713 Sheffield RdX0
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 I1 of G.S. Chapter 138A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME st e ,,\\c.`n��c�\ (QN1t\�4OPERTY ADDRESS -S h P- Ei F.) �y= a °a b DATE -a1- C
LOCATIONUr.04`
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE V\.�Ma I BEDROOMS -� # BATHS �'S N OCCUPANTS A GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: FACILITY TYPE ` �'*,PEOPLE # PEOPLE/SHIFT I SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE Vq Q51—,,,- TYPE WATER SUPPLY , DESIGN WASTEWATER FLOW (GPD) 2 (� O "MEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE DGAL. PUMP TANK' GAL. TRENCH WIDTH 3 ROCK DEPTH _.�_6 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS 09 -THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE.SYSTEM.
LL o
uu'
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY:NEALTH D RTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INS ALL ION. TELEPHONE I IS (704) 634-8760.
OPERATION PERMIT
5 STE Nf
f
BY
AUTHORIZATION N0. b 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
Davie County Health Department
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)
d -/X0
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to
issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County'Suilding Inspections
Office when applying for Building Permits.***b
1s'kwot'��Tm DATE AUTHORIZATION NMR
fi 2 U 3 ( ,,
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION e F F e �� o
COEMITS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT. WASTEWATER SYSTEM
s
*HNDTICE**t THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665 ��R 6
Mocksville, NC 27028 Loo
1. Application/Permit Requested By M6 Ixma MAI W/4t
Mailing Address 713 1 H . LD Home Phone 7A4
r�LYVI rl t°' i Nr a Z � Business Phone10--7kEL/rn77e ,L f%
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve: ❑ House
❑ General Evaluation
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms I
No. of Bathrooms
Dwelling Dimensions / , T�/� 0
bg Septic Tank Installation Permit
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 Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: j$1 Public ❑ Private
8. Property Dimensions �•y Sewage Disposal Contractor
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
Z Washing Machine
❑ Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes X No
If yes, what type?
❑ Community
'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.
Directions to Property: Tgx -7-0 / 310 Tax Office PIN: # Sal n - I a ^ S-4597
l / Lw Z -o 510F✓5eLD ej), 1j"014 " a ��/ 0 s PROPERTY ADDRESS, as f�}o-1 lows:
d W LG1 r (Pp5ID15 -Z�7 50EF FLD AD) Road Name:r�t
City: ACC&WILL E
This is to certify that the information provided is correct to the best of
incurred from thisap lication.
//,Z/6 �
DATE
SU13NILT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
knowledge, and 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. )< 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 representatY of the D,�yie C unty Health Department to enter upon above described
property located in Davie County and owned by /�. �'/1��f"i. . �l�ZL►n� ? LL7i�l1�ll
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and dispo al system. '
DATE SIGNATURE
DCHD (1193)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME P\W , \6 DATE EVALUATED 4 -a4
ADDRESS S �yC�nQ
PROPOSED FACIILTY ' ` D
PROPERTY SIZE 1.6 num
LOCATION OF SITE,
Water Supply: On -Site Well _ Community Public V
Evaluation By :V \.,. Auger Boring I% Pit Cut
FACTORS
1
2 3 4
Landscape position
Sloe %
- -
HORIZON I DEPTH
t1
'
Texture group
I—
Consistence
-"S.
Structure
Q, Iva_C
Mineralogy
HORIZON II DEPTH
`'
-W%
Texture group
G
Consistence
Structure
k
Mineralogy
`
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
1A IL
SITE CLASSIFICATION: � *> - EVALUATED BY: Q_�„
LONG-TERM ACCEPTANCE RATE: i 1A OTHER(S) PRESENT: �r
REMARKS:_ cam^
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+--. -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
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