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139 Green Court Lot 8• ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT M w, IMPkOVEMENT 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 It of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME �^,,/lt fir.-; .> .*' PROPERTY ADDRESS cICc'I : (j ; epi Gi._ DATE � '�'✓ ��` ...._...) LOCATION , ,%;,J %�,, SUBDIVISION NAME �'% ; f ;' >-a LOT NUMBER`; SEC. /BLOCK NUMBER O \ f RESIDENTAL SPECIFICATION: BUILDING TYPE ,: # BEDROOMS # BATHS '%> # OCCUPANTS GARBAGE DISPOSAL: Yes/Nfo7 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 i i, GAL. PUMP TANK GAL. TRENCH WIDTH = ROCK DEPTH LINEAR FT. OTHER REQUIRED 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. "z T R. MPRDVEMENT PERMIT BY **CONTACT A REPRESENTATIVE THE DAVIE TY MH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:N-1:30 P.M. ONY OF ITALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT r TEM INST q . AUTHORIZATION NO. OPERATION PERMIT BY ��C� 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 / o f "z T R. MPRDVEMENT PERMIT BY **CONTACT A REPRESENTATIVE THE DAVIE TY MH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:N-1:30 P.M. ONY OF ITALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT r TEM INST q . AUTHORIZATION NO. OPERATION PERMIT BY ��C� 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 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 ery Application/Permit Requested ByC/ Mailing Address -13 d L kr,� Home Phone f V C % 7cJ Z g Business Phone��f� 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation 4. System to Serve: C�, House IdSeptic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision �{� r ��s� _ Section Lot # No. of People No. of Bedrooms 7 No. of Bathrooms 3 Dwelling Dimensions � 2S6 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: 2 Public ❑ Private ❑ Community 8. Property Dimensions _SLA ,- Sewage Disposal Contractor a,,, C�-, /- 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2-1o ❑ Basement/Plumbing [IB sementlNo Plumbing p Washing Machine p Dishwasher ❑ Garbage Disposal If yes, what type? '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. PROPLIMI INFUINATION KbQULKZ1)- Directions to Property: / Tax Office PIN: ,# �,w7tr, 14,7 RVl u i v1 Gc P/ PROPERTYADDRESS, as follows: 07 ,9�Q_�/ �� Road Name: U i� �''c /P `'r�� - t T �1-1 ins vh 7`4 fe)wi City: SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. 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 this application. If / ZZ DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: R6. 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 County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. --17 119Z n /,/ � 4/?, � /y� — / DATE DCHD (193) SIGNATURE y NAME O�'nr ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED PROPERTY SIZE f! �C LOCATION OF SITE -DGIda I Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit 1/ Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogyl ' / 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: L EVALUATED BY: A� /// LONG-TERM ACCEPTANCE RA REMARKS: <�"."- /2"- DCHD(01-901 OTHER(S) PRESENT: 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 'r -f.1 - 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 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 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 ■■■■■■■■■■■■■■■■■■■■.■■■■■■ Moll ■■.■.■■■.■■■..■■..■.■■■■.■ .■■.■■■■■■■■■■■■■■■■■■■■..■....■.■CMEMO ■■■■■■■■■■■■■■■■■■.■.■■■■■■■■■.■ ■■■■■■■■■■■■■■■...■■■■.N■■■■..■ ■■■■■■■■■.■■■MENU■.■■moss■>!■■■■. ■■■mm■om■■■■■■.■■■■�■■■.■■■■_■.■■■■■■■■■ ■■■■■■■.■■mom■■■■■■■■■■■■■■m■■ ■■■■■■■■m■■■■■ NUUMMUMMEMMEEMMMEMS MEMO MONSOON MMOMMENME ■ MOM■EN■EC■E■MEME■ NiMEMMEME■■OMEMEMO■■■E■ M■ 11MOMMImHH M■■■■■■■■■■■■■■■■■■mm■■■■■■■■N■■m■■■■■■■ ■■mm■mm■■■.H■■...■■■■■. ..■ .■..MM■.■M...M■■■.■...■■....■.....M.■ ■MME■EMNMM■MEME■H■■m.■ ■■■C■■■ ■■■■■■■■■■■■■■■m.■■■■■■■■■N■■■■ ■■MMCMMONSOON.H■M.CONE ■CN..M■.M�i..■■M.■■■■■■■■■■■..■.M■M.M.M.■■■ ■MEN '■ ■NC■■�1C0 mom■ . on CC■• ■ NONE C�HCCC■■C..■C.■CCM■Ci■!C611,C■■■CC.■C■■C.■■C■C.■■C.M■:Cm■■CM.■CC.■C■■C■■C.■C■■C■■C.■C.■'C.■■■'■■m■■o■.m.Mm..o..m.. 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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.*** /! AUTHORIZATION NUMBER NAME C DATE �/ 2 ) NAME ON IMPROVEMENT PERMIT IIf different t n above) SITE LOCATION ' L Ir/ ��/-% _r' �H— COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION F7WAWATER SYGT ;CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. -- Z,� ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD`10/95