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567 Davie Academy 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 G.S. Chapter 13A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME in .fi t PROPERTY ADDRESS DATE / _./ ) A �� v LOCATION ii'' J ' %r /1 Y ✓ p� r� SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ # BATHS 4V— # OCCUPANTS_F GARBAGE DISPOSAL: Ye6 COMMERCIALSPECIFICATION: FACILITY TYPE �s # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE f� TYPE WATER SUPPLY n DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE e&j GAL. PUMP TANK GAL. TRENCH WIDTH cr'l„ ROCK DEPTH 0 LINEAR FT. Q 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. A f ' f IMPROVEMENT PERMIT BYi�f� **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 6s� y EvFp Od�EvFla AUTHORIZATION NO. O O O OPERATION PERMIT BY �c�\, 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 Davie County Health'Department 4S ENVIRONMENTAL HEALTH SECTION P.O. Box 665 ' Mocksville, N.C. 27028 AUTHORIZATION 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 Davie County Environmental Health Section.prior to issua o any ui ing Permit . This Form/Authorization Number should be presented to the..Davie County Building Inspections Offic when applying for Buildi g Permits.*** s' AUTHORIZATION NUMBER NAME DATE ' -, N2 J 0 4. ,NAME ON IMPROVED M PERMIT (If different than above) SITE.LOCATION ac�''(�lFr 7UJi`/i P COMMENTS/CONDITIONS ON AUTHORIIATION TO CONSTRUCT NASTEWATER SYSTEM *}{NOTICE*H THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR PERIOD OF FIVE (5) YEARS.- -/ r. ENVIRONENTAL HEALTHIMIALIST., DATEvDCHD, 10/95 -� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT / Davie County Health Department �19� Environmental Health Section �J P. O. Box 665 Mocksville, NC 27028 11. Application/Permit Requested By !/Mailing Address S\zn c-"H-ome PhoneSlC�� 4.-Business v2-Name on Permit if Different than Above 3. Application for: ❑General Evaluation &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 Section Lot# ❑ Basement/Plumbing C/No. of People ❑ Basement/No Plumbing .,-"No. of Bedrooms 3 Q Vashing Machine /"N"o. of Bathrooms 2`6ishwasher 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: 1 ublic ❑ Private ❑ Community 8. Property Dimensions s;2 �Yey C Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No 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: �Qy \t ecC�` ,0s . NUr C1 ('\OJ�� OV1 S VNOT6 O.Vp. fir\ '�a.V�� Cr✓.C�e�S1U, �G. LO.S� c�.c�v 2. 6n \e�� C�d�e ujOU 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 application. , DATE 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 \-,\.c "K\,4 to conduct all testing procedures as necessary to determirfe said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED �6'c3J ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE ,oAil&A5Z Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring L11 Pit Cut FACTORS 1 1 2 3 4 Landscape position L, 1 ,L Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogZ HORIZON II DEPTH Texture groupG' 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: __72�7_ EVALUATED BY:' LONG-TERM ACCEPTANCE RATE: - OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Footslope 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-Vc.-y friable FR-Friable FI-Finn 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. 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