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548 Pineville Rd✓XO ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NOTE** This ieproyeaent 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 !.' , /i Flt/Cti PROPERTY ADDRESS / I �/� ✓t Le- '_ T CL, ` J `fid DATE LOCATIONV i% r1 SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE 271-1 # BEDROOMS .? # BATHS # OCCUPANTS � GARBAGE DISPOSAL: Yes/10 COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE ire TYPE WATER SUPPLY 6 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 14,9d GAL. PUMP TANK GAL. TRENCH WIDTH T6' ROCK DEPTH /? • LINEAR FT. &4.0 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. r IMPROVEMENT PERMIT BY 1/ **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 SYS STALLED BY AD11,4 epeAe AUTHORIZATION N0. ,1OPERATION PERMIT BY Aleeev 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. DOHD 10/95 Davie County Health DepartaA I ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUMIZATION FOR WASTEWATER SYSTEM CONNSTRUCTION (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 issuance of any Building Permits. This For Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** /-- �/ a/ AUTHORIZATION NUMBER NAME /J:11 .",ea �U�� DATE % S"" �� N12 J, ? r NAME ON IMPROVEMENT P,ER�MIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM *##NOTICE"* THIS AUTHORIZATION FO A TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.` ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested Mailing Address Home Phone Business Phone 197-6111 2. Name on Permit if Different than Above 13urc Cr 3. Application for: a General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: ❑ House f� Mobile Home OW ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision 11 C' No. of People No. of Bedrooms 3 No. of Bathrooms l / Dwelling Dimensions 92 X Y 6. If business, industry, place of public assembly, other: Specify type No. of People Served L�r No. of Commodes a No. of Lavatories a No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions Sf o ev tpc�be� Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Yes No ❑ Community I '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. rROPERTY INFORMATION REQUIRED: Directions to Property: d0161 e5�� Tax Of f ice PIN # ,fi?43 -,27 - `9 //6 Road Name -/ he ✓We d Box irk (if available) City 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. P 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 Dave County Health Department to enter upon above described 4 property located in Davie County and owned by -Buy), ro�K, .Tr to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1/93) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested Mailing Address 141q 2. Name on Permit if Different than Above 3. Application for: Home Phone q qg - q6 o (� Business Phon #/6) 1.21-310o ❑ General Evaluation 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No. of People t No. of Bedrooms .3 No. of Bathrooms Z Dwelling Dimensions UdSeptic Tank Installation Permit R Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers — Water Usage Figures 2" 7. Type of water supply: (" Public ❑ Private 8. Property Dimensions ar—vi, Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ET—Washing Machine (Dishwasher ❑ Garbage Disposal If yes, what type? E1 -`No ❑ Community `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: g011V �o �arm�ny-on Rd Gl�f on �in�✓�1�� i�c J hf a 131 k-, This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. JI-11�3 6- AA,/ ATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. e2. 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 D i Copnty HIth Department to enter upon above described property located in Davie County and owned by 4 r1)C to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal pystem. DATE SIGNATURE DCHD (1/93) • DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/Site Evaluation NAME ' fes` n ADDRESS PROPOSED FACIILTY 11-1yAwl DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape 2osition L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group' Consistence -� Structure J r 5✓✓� 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: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: a /Z OTHER(S) PRESENT: 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- Ve-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 ■��■��nu��nv��nM■n . ��■��/A ■ ��■�� ■��■��\��N��■Y��■��■��■n��■�� ■�H�� ■�� ■ ��u��n��■ �� v��■■�� n��■�� u��■�� n�■ �� ■ �� ■ ■�� n��■■ ��v��vv�� vvd��■ u ��n��■�� ■��■�� .■��a�� ■�� ■ ■��N��/■�■�� ■� H�� A�� ■ � ■ ■� ■ �� /��N�� ■ ��■ ■�� u��n��■��■■��■��_ �� n ■ � ��'�C��■ ��Nh��u■�■�=�� _ ■ ■��■ ■��■ ■h��■��■u�u ■�/�� ■ ■ ��■■ ■��N��N��h■h� �N�v�/�� ■ ■ ��■ ��■��l�u�� ■ ��N�� t�■��n� ��■■■�� ■.■� ■ ■ ■ ��/�■ ��■��■�n�� ■��■��H��■��NN��■�� ■��■��■ �N��v��N�� .■��E� ■ �� nu�� _ ��■ ■�i�� ■��N -- ■ ■ ��H�■ ��■�� ■ N�� ■��■ �� ■ �� N � ��■��■■��■ i�iiiiiiii'iiiiiiiiiii�iiiii�iiiii�iiii��iuii=� �� ini�� ■��iiiiiiiii ■��H��i!N■■ �H■■�HI��M �� ■��■� ■■ ■��■�■ . ■��■��■ ��■1� ��u� . �I�� ►�l�� ■�■ . ■��■■ ■ ii�iiiiii�iiiiiii�■iiiiii�iiiiiii�ii=�ii�i ii�n��■i�ii��i� �i�i�=iii=i�iiiiiiii�i� ■��/��/��N�1��1�� /�■ ■■��■ ■��■■��■��■��■■��11�� ■�I�� n ��\��■��■�■ ■��i��■■��■��■■��■��i��■��n��N ��u��■��■��■■ iiiiiiiiiiii�iiiiiiiiiiiiiiiiiiiiiiiiiii�iiuii=ii� iiii�iiiiiii�iii=■�i=�iii■�iii�iiii ■�� ■ ■ �� ■ ■��■��■��■��Y��iiii�� i=iiiiiiiiiiiiiiiiiiiiiiii■i�=iiii�ii��n��■ ■��■�t��_�■■��_��.�■��■��■��■��■��■�■ ■��■��■��■��■ ■��■ ��■�■U��■ ■��■��■��■��■��u��= ��■��■��■��■ ■��■��■��■��■ ■�■��■�■��■ ■ ��■ ��■ ■��u��■ ■��■ ■�■t��■��■��■��t��■■�=��u��■��_�� i�=��■��■ ��t��_�� _��_� ��t��_��■ ■��■��■�■��■��■ ��■��■ ■■ ■�� u�■��■�■ ■ ��■■ ■��■��■t■��■��■ ■�� ■�� ■�■ �� ■ ■��■ ■��■��■��■■��■��___�_��■■ =�n��■■ =�i�i��■ ■H��■��■■■��■ ■��■��■��■■ �� ■ �� v��■ ■■ ■�� ■��\�\�� /��/�� ■ ■�� ■��■��■��■�■�■■��■ ��■ �� v�� O� ■��■ ■��■��■��■��_��■�s��u�� ■��u�� ■��■��■��■��■�� ■�� ■��■��■ ■�� ■�� ■■ ��■�� ..........................C..................■...�...■....�_:�.......��.■...... ....................................�...■....... ........ ._.......... .......... .......■......................... .. .......■.............. .....■�......■.......... ■��\��■��■��n��■�■�� ■��■��H�■ ■�\�■��■��■��■�■■��■��■�■■�■■ ■�■��■��■�■��■ ■��/�� N��/�� ■��■�■��■��■�■��■��■��■��■��■��■��■��/�� ■■��t� ■��■ ■��■\��■��■■�■�■ ■��■ ■��■��■��■��■�� ■ ■��■■�!N