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261 Cornwallis Drive Lot 27 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 G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME PROPERTY ADDRESSo r n uja DATE LOCATION SUBDIVISION NAME f' !/ i i //I P LOT NUMBER _ [� � SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE i f N BEDROOMS.. # BATHS OYa # OCCUPANTS GARBAGE DISPOSAL: Yesdo COMMERCIAL SPECIFICATION: FACILITY TYPE , # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE fA e- TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE 1,,-' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /47P GAL. PUMP TANK GAL. TRENCH WIDTH " ROCK DEPTH IVB LINEAR FT. J'd O 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. IMPROVEMENT PERMIT BY Vii �f **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 INSTALLE SY %o c �cc ----------------- �T. AUTHORIZATION N0. D q OPERATION PERMIT BY fDATE **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 FICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 y ' . »r Davie County Health Department 4 ENVIRONMENTAL HEALTH SECTION P.O. Box 665 ` Mocksville, N.C. 27028 `,AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION x` r 4 '(Issued in compliance with Article 11 of G.S.'Chapter 13@A, Wastewater Systems) T4'2 3� ,, ***This Authorization For Wastewater System Construction must be issued by the Davie County Environme7nt1 Health Section prior.to .. issuance of any Building Permits. This Form/Authorization Number should be presen d to the Dave County Building Inspections Office when applying for Building Permits.*** � AUTHORIZATION NUMBER NAME !/Yl ,/' ��'��,�f%/� DATE NAME ON IMPROVEMENT PERMIT (If different than`above) SITE LOCATION ) COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR W TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department i. Environmental Health Section r P. O. Box 665 �. Mocksville, NC 27028 � �X_ s 1. Application/Permit Requested By 6 Mailing Address CDU S ' Home Phone N', (; �� Business Phone � f f. 2. Name on Permit if Different than Above f' 3. Application for: ❑General Evaluation Er-Septic Tank Installation Permit 4. System to Serve: El House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown X!2 c� 5. If house, mobile home: Subdivision oe&ele /�h�L, 5 `e Section Lot # X 1— i ❑ Basement/Plumbing 1_ No. of People ❑ Basement/No Plumbing ' No. of Bedrooms prWashing Machine e No. of Bathrooms ��- td'Dishwasher i Dwelling Dimensions 40 a.s �- ❑ Garbage Disposal j i' 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks I, No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers i No. of Showers Water Usage Figures 7. Type of water supply: R11"Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0No If yes, what type? } i 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementd Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY INFORMATION REQUIRED: � Directions to Property: Tax Office PIN # Road Name ZD hew--- e-W G•i^e j Box # (if available) city f / I E 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. I DATE SIGNATURE F f i CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY ; MUST CHECK ONE: ❑ 1. 1 OWN the property. 0 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 CouDW Health Department to enter upon above described ¢ property located in Davie County and owned by (r a,r-(n r-6c , to conduct all testing procedures as necessary to determine said 's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �DG� DATE EVALUATED o`2 ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well // Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH a? Texture groupC Consistence i Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 721 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: —1-2r EVALUATED BY: ./`l 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 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1. 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