106 Winchester Road Lot 15IMPROVEMENT PERMIT
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
*iWTE** 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME{"!' %PROPERTY ADDRESS I
LOCATION ( r°. kr !' A,, / :'•E �� f
SUBDIVISION NAME t� lr`.�'.,, %% s'" :. LOT NUMBER SEC. /BLOCK NUMBER 11/
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS -.,L_' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE A TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE 4," m REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ':_ -' GAL. PUMP TANK GAL. TRENCH WIDTH e' ROCK DEPTH /:) � LINEAR FT. ;6V
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MAST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN n
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF I TALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTI T ED BYI i
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AUTHORIZATION NO. OPERATION PERMIT BY /'} DATE S _
**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 138A, SECTION .1988 "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
v' " • APPLICATION FOR SITE EVALUATIONAMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address a S id)/,(l� /3✓� L A.( Home Phone 5�9�- 71 7
iC,C , C 4 -7 e-) ,F Business Phone , - 7.2 - 2
2. Name on Permit if Different than Above
3. Application for: General Evaluation Septic Tank Installation Permit
IY
4. System to Serve: Houses ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision f �a/ �O'" ' Section Lot #
❑ Basement/Plumbing
fin.
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
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: Public ❑ Private
8. Property Dimensions = Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑ No
❑ Community
'NATE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
a
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
/s$ r
This is to certify that the information provided is correct to the
incurred from this application.
DATE
A,
my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON AB VE 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 of the Davie County Health Department to enter upon above described
property located in Davie County and owned by !.0 -,-
to conduct all testing procedures as necessary to determine said site's suitability tor a ground absorption sewage treatment
and disposal system.
DATE
DCHD'(1193)
' DAVIE COUNTY HEALTH DEPARTMENT S
Environmental Health Section
E alu t"on
NAME -�� 3-.
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well _
Evaluation By: Auger Boring
DATE EVALUATED '_Z/"P '_12A
PROPERTY SIZE �/
LOCATION OF SITE
Community
Pit //
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH C, r
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 71
LONG-TERM ACCEPTANCE RATE C r --
Public
Cut
SITE CLASSIFICATION: i EVALUATED BY: Al /�
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- Vl--ry 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
DCHD(01-901
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Davie County Health Department
` ENVIRONMENTAL HEALTH SECTION
P.D. 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 NUF3ER
NAME' DAT4�a 03�`�/i'
NAME ON IMPROVEMENT PE�ER//MIT (If different than above)
SITE LOCATION �/YC/J1 ye -1-j— 8: /, 2!!�
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FORWA ATER SYSTEM CONSTRUCTION IS, VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIDIMERTAL HEALTH SPEC IST DATE
DCHD 10/95