133 Canton Road Lot 13, Sec 2 At b TiONavo 4 DAME COUNTY HE,ALTHDEPARTMENT •_,
Environmental Health Section PROPERTY INFORMATION
Permittee:SA. O.:Box 848
Name:" W ksville,NC 27028 , Subd�yision Name:;
;�G Phone# 704 634-8760 !
Directions to property: .U��� f :Section Lot:
AUTHORIZATION FOR • ..
WASTEWATER
SYSTEM CONSTRUCTION T Of e1PIN:# d
Road Name: e-a �Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County'Environmental Health Section prior
to`iss�ance of any Building Permits.This 136mdAuthorization Number.should be presented to the Davie County Building Inspections'
Office when applying for Building Pemvts.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section 1900 Sewage Treatment and Disposal Systems)
***NOTICE4!"THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
-ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED:
1 3 2 4 DAVIE COUNTY HEALTH DEPARTMENT
Y f ' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
.i''
Permittee's Z !
-
~ Name:' +�,,r k*1AT' .f ii'!1j,4 'd.li 'qtr `� ?t1: b�� -Subdivision Name 11 f•;/ ? %'�a
— --- f r
Directions to property:,/i '- r' Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: e '.,`-y.,f; ' '' ip:
**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/mstallation 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
"":fes,_1 ::... <" r,r'f� »F -' ,✓` '! �''i'�,
ENVIRONMENTAL HEALTH S ECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS U/M1 r#OCCUPANTS_ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK—Z(o ,-O—GAL. TRENCH WIDTH ROCK DEPTH [) LINEAR FT.MI6
OTHER MYAJS1I �C ' /D-1SdX
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
J
**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
S INSTALLED B
5-y-sxe,111
is
1,
AUTHORIZATION NO. Z?VOPERATION PERMIT BY: DATE: �r
**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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05196(Revised)
13 V DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Natr)e:' f1 _,` ` 0„i -?(,4rP.;,;r, r' r ryJ/ , ;: 'st t, Subdivision Name 1���Aff /r'`Yf I'dl
1 fir.'
Directions to property:',/"+ %" Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# j
Road Name �.•ra r': ') fff Zip:
**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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS [V.r#OCCUPANTS 9 GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE- #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY G` DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE I
t✓��`° S'O�C� 7v"! ,r
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKGAL. TRENCH WIDTHl r ROCK DEPTH f LINEAR FT. de
OTHER, f.�rs//
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ,
0
**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.
i
OPERATION PERMIT .. ----•�.
S INSTAI LLD�3Y- /0111
E�
AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE: J/y`� J/
**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 05/96(Revised)
DAVIE COUNTY' HEALTH DEPARTMENT ..'. r .
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE:issuedLnCompliance With Article II of G.S.Chapter 130a
a -/nitary Sewage Systems X � y Permit Number
Name. t Z. il' � ��vv'�� Date r:24,11- :< ,� N.0 7899 , . -
Location
Subdivision Name _ –w' 1t Jd /J'+ �u, Lot No. / Sec. or Block No. '
Lot Size /_l�— — House v� Mobile Home —__ Business._— Industry
No: Bedrooms —,No. Baths No. in Family — ,Public Assembly Other
Garbage Disposal YES NO p .
Specifications for System:
Auto Dish Washer YES "NO ❑
Auto Wash Ma^hine YES .:NO ❑ � '
Type Water-.Supply
"This permit Void if sewage system described below isnot installed within 5 years from date of issue.
This-permit is subject t6revocation if site plans or the intended-use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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., `
1:00-1:30 P.M. or 4:30-5:00 P.M:on day of completion.Telephone Number: 704-634-5886!g740
- Final Installation Diagram:, !� � System. Installed by
i
II Certificate.of Completion �1 Date _
'The signing of this certificate shallindicate 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. fi
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P MtT.�__...r...,.-•- ;
✓ ���,�<r �„>�l4 Davie County Health Department 1
✓ ! _ Environmental Health Section �•,t �K � 5 1993 �
P. O. Box 665 - }
Mocksville, NC 27028 '.
_l s.
1. Application/Permit Requested By D(Cle /,wZ2�_R n,O a V 5 i' -ZwC.
Mailing Address ei fS Civ X 7 1920 C/eS}[.'tom Al,C. 7"
Home Phone 474�.P- 7.5 21 Business Phone_(99k - 7.;) 7 c1
2. Name on Permit if Different than Above
3. Application/Permit for: General Evaluation ❑ Septic Tank Installation
4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision !L A/O LL6 CJ Section Lot #_)3
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms Washing Machine
No. of Bathrooms2 7 UrDishwasher
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 a 2 -3 No. of Urinals
No. of Lavatories <:�I, -3 No. of Water Coolers
No. of Showers - Water Usage Figures
7. Type of water supply: Evublic ❑ Private ❑ Community
8. Property Dimensions / 4 C.A—r 4-0 7Z Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EVNo
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 oLmy knowledge, and I understand I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION LO BE DONE ON 6BOVE 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 SIGNATURE
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �,at 4+
\ Soil/Site Evaluation
NAME �� N C �'Z S 0 DATE EVALUATED
ADDRESS �A 26 3 1, PROPERTY SIZE v�cltR
PROPOSED FACIILTY oy s Q LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By:C C L. Auger Boring Pit ✓ Cut
FACTORS 1 2 3 4
Landscape position
Slope % ••- •�/
HORIZON I DEPTH lie
Texture group .L S fG
Consistence
Structure
Mineralogy
HORIZON II DEPTH r t 1
Texture group
Consistence
Structure
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: > EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: G 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
Min eraloay
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
■.■.■■.■■.■■■�\I�!'.7..■..■..■■...■..■.MEMO■.//.■......../■■.......■.■
■■■■■■■■■..■■..i■M...M..■■■..■...■...■..■..■.. ■ ■MEMO■ ■.■■■■EOE■
■■■■.■■■..■...■■■■.■.■■...■.■■...■■■■.■■/E.E..E■I�C91■EE.E./..■■I.■■
■.■...■n..■■..■..■■.■■■.■...■■.�....■■/......EM.!//..■....... ■■■
.................................................... .... ■■■E■■.
........................................■....... ■E■■■. ■■■■■■■■■MEMMUSIMMMEMC
■...■■ MEMO■■ ■.■■■■ ■■.■.■ � ■■.■■. ■...■■ ...... ■MEMO■
■.■■..■.■.■■■.■.■.■MEMO.//MEMO.../......■.../..■ ..■....■■■■■..■
........................■................ ■.......N...■M ■■..■■O.
..............................................................■...............................E...................................�....................�....C...■■■N.. ■.■■.
.■
I.■■■...I MMMMMMMMM.M...M...M
■ ■■ .EN ■.�. ■MUMECE.:... ■■■. ■. C
................................ M■ ■■.■■N■ .. .■■■NMN MEMO
■■■l�■■.■■...■■..■■.E■....■.■.M.E.E.■■■■■.■■/ ■ .E ■..■■■. .E■■./
■.■...■iiia,I•■■■■......■■■....■................■.■...■.■ .....E..
■.EOE■.E...EEOti//.EEE■■/..■■■■■E..�■....�.......�.....■.D/■/E..M■
..................I,............. ■._■■■MU;;;■ E■■■■■■.N.■■■■■■.
...................■.•■............■ ■■■ .. ■■■■■■■■■■...M■■■C
....... .......... ............... .. ... ... ........ ....
M■/NE■. C■■=■■■■■■. ....■.............�..... .■.._........_..�.�
■■MEMNE■ MEN ■■............................... .■..■■.■■■N■MEM ..
■■..■■■NOO!!i\7��N■.N.NN..■.■.■■■■ ■■■■ONO ■M■■■■.■■.. ■■.■NOME■■.■
.......NM../■■■.E.■.■...E■■■...E..EMMEMMOMM`�1■■ME. .MMMMC u �1
...............0..■■ .............■..■....MNNEEM E:/..M.. MMI 0
uNEE■=ONNOMMOE
■■■■..■■■■■■■E■■■■■.....■...■./■ ■■N.�..■.....■.E■.E■■...E■...■EE