132 Winchester Road Lot 11DAVIE 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 a y 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)
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NAME (l//i`l /� �`/�/'��Sn +� PROPERTY ADDRESS C-med (0/(S' i� `- �C.,"DATE
LOCATION
SUBDIVISION NAME 7 LOT NUMBER AM SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 7 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Y�s%Fly�
CRCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE ' .r� TYPE WATER SUPPLY 1_ DESIGN WASTEWATER FLOW (GPD) S NEW SITE t-f-IREPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /(/a'jGAL. PMR TAW GAL. TRENCH WIDTH -7 ' 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.
IMPROVEMENT PERMIT BY
**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 SYS EM IN0A
STALLE BY
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/DATE �Wta*!�e
AUTHORIZATION NO. OPERATION PERMIT BY
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN JNSTALLED 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
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
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6 --5--CA
***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.***
NAME
DATE
AUTNDRIIATION NUMBER
0 2 7 0
NAME ON,IMPROVEMENT PERMIT (If different than above)
SITE LOCATION//fin
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COMMENTS/CO DITIOIS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
Na of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: ?Public
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
❑ Garbage Disposal
8: Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ 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.
PROPERTY 1REQUIRED:
Directions to Property:
C: ,c (f L -UG A>,-413
This is to certify that the information provided is correct
incurred from this application.
7— g&
DATE
Tax Office PIN // n
Road Name IV/y C *t-= S
Box # (if available)
City
of my knowledge,andI understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVAL ATION 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:
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 deter 'ne Said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
. DCHD (1193)'.
/�pp,�,r(✓`��P �'�`� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
PERM
n
Q 1'1 IS
�C a Davie County Health Department
Environmental Health Section
JAN 2 9 X996
P. O. Box 665
y' Mocksville, NC 27028
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1. Application/Permit Requested By 2,3c+�/
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Mailing Address ,2$ Gl%,— f1A✓E t) A/
Home Phone
4ee S t/) L-LEr /U C A 7U :2- F
Business Phone
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2. Name on Permit if Different than Above
3: Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other
❑ Unknown
II
5.. If house, mobile home: Subdivision //��2Yf�'h-�%� 7
Section _�� Lot #,'
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing
j
No. of Bedrooms
❑ Washing Machine
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L
No. of Bathrooms 1,
❑ Dishwasher
{ :
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
Na of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: ?Public
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
❑ Garbage Disposal
8: Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ 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.
PROPERTY 1REQUIRED:
Directions to Property:
C: ,c (f L -UG A>,-413
This is to certify that the information provided is correct
incurred from this application.
7— g&
DATE
Tax Office PIN // n
Road Name IV/y C *t-= S
Box # (if available)
City
of my knowledge,andI understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVAL ATION 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:
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 deter 'ne Said site'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 l
NAME AIZ4�s6� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY
LOCATION OF SITE
Water Supply:
On -Site Well
_ Community
Public
Evaluation By:
Auger Boring
Pit i
Cut
FACTORS 1 2 3 4
Landscape position L, L
Sloe % o
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH ZIA(—
Texture groupG'-
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 777 7-T
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 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 <;lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vf--.-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
Mineraloiry
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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