129 Winchester Road Lot 2v.+�,�„-7' `7 ISP�►�'
" f DAME COUNTY HEALTH DEPARTMENT
p, J
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION .
Perm'ttee's� '
"? Namer' tr rt All Subdivision Name:
r rort1;
,Diections rSectLot: i
t t •BWRQVEMENT
PEItNIIT Tax Office PIN:: - -
Road Name: -tTil �[ V tl K
*.*NOTE** This Improvement Permit DOES NOT -authorize the construction or tallation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRU � ON.; must be obtained from this Department prior to the
constructionfmstallation of a system or the issuance of a building permiC
(In compliancpWith Article 1.1 of G.S. Chapter 13.0A, Wastewater Systems, Sections 1900 Sewagz, Treatment and Disposal Systems)
***NOTICE***. THIS PERMIT IS SUBJECT TO REVOCATION IF SITE .
wt,�`+'' �/s , 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 y -:P # BATHS,- # OCCUPANTSGARBAGE DISPOSAL: Yes or Na
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEtswr # SEATS INDUSTRIAL' WASTE: Yes or No
LOT SIZE C TYPE WATER SUPPLY¢_ DESIGN WASTEWATER FLOW (GPD) NEW SITE (/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH_ LINEAR Fr. `Pm
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
0
IMPROVEMENT PERMIT LAYOUT
i � it •
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT
BETWEEN 8:30:- 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATIC
9R FINAL INSPECTION OF THIS SYSTEM
TELEPHONE # IS (704) 634-8760. ,
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME -, o A-.
ADDRESS
)�2
DATE EVALUATED LJ JI:2
PROPERTY SIZE
PROPOSED FACIILTY 1144a S-1 LOCATION OF SITE
Water Supply: On -Site Well _ Community
Public L---,'
Evaluation By: Auger Boring Pit i Cut
FACTORS 1 2 3 4
Landscape position
Sloe Z
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group C
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: 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- Vl---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
LD- 9 -fib
Mineralogy ZU44
1:1, 2:1, Mixed
Notes
Horizon depth - In inches loot
%
Depth of fill - In inches ea'A -ZN44"
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
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
JUL 1 1 1995
1. Application/Permit Requested By 221ele_-41\10 2$��
Mailing Address a P S U)iXJl !:71A✓eJ L/,( • Home Phone 5/-!92 7:5' 7
M/15 %/ . C a?7) -�_ X Business Phone I J9 - 7.a -7
-2. Name on Permit if Different than Above
3, Application for: )(General Evaluation Septic Tank Installation Permit
4.; System to Serve: HouseS ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown /)
5:If house, mobile home: Subdivision !�(O �`''4e Section Z Lot # aS._
Jz% ❑ Basement/Plumbing
CLQ) cl_U6" )eo.No. of PeoplePlumbing
D ❑ Basement/No
No.'of Bedrooms 9
�'1UC- (%,}LLL/-7D� ❑ Washing Machine
_
No" of Bathrooms 7V SC=e!E-7 // 69N0 1t)1LL_ A'510e ❑ Dishwasher
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
'No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private
8. Property Dimensions ACIfl-- Sewage Disposal Contractor
9:';
AUTHORIZATION NO: O 5 3 S DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's r P.O. Box 848
Name:/i f? r�.'j�'�r'�v� .1 Mocksville, NC 27028 Subdivision Name:
Phone #:704-634-8760
Directions to property: �J(��'/�r% �tl Section: /� Lot: a
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
Road Name: (TZl7{ L.(tCf� Zip:7ad6
**NOTE** 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.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
��o'�" ,l j�, 2?,w �? %(J%%a f� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED