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235 Clayton Foster Ln - Xa 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 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage.Treatment and Disposal Systems) NAME 'P�tit�.s tiV t�hy�e SAU�Ci�: VKPROPERTY ADDRESS _YA,DI�/N I/ALL"g�f XX). °�I� DATE 2 LOCATION '�i r LSV 1 N — Cl,, NJ I•�6 . SUBDIVISION ME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE o vs a # BEDROOMS _:�_ # BATHS „ # OCCUPANTS 'i GARBAGE DISPOSAL: Yes No V k COMMERCIALSPECIFICATION FACILITY TYPE � e; #PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yis(No r LOT SIZE S ,,TYPE WATER SUPPLY i � D S I GN,WASTEWATER FLOW (6PD) 3 V) NEW'SITE'' . REPAIR SITE SYSTEM SPECIFICATIONS TANK SIIE Dob `GAL 'PMR TANK GAL TRENCH WIDTH `' 3 ROCK DEPTH LINEAR FT. 00' OTHER' REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANkR'THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE,SYSTEM. 1 d ) l3J N ` IMRRDUEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:38 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8768. OPERATION PERMIT �?' " .. .. . ...r . . SYSTEM INSTALLED BYhyx Wl:.L, t1... k 3 » tg .o �z �3 AUTHORIZATION NO. / b 2 OPERATION PERMIT BY o �e DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEA DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE it OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS-, BUT SHALL" IN NO WAY BE`TAKS_A5'A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DOHD 10/95 „...n_ t ..,.. ADavie County�Health Department ENVIRONMENTAL HEALTH SECTION 166. 00 ,P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION g+' (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) i ***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 NAME A N hes c3 Q r SAN F 1�t es DATE �d " c1 ° 6 2 NAWON IMPROVEMENT PERMIT (If different than above) SITE LOCATION �a� AA COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT.WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID,FOR A PERIOD OF FIVE. (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 ..cfa .. tr _.. _ r _.x �°_. L ,? 7 ,t...__' +`,.. },a. .. _, x .t, ,5 1,1'? _ 1 z .fir% _.r. rw _ f•... _� - " APPLICATION FOR SITE EVALUATION/IMPROVEMENTS • O vV P r1l. / 9� Davie County Health Department 19 n /�j' II Environmental Health Section _ g�c�' �� ' � r�'o 1cP �I�Mo P. O..Box 27oi8 JAN � � R pc 1. Application��it Requeld By WNCA5 Mailing Address gg 1,om mcwS A)C 2 70Z 2- Home Phone Y/O 19 111) Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: jW General Evaluation fid•Septic Tank Installation 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 No.of People �" ❑ Basement/No Plumbing No.of Bedrooms s-3 / ❑ Washing Machine No.of Bathrooms Dishwasher, Dwelling Dimensions 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: ❑ Public IvPrivate ❑ Community 8. Property Dimensions 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: / �Q N +0 SDI �� f„ h.e� Q �e0.5l .Lc A I D a�_ -pro �, g y�, ) l� � q��t� h Val [ek �o y {� (v Vel mourn ri �� 1�Y� L� hvul5� �n �ra ra ✓�, - Set✓ al[4CAed �4 - i5 'LctdS -�v J `rrn - �- r1 This is to certify that the information provided is correct t the best of my knowledge,and I understand I am responsible for all charges incurred from this application. DATE SIGNATU CONSENT FOR SITE EVALUATION TQ BED NE 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 f he Davie Co ty 1�eatth Department to enter upon above described property located in Davie County and owned by 1 1 ,_,Pe p P to conduct all testing procedures as necessary to determin s ' site's suitabili fora round absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(12-90) ! ' i Y! r x 'a Ap e � �• l• sit � } i pi DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section `\ Soil/Site Evaluation NAME � �ay k0`ps� AiJ 1� rp�0 DATE EVALUATED �•i ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: , On-Site Well Community Public Evaluation By:�`�AugerBoring V Pit Cut FACTORS 1 2 3 4 Landscape position 5 Sloe Z C3 _F56 O-$D O-$ HORIZON I DEPTH 1 -37" Texture group _ L Consistence Structure C Mineralogy 1P, tI '1 HORIZON II DEPTH 3& 11 3 3 Texture group C Consistence L �� Structure 6K BK 131c S3 Mineralogy \ 1 \ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 55 S -5--S SS RESTRICTIVE HORIZON — _ — SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �(�->' EVALUATED BY: LONG-TERM ACCEPT NCE RATE`: •3 OTHER(S) PRESENT: 1N C) N 4 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/ftz DCHD(01-90) ■■■■■■■■■■■■■■.■■■■■.■.■■■■■■■■■■■■.■■■■ MEMO■■■ ■■MEMO■■ ■■mmommommoomm ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■EEE■.■.■.■■■■nE■■■■■■E.■O■■ ■■■■■■■■■■■■■■■■■■■■■■■■O■■■■■■■■■■■■■■■EEE■■■.■.■■■ ■NE■■.■m.■..■ ■■E....EME■■■E■■N■■■■■■■■■.EEE■■....■..■..■..■.■■.. ■..■■...■■.■■ ■■■■■■■■■■■■■■■EEE.■■■■■■■■■■■■.■■..■■■.■■■...mmm■m= .■.SmmSM■■..■ ...........................C■■■m■■■■■■■O■■■■m..�■.■._.■■.°........ =IN iii =lENO EMEMEMimN ON ■■■■N■■■■■■■■m■■■■■■■NESE.■..m■ MEMO NSMS.mS■■M...mm■S.ES■MEN ■m■■ ■■■.■■■■■■■■.■■■■■MESE■■■■E..■..■m■m�.H■..■..■.■■ ■■■■.l■m■S■■..� ■■■■■■E■■■■■■■E.E..■.■■.■■■■■■■■■■...E..E...E■H■..■C...E■■..■loom Man mommom C■■':on momNo CEMMEMMI� HIMMOMME NoMM■M"MMEMMEME ■E■. ..E■.■EE■■.■■■■■.■■■..■■■■■■ iSE■■ OMEN■■moiMEM .MEM■MS ■■.■■E■■■■■■E.■■■E.■■■■■■■■.■■■.!\7■■.� E■■E■■soMirim ■■E�ME■■EN ■■■.■mmNN■.■■mmNEmm.mENm■■■== =--_ ■� . ,CCI■ ME No li m■■= ■■■■■■ ■SEMS■ ■■■■■N tl■.E.E MEMEMEN mmMN MRS MR ■SEEN■ . ■'■ M■■■■■■M■■■N■■M M■■■■MSEUME ■Mmm■■ �M ■ N■■■M■■N■■■ MMUMMOMMEMER ■mEN■SSE■S■■NH■■■mmmm■mNl�m■■!'S^lllt�7 ■HNON ■■■■■.■■ ...Ott■.....H............I�...lj,.�.rN ■■ M■■M■ME■ CCCCCC::CMCIM::C:CCCMC��CCICCCCCC■ N :CCCCCCCCCC :::lll:ClCCI::C:I:lICIIM'.'lC:ll'.:MC:_ I. 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