112 Winchester Road Lot 14IMPROVEMENT PERMIT
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTNRIZATION 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 ADDRESS 1. /74 Che--: I' A— —A9 'DATE
LOCATION
SUBDIVISION NAME ,�!��l�.-S n:,., LOT NUMBER ,f'�/ SEC./BLOCK NUMBER
a
RESIDENTAL SPECIFICATION: BUILDING TYPE �� # BEDROOMS,.7 BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye6
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE /r'/C' TYPE WATER SUPPLY ('C DESIGN WASTEWATER FLOW (GPD). s'�/ <� NEW SITE a -<PAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE DP GAL. PUMP TANK GAL. TRENCH WIDTH ',a� ROCK DEPTH /�� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INENDED USE CHANGE. YOUR WASTERWAER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FO FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. �EL ONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM
10.
AUTHORIZATION NO. L'9j 7j OPERATION PERMIT BY Aa4� DATE I <Q
**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
0
-Davie County Health Department
ENVIRONMENTAL HEALTH SEfTION
P.O. Box 665
Mocksville, N.C. 27028
xZ1
AUTHORIZATION FOR WASTEWATER. -SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
Chapter I30A, 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 NMER
NAME DATE '� /� ' l' 0, v 0 2 �)
WE ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION >'P�r vl�.',� .4ai,� ��} ,✓✓ �jG�� 7�C �1S {� ,�✓l
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
1W� rC,C� X/JOPISO
o�o`�.SrG��;•r� �a �e � .
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM
�� QAC Y Davie County Health Department
%' `I'��' /tJ,��)- P. Environmental Health Section -AP Moc svilille, NC 27028
1. Application/Permit Requested By /-►aJl�2$c;,�/ l ��%�� .L ,U G
�/
Mailing Address ��� L� 'Va-- f/A✓E'-t) GN Home Phone
/Z0 fCe S t/, t_t-Ar /(% 2 70 :2- Business Phone
Y;= I
2. Name on Permit if Different than Above r'
3. Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit t
.t
4. System to Serve: 21House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry �❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section _� Lot # Z!$� `
❑ Basement/Plumbing .
No. of People ❑ Basement/No Plumbing k
No. of Bedrooms ❑ Washing Machine
I
No. of Bathrooms L2 ❑ Dishwasher
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 No. of Urinals
No. of Lavatories No. of Water Coolers _
No. of Showers Water Usage Figures .
7. Type of water supply: ZrPublic ❑ Private
8. Property Dimensions Sewage Disposal Contractor
9.. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes ❑ No
❑ Community
t
'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.
FRUPERlY t
Directions to Property:
This is to certify that the information provided is correct
incurred from this application.
DATE
Tax Office PIN fir` n
Road Nance W V r- *Z5 ST
Box # (if available)
City
best of
my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 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 deLeraid site's suitability for a ground absorption sewage treatment
and disposal system.
s
DATE SIGNATURE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT L/
Environmental Health Section LDYIT
Soil/Site Evaluation
NAME �� �e�1S4�✓
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public t -"-
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4
Landscape position
L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
JVP vf- A/6 ~-
Texture group
Consistence
Structure
.0
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: L—_ -) EVALUATED BY: Xyll l/
LONG-TERM ACCEPTANCE RATE: r/61 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+:! -y 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