342 Gun Club Road Lot 16✓Xa
• DAVIE 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.DiSoosal Systeist
NAME�� A `�; <, s i` PROPERTY ADDRESS A,( 1t l- U9406—GO � DATE
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LOCATION 4, �, ,��✓
SUBDIVISION NAME ����� f: LOT NUMBER SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS. # BATHS t OCCUPANTS GARBAGE DISPOSAL: Yes to
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE r` TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) , 7X /) NEW SITE !.,/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE % GAL. PUMP TRh6( GAL. TRENCH WIDTH" ?6 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 ,Aw��
**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
.Za�„ S 7�
AUTHORIZATION N0.19d OPERATION PERMIT BY �w DATE °L
**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=
DiVie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
_ Mocksville, N.C. 27028
AUTHORIZATION FOR W 61 WTER 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:gresented to the Davie County Building Inspections
Office when applying for Building Permits.***
�f% , AUTHORIZATION NUMBER
NAME 0 '/,/ f�`/dI �,f /S O , I ( r7rJ r t DATE . %�9/ �9� j bS �} I ? F?
NAME ON IMPROVEMENT
,JPERMIT
/(If different than above)
SITE LOCATION /t��,*,� %ltr Cr
CDIMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*HNaTICE*** THIS AUTHORIZATION FOR WAS TER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALWSPECIALIST DATE
DCHD 10/95
00
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address a Q 9 COWe LAV • Home Phone S4!&— 7 S 7 %
OCA SV C. --'� 7Q Q- Business Phone 7.2 -7
2. Name on Permit if Different than Above
3; Application for: General EvaluationSeptic Tank Installation Permit
4. System to Serve: Houses ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown /l
5. If house, mobile home: Subdivision f �Af- �(° �''"� Section _—Z Lot #
C2Z� Z&1C,1q.1 0 DA) ❑ Basement/Plumbing
G u cl . DIE D /�
No. of People cl-U6 ieocjX'SasementMo Plumbing
C' rfJ � J1Ae-e to/-7a�
No. of Bedrooms � 'Washing Machine
No. of Bathrooms M 94F� /,Z-- 6q'10 C!JlLL_ 125--/C CEr'bishwasher
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 Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Garbage Disposal
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions Ac/ex-z— 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:. // % J A
.76 C"C,�,c1 GCGl3 /ate
�'tt'.dL��Oc.c•tJDE.�.� ��
This is to certify that the information provided is correct to the
incurred from this application.
:Z .— , -C, a
DATE
fj,0,06k
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. 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 !.0/n/f=2E 0 -1-S�
to conduct all testing procedures as necessary to determine said site's suitability or a ground absorption sewage treatment
and disposal system. n "--7 Z-1
7— 9,S;""
DATE
DCHD (1193)
SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �/h �r'SOy✓
ADDRESS
PROPOSED FACIILTY &FUS�a
DATE EVALUATED e
PROPERTY SIZE -?e GOO S'
LOCATION OF SITE
Water Supply: On -Site Well _ Community Public !/
Evaluation By: Auger Boring L1___ Pit t./ Cut
FACTORS
1 2 3 4
Landscape position
L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
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
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: i 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
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