P0173 Swicegood St -� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT i
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 apd Disposal Systems)
PROPERTY ADDRESS
LOCATION y
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION:BUILDING TYPE # BEDROOMS # BATHS J, # OCCUPANTS � GARBAGE DISPOSAL: Ye f�(I
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE JA�We- TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD)_ *&4 NEW SITE IZREPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/Q� GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH .� a LINEAR FT. �
OTHER , l /
REQUIRED SITE MODIFICATIONS/CONDITIONS: 4,4x/1 444 r—,9 ,4'
***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
01
AUTHORIZATION NO. OPERATION PERMIT BY � DATE 'c
**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 Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
- Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
S.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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.***
/ AUTHORIZATION NUMBER w.
/7 � .%/�?ls9/t/ .(a DATE
N2 t 7 3
NAME ON IMPROVEMENT PERMIT (If different than above)
f SITE LOCATION �'•7// ,l�/il'��OD !Y diI �7�
C01MITS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**OWICE*** THIS AUTHORIZATION FDR ASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENOIRMWALLWIM TH SPECIALIST DATE .
- DHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT l
Davie County Health Department ,
Environmental Health Section
P. O.'Box 665
Mocksville,NC 27028
.y
1. Ap lication/Permit Requested By f�Q/y�� 0-
Z., •1 4-0. 640,V 251 Home Home Phone o29
Nai(i�g Address
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House VMobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
h
❑ Basement/Plumbing
No.' f People � ❑ Basement/No Plumbing
Z
Notof Bedrooms J 09lWashing Machine
No'of Bathrooms .2- p""Dishwasher
"'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. a
7. Type of water supply: ,VPublic ❑ Private O Community
8. Property Dimensions Qe.,u, Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended,to serve? ❑ Yes VNO
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:
"'r � c��►^� ..X°`� Se CQOf r ►�, p,�.. ' 1� c- ref ,`s
40u-
//v-�' • 7 Sys— 6— �
CL
Cooleemee
Z
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 7thio,application.
6/fl; '
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: L?'� 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 Coupty and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and dispy sal sy tem.
DATE SIGNATURE
DCHD(1/83)
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44
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NORTH
L - 4 L - 5 L - 6
M - 4 M- M - 6
N - 4 N - 5 N - 6 -
OW DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ilTJ DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE Si;* C 5-i-
Water Supply: On-Site Well _ Community Public t/
Evaluation By: Auger Boring L/ Pit Cut
FACTORS 1 2 3 4
Landscape position L L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH 2�'
Texture group
Consistence
Structure /[
Mineralogy 'e
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: ��' Z4a �� /�C%' EVALUATED BY: W9
LONG-TERM ACCEPTANCE RA E: �� 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-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
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