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121 Canton Road Lot 12, Sec 2 �Co DAVIE COUNTY HEALTH DEPARTMENT ' . + IMPROVEMENT PERMIT and OPERATION PERMIT 1 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) NAME � �1n/�'PlrY�r PROPERTY ADDRESS ,�f1 L�n11dream •-a7d �' DATE LOCATION of SUBDIVISION NAME (, /�,rGt: �Yl��/ui LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE k7 SSP # BEDROOMS Z7 # BATHS ,')— # OCCUPANTS GARBAGE DISPOSAL: Yes COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY z DESIGN WASTEWATER FLOW (GPD)-�_ NEW SITE REPAIR SITE L-� SYSTEM SPECIFICATIONS: TANK SIIE GAL. PUMP TANK 14VO 'GAL. TRENCH WIDTH --?4 ROCK DEPTH „0 LINEAR FT. -rOb OTHER a ylii✓ V4 'D ` .< RE1)UIRED 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 .• yG 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. J, OPERATION PERMIT SYSTEM INSTALLED BY /—.Oexd AUTHORIZATION N0. � OPERATION PERMIT BY 1e�VaAll 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. I DOHD 10/95 `- DAVIE COUNTY HEALTH DEPARTMENT ►C'� - � �„ IMPROVEMENT PERMIT and OPERATION PERMIT IMPROV ENT PERMIT **NOTEf* 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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME.`.� ` ,�/��lf � PROPERTY ADDRESS A t L`p/�1 C :) .�' J© DATE LOCATION r / f 79G r r l� ��x� cmf77r'� SUBDIVISION NAME 1% �/�� n�/.�%r�ri LOT NUMBER SEC./BLOCS NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE l'�r1�riSN # BEDROOMS �' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes ~COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ,/, NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK Z L GAL. TRENCH WIDTH --24 ROCK DEPTH _ 0 LINEAR FT. 3`4� OTHER VX, . / - !`may " RE(IUIRED 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. /7p 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 � � AUTHORIZATION NO. ` OPERATION PERMIT BY DATE <//PAW **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 136A, SECTION .1900 -SEWAGE TREATMENT AND DISPOSAL SYSTEMS , BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 Rei .� Davie County Health Department !'t• ENVIRONMENTAL HEALTH SECTION r 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) ***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.** , ,41 f AUTHORIZATION NUY.BER NAME (f /i/'/l �l'�� �'/TDA✓ DATE j p '' NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION % /r p COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION FOR ASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH 4ttfALIST DATE DCHD 10/95 DAVIE COUNTY HEALTH- DEPARTMENT ^ ;_ -'IMPROVEMENTS' PERMIT AND CERTIFICATE ,OF COMPLETION' *NOTE:Issued in Compliance With Article.IJ of G.S.Chapter 130a- Sanitary Sewage Systems = -': ;PermU, Number Name ,ri�ir crati r/• l %i_. _;Date /„7�J//fes NO_ 7&98 Q � + Location xL1�f��(11 f'I /• M Subdivision Name Lot No. Sec. or Block No. ,r� Lot'Size _ ('House ! Mobile•Home _ _ Business _— Industry ' No. Bedrooms' No'. Baths•_' - No.'in Family _ Public Assembly Other ' Garbage Disposal YES' NOJ❑ f Auto Dish Washer YES NO Specifications for System: Auto.Wash Ma^hine YES NO .❑ ' Type Water'Supply 'This permit Void if sewage system described below is not installed within 5 years from date of'issue. This permit is subject to revocation if site plans or the intended use'change ATTENTIbN .- . YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. • 11 � � '. ' _, ., - •. Improvements permit by *Contact a representative,of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:004:30,11?M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-63449*. D ..— 4.� f Final Installation Diagram:, Fi System Installed14. �� . 7. a y Certificate of Completion Date" 'J 'The signing of this certificate shall indicate that the system described above has been installed 'in compliance with the standards set forth in'the above regulation, but shall in NO way be taken:as a guarantee that the system will function satisfactorily for-any given period of time'. zor-Y APPLICATION FOR SITE EVALUATION/IMPROVEMENT P MIT.._._.._�..�•�-•--�� Davie County Health Department } ✓ �' ' Environmental Health Section1 5 19 C P. O. Box 665 , Mocksville, NC 27028 1. Application/Permit Requested By 1-(C& 4iVaE r�.c) LO•US -�.uC Mailing Address /ec /YIOC/e-S✓/c c _ AZ.C, :270.2 Home Phone Business Phone 7--;) 7/ 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: Vf ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision CUAIL!L A 6 LLd cc.) Section Lot # J a ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ( Washing Machine No. of Bathrooms a:2 7-70 a Q'"Dishwasher Dwelling Dimensions 05,'Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes al b 2 No. of Urinals No. of Lavatories �•_ —'S No. of Water Coolers No. of Showers D— Water Usage Figures 7. Type of water supply: Ompublic ❑ Private ❑ Community 8. Property Dimensions / A ce'E Lo Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes GKNo 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: This is to certify that the Information provided is correct to the best qLiry knowledge, and I understand I am responsible for all charges incurred from this application. - ,?,3 DATE SIGNATURE CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY Fand ECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box #2,the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system. DATE SIrP(ATI IRE DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section \ Soil/Site Evaluation NAME �-� .'N C �Z S n +� DATE EVALUATED 3 - Cl 93 ADDRESS SA 26 '6 3 0 PROPERTY SIZE PROPOSED FACIILTY \�o u s Q LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By:(' C L. Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position GfC_ Sloe % HORIZON I DEPTH Texture group 5-4 lG Consistence Structure Mineralogy HORIZON II DEPTH �> /rip Texture group Consistence Structure ,/ l Mineralo % HORIZON III DEPTH Texture group Consistence V- Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , r— -• SITE CLASSIFICATION: __� ///1 EVALUATED BY: � - LONG-TERM ACCEPTANCE RATE: 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 clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very 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 SC-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 NOON■t...........■ ■t■t■.....■■...■..■■...■.■.....■■...■....■■...■ ■■ ■.■■■.■.■.i.■t■�■■....■....■.■.■NOON■..■■t.■■■■■.■■.■■■■■.■.■■■ ■.■.■■■.■.■■...■■/.■■■■■.■.■.■■■�■.NOON/■.■■■■■■■■■■■■■■■■■■.■■■■ Ott■i■■■■■..■.■■■...■■■i■/. ■.■■■/.■.NOON.■t■■.■■■■.■■■■.■■../.■■■ ................................ ......................■..■.■■■.. ....................1... ■■■■..■�SOMEONE�.■.■■■■■■■■■■.■■■.■■■■■■ ■■..■■.N■■■...■■.■.....■■.■■■■■ ■....■....w■G7■........■.... ■.■ ■■■■■■■■■■■■■■■■■■._■■■■■■■■■.■■■■■N■■■■■■.r ■:u.■■■.■.■■■■■■■■. •................................. ■■.■■■■■.. ■■■■■■■■■ ■.■■■.■■■■ ................................... .............................. .................................................................. ....................................................=....C■■■■■■■■ ........................■............... ........... ■■N■■■■■■■■i■ •••••• ......�......�......�■■■.■.0■■■.■■ ■■N■■ ■..... ■....■ ■■■.N■ ■....■ ■■■■.■ ' NOON.■ ■■.■■■ ..■■■■ .■■■■■ ■..■..■r�■...■..■.■■....■..N.■■■......mom.C■■■.■■■..■■....�..N■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ no t.N■/ ■■■■■■■■ ....I■■■■....■■■..■■■■.■■...■■■.■■.■..�.....■■■C!IN ■I■■■.■t■■■■.■■ ■..■■■■■..■■NON N■■■. .............. ... . .■ . ■. ■■■ ■. ■■■■■■■■■■■■■n■C■...■■_■■■■■... .... ... ■ ■GONG=■■.'�..� ....■....n........■............�■■.�■■■. 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