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260 Ijames Church Rd Lot 5,.., .. iw i � N^*. i.i) .+.! re,�'a.<' kJ,➢ya f1 w.�r .,.rr Yr i4. .., ,fi,:y,., � iAl ,'Yui�K` ' � .. 'I �h „{:.: ., . .. : v'/.1... 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) + � *�•� r7 NAME CA PROPERTY ADDRESS =\a•-rneS DATE ` L LOCATION SUBDIVISION NAME Q tz\� t1 EE.� CA-- LOT NUMBER SEC./BLOCK NUMBER ' RESIDENTAL SPECIFICATION: BUILDING TYPE aysQ # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: YesNo COMMERCIAL`SPECIFICATION:FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIIE I 6u X3 LO TYPE WATER SUPPLY!, �� DESIGN WASTEWATER FLOW (GPD) (v0 NEW SITE L--'/ REPAIR,SITE SYSTEM SPECIFICATIONS: TANK SIZE ,PUMP TAME( GAL. TRENCH WIDTH 3.9 ROCK DEPTH I�� LINEAR FT, OTHER F s REQUIRED SITE MODIFICATIONSXONDITIONS ' ***THIS PERMIT IS SUBJECT JO REVOCATION IF SITE PLANS OR THE INTENDED,USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 1°V� J F o Vs17. . . . , •. .._. . . .. _.,...,. ._ . _ cam„ t ` p c IMPROVEMENT PERMIT BY Ce.J **CONTACT A REPRESENTATIVE OFJHE 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 �� W a F � oar ('1 o V s a L al ACKRAT, AUTHORIZATION NO. C) �3 � PERMIT BY DATE ��6 1 **THE ISSUANCE OF THIS OPERATION PERMIT L INDICA THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTI .1900 " TREATMENT AND DISPOSAL. SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI SATISFACTO LY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 L 14 sii� Davie County Health Department y ' Y„ ENVIRONMENTAL HEALTH SECTION P.O. Box 665 .� Mocksville, N.C. 2702�� Q ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article.11.of G.S. Chapter 130A, Wastewater Systems) ' ***This'Authorization For Wastewater Systes:Construction must be issued by the Davie County Environmental Health Section prior to issuance of'any Building Permits. This Fore/Authorization Number should be presented to the Davie County Budding Inspections Office whensapplying for. Building Permits.*** AUTHORIZATION NUMBER DATE ' 3 G NA J ;2 s 5 NAME-ON-IMPROVEMENT PERMIT (If different than above) ! SITE,;LOCATION _ •\ A `tm e s �:�. �� ` pr' �r00 t� �� COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTMTER SYSTEM *HMICE*t* THIS AUTHORIZATION FOR WASTEWATER-SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRON ENTAL HEALTH SPECIALIST DATE DCHD 10/95, t .. r ._ .ie _r._ s,..�..,._ ...mss �.....i--"'L"'"-�. ._.s....J.�.� ..._�,_._ ._-...-�,.��xr,��...y..�__t"t__z—_�_.�L..t li,�.ie__,r....�'.ti _,._W__i..f 3.._2_.� ._ti,._._.s_�.r_..rte• a .. .__ ____a. ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department ' ^ Environmental Health Section .Vd P. O. Box 665 Mocksville, NC 27028 Application/Permit Request/ed By �P� j Mailing Address. Home Phone �W elt,�y.3 l Ulfj(/CG a27d��o Business Phone ' qc�"t �5 / 2 Name on Permit if Different than Above 3. Application for: ❑General Evaluation " ' Septic Tank Installation Permit s, 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly }i O Business Industry ❑ Other Q Unknown house, mobile home:Subdivision /�'�'7 ��00/` { Section Lot# i • ❑ BasemenVPlumbing ,s No.of People ❑�Basement/No Plumbing No.of Bedrooms p'Washing Machine No. of Bathrooms °2- Dishwasher q 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: d Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor { 9. Do you anticipate additions/expansion of the facility this sytem.is intended to serve? ❑ Yes 0"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. PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Off i ce PIN: # PROPERTY ADDRESS, as foIIows: Road Name: .l L�/linf5 a 1C!/. a / City: Ayee4S' /!/• C r SUBMIT A PLAT WZTH THIS APPLICATION. hr f Revisions effective October 1, 1995. 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 this application. DATE SIGNATURE r , t CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: L!3 7. 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 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 fora ground absorption sewage treatment and disposal system. J DATE SIGNATURE t DCHD 0)93) APPLICATION F0:7 °?ITE EVALUATIONIIM"qOVEMENTS PERMIT a v County Health Dcpa :,ant ( ' Environments alth Sec"cn P. C ^.65 h'ocksb'1 2702 . ENVIRONMEN:FA"EALTH DAVIE C011141TY j 1. Application/Permit Requested Byr1P.0 1/7 617 l , h,aiiing Address �:: Z/ 7 ZLL� Hone Phone S? -rBusiness Phone_ 2. Name on Permit if Different than Above 3. Application/Permit for: ❑rIG"enerai Evaluation ❑ Septic Tank Installation 4. System to Serve: E -i ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision s Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms _ ❑ Dishwasher Dwelling Dimensions Z;Z q ❑ 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: il4ubllc ❑ Private ❑ Community 8. Property Dimensions LqA ,r iZe . +y ) a.2.a�l Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? fes ❑ No If yes, what type? r ,p r� '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: e0,-r( L1 4e4V d o 1 — e awV 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. V ry J _ DA E SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 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 representativeof the Davie Coup Ly Health Depa merit to enter upon ab ve d s ib property located in Davie County and owned by to conduct all testing procedures as necessary to dee mine said site's suitability f ground absorption swage treatment and disposal system. ATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED -7 - D 9� ADDRESS S PROPERTY SIZE ` PROPOSED FACIILTY 6LOCATION OF SITE Water Supply//..: On-Site Well _ Community Public Evaluation BSc; L Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % -\S HORIZON I DEPTH ° �t Texture groupCr✓ L Consistence F Structure C'Cz C MineralogZ \'. \ HORIZON II DEPTH Texture groupC Consistence v-17— FT Structure C Mineralogy '. f J.j HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS $S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �5•, EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: � � v 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-Vc.-y 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 ■.■■.■■■.■.■■■............■■■.■■■■......e........=..M.■.N■ ■.■NEEM ■.■.■■...■.icy■■�■■■■�d..■■■.■.■.■■■■■■.....o...aM.......■■...■..■ ' ��0000.■\0000000�■■��M000000000000a ■.■...■■..........■...■■..■.■...........■■■.■��■.■...H■■.moi......■■ ■■■■■.■■■■.■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■�■■■ ■ ■o■/.El�N■N■NMN ■..........■..■■..................■.■..■ ■■E ■ loom■ ■■■■■■N ■■ 0000000000000000000000000000000000�ii�o i0000i MMMMMMMMMMMM MMMMMlM o ■......H■..■..■...■.■■■!Ci/■.■■�■......N.�■� N■■�■..OMO.HoMEN ■■■....■...■.■■■.■....�/%.NEEM.■ ■......■ ::0000000000::0000 :::0000000000000 0000000000■ OMEN minoo000000�0 0000:.00000::_ :0000000000000000000�oo:o000�o'.000000.:'0000ONE 0 .........C...........u■M.M■.■..�.■..�.....u�u■■■.■.oM■EMEME■ ■■M.Mci/......■■..■■.....■.■..■■ ....H...■.■ ■■■■.■■■ ■■■■■■■■ ■.■■ .■■■.■..■■.■■■..■.■■■■■■■■■■■■■■■�■■■■■■■■ ■ No ■�■■.■■■i ■.........■■.■■..■....■■.EO...N.■�■ % ■INEMO ■ ■ Moo■ .■ om■ N ■ .■ NEEM_ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■ u■■ �■ ■■■■... is000000�loo0000�30000 moi==::::: :No :■■ ■ . soo.uMEMom ENO 0000000000:0000000000:oo.000� :o C ..:�:::� ■.....■....■■.eMM......N■■■....■000u ■ ii sooe0000 .......■■..uu.....M■■■■■.. u 0o00oo:ooM■mmoo00000000MUSEUM■■■■ ON 0MEMO 0 ■.....■■.....■...■■...■..■....■■ WMN ■ ■■■ ■■■■EMM■.■■. ■N.Nu■ ■.. ■■■ ■■■■ ■o.00..■ ■■■■■■■E■i■■oo■■■MM■.■. ■■■_■■■ ■■ ■■ NOME.■■�■ ■■■NEEM■■ ■■■■■■■uu■ .N ■■N■ ■. 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