when applying for Building Permits.*** AUTHORIZATION NX&R MINE ., Otr i.f ./�D;,O a DATEI""'47-, 0 ,"'j97 r NAME ON IMPROVO W PERMIT (If different than above) -�-' yyy� SITE LOCATION 00q,'1✓ / s� Apd COMMENTS/CONDITIM ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION FO A SYSTEM CONSTRUCTION IS VALID FOR PERIOD OF FIVE (5) YEARS. 1, / ENVIRONMENTAL EEAI.TH IALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIFitjt ; D Davie County Health Department Environmental Health Section P. O. Box 665 MAY 2 8 Mocksville, NC 27028 k a,a 1. Application/Permit Requested By Louis L- and Taha+-ha M- Mailing Addressa9nn us Hwy.-2.9—N_.—LGt #460 Home Phone 910-691 ---4466 Greensboro, N. C. 27045 Business Phone 910-722-18'A11 2. Name on Permit if Different than Above 3. Application for: RI General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House CA7 Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑ Basement/Plumbing No. of People 2 ❑ Basement/No Plumbing No. of Bedrooms 1 [R Washing Machine No. of Bathrooms —2 [R Dishwasher Dwelling Dimensions gg ft-. by 14 f t . CR 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 A Water Usage Figures 7. Type of water supply: Q Public 1 ❑.Private ❑ Community 8. Property Dimensions S it Q w i l lbae approx. Sewage Disposal Contractor 9. Do you anticipate additions/expASib%4of�ArAgty this sytem is intended to serve? ❑ Yes No If yes, what type? 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERT11 INFORMATION UIRED: Directions to Property: Tax Off i cc PIN: # D— !S 3—.5a A From W—s take I-40 to 601 exit PROPERTY ADDRESS, as follows: turn right at top of exit then Road Name: 6Z — turn right on Main Church Ext. City: lot is located on left--has a Hubbard Sign up on property. SUBMIT A PLAT WITH THIS APPLICATION. Please call & schedule for someonkevisions effective October 1, 1995. to meet you there. Call at work for Tabatha at 910-722-1834 or 910-724-3806 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 app ication. DATE SI NATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Q'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 representative of the Davie County Health Dgartme�t to,enter upon above described property located in Davie County and owned by �r I c y� 1�oc�s and to conduct all testing procedures as necessary to deter site's uit bili for a ground absorption sewage treatment and disposal system. I,./:, �6 s�_Jb/y� S— oZD �f� .?v DATE SAGNATURE pCHO(11193) CIS 01 6 L 8 J � n p C 5 c N N t7 S bf Zl 11 47 jJ9- LZ bZ/^ 5 �t co � — £sz Zti 9- b 6i 9b �8ti� z� oz 8ti Gtr 2 sz ooz T`0A S - . 8G �G 00; b- G t fvE E - / N OS Q1 6 Z 8Z y� c O 12 N N O 1 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation �= NAME OyJ !o N DATE EVALUATED 1�6 ADDRESS PROPERTY SIZE ` L' PROPOSED FACIILTY LOCATION OF SITE/,�, Water Supply: On-Site Well _ Community Publico Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L Sloe Z d2 �- HORIZON I DEPTH ,i Texture group Consistence Structure Mineralogy HORIZON II DEPTH F C Texture groupC Consistence Structure Mineralogy j HORIZON III DEPTH Texture grouR Consistence Structure j Mineralogy i HORIZON IV DEPTH Texture group Consistence Structure Mineralogy 1 SOIL WETNESS j RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE j SITE CLASSIFICATION: EVALUATED BY: //z V, ` 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-Vczy 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 ��/CM��\CCCC.CCCC.CCCCC..�C■I:.CCCCCC■■tCN�NCCCCMCNCe■■■ ■...■.....■.■...........■■NMN...MNNe■a.■oNN■N■M.E■.N■MNEM■NMM..■NC mom mommomommmoom ................................ ................�_■....■■.■■■.■■ ...........■..............��.......■.■Nom■■.■■.�.. ■IM.■M■■MUEMM .......................... ........... ...... .... . ■. 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