145 Winchester Road Lot 4DAVIE 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 ADDRESS I uQV1 CIN Z70oL DATE 7 /�,1
LOCATION ell -7X
SUBDIVISION NAME LOT NUMBER '51 SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE /fe # BEDROOMS S # BATHS aA # 0CCUPANTS GARBAGE DISPOSAL: Yes6
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PENq-E/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE 1C TYPE WATER SUPPLY I -lo DESIGN WASTEWATER FLOW (GPD) � NEW SITE I/' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Z,,,I)L GAL. PUMP TANK
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
GAL. TRENCH WIDTH !;V" ROCK DEPTH /.�' LINEAR FT. &
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY`� 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 \ (SYST INSA�AEDY
F
AUTHORIZATION NO. to ' 2 OPERATION PERMIT BY � DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF B.S. CHAPTER 136A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL. SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FINJCTION 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)
vf( a
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to
issuance of any Building Permits. This Fore/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building ermits.*** '
1�/J AUTHORIZATION NUY9ER
NAME _ F/i0 r DATE _ ' % ` % N o 0 " C 0
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION l//l e6 T
CONENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
I
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
Jul. 1 1 1995
Application/Permit Requested By, ��/C/G L/NDE/LfSnili
Mailing Address a S wwe- z�A✓eA) LA,( . Home Phone SLCf.;?- 7:7
M06:=.SV C x'76 Q_ ,F Business Phone d - 7. -7 Cj
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 ��(° ��"� "� Section �_ Lot # 7
%Z/ C /�� �i"�D O� ❑ Basement/Plumbing
No. of People len'%ESD
p ❑ Basement/No Plumbing
c`rUc ,4L[.Ci�O�
No. of Bedrooms � ❑Washing Machine
No. of Bathrooms � /Z;IV 6qA10 ❑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 ❑ Community
8. Property Dimensions Iq C/f — Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
'-If yes, what type?
`NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation. if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
m/ .
cam- f-=2v�'1 /�'r�' �/u 7N �.
This is to certify that the information provided is correct to the
incurred from this application.
7- 9!2S
DATE
of my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOV DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 1� 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 GU - D V- ,. 4,
to conduct all testing procedures as necessary to determine said site's suitability toEr a ground absorption sewage treatment
and disposal system.
��.4A4DATE SIGNATURE
DCHD (1A3)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME A e-11 CC 0 �-
ADDRESS
PROPOSED FACIILTY
?0
DATE EVALUATED _F1� ` %b
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well _ Community Public 1/
Evaluation By: Auger Boring Pit 1---, Cut
FACTORS
1 2 3 4
Landscape position
.�
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
> t
Texture group
Consistence
Structure
S ✓�
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texturegroup
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
<�
SITE CLASSIFICATION: ig
LONG-TERM ACCEPTANCE RATE:
REMARKS: _
DCHD(01-901
EVALUATED BY: LCIa /Z
OTHER(S) PRESENT:
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