295 Griffith Road Lot 23DAVIE 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME &,� l�; ��ir PROPERTY ADDRESS Cr A4L W 2,260(0 DATE
LOCATION
SUBDIVISION NAME U�/P . [P �� /S LOT NUMBER 2;2�12 SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ',? # BATHS 4 # OCCUPANTS 4-9 GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE -!! S"lrllt TYPE WATER SUPPLY . l l DESIGN WASTEWATER FLOW (GPD) �Z�O NEW SITE t.-/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE , iso GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH eZ'j' LINEAR FT.
3G'
OTHER 4J<.fi l��%!i i �O.�LY ID/J�
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 SYSTEM INSTALLED BY
/jAQ:+
r
'T, rJ K C A7z —711C)
�
r
-330
a�
r. CA i
I
�(aQ �
AUTHORIZATION NO. O 14� OPERATION PER
DATE //'a?' fe
**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
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),
�-O
T ko
***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 A
-'v
mss.
DATE l�.��%� �
AUTHORIZATION NUM.9ER
i v U J
NAME ON IMPROVEMENT PERMIT
(If different than above)
SITE LOCATION
COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*HNDTICE*H THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
0.01
MA's w• M Ow dw O -r
ONe
-V W.—W tool 7r ...r sor
of — ,.
KAL a r ••• ---
rC-✓- "-a_r_
Ih cor+-sem ..vim
—_� 15.07' 1C. _
�^-'C, • -
214.64,
S 13`23'20"*
OL
cl
-_- ---
o _
cv n
m o
h co
47 x Yo Ic9z'-an
3.436 aC.
155.00'` '
282.02'
S R
1 X53
?.62'
c.
�
v�
30
•1
C,,
S 13`23'20"*
OL
cl
-_- ---
o _
cv n
m o
h co
47 x Yo Ic9z'-an
3.436 aC.
155.00'` '
282.02'
S R
1 X53
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department JUL 2 2 1996
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By 2, � ' A As aA S�L
Mailing Address 1 10 " t Cg 4 D r Home Phone 7 7 q' I gS-0
&)-C. X7 /0 Business Phone '7 6 (-� • I -) 8Z
2. Name on Permit if Different than Above
3. Application for:
❑ General Evaluation Sr -Septic Tank Installation Permit
4. System to Serve: f(House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision =M,6�kS Section 1 Lot # 13
No. of People 2—
No.
No. of Bedrooms 3
No. of Bathrooms d\
Dwelling Dimensions 67 X y
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
f
leBasement/Plumbing
, J
❑ Basement/No Plumbing
j .
Washing Machine
eDishwasher
❑ Garbage Disposal
No. of Sinks
No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public VPrivate ❑ Community
8. Property Dimensions a` '0 X `i 48 Sewage Disposal Contractor M A k TI►N
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes - V No
"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: nn nn
S101 Yaj kin VoAk"a- 0.4 +'
Lo Ir .23 o,,j L�+ ; s
4.1, -►'ll,-4 to 4-- ont -}-ti„L 4.
Tax Office PIN: #
PROPERTY ADDRESS, as follows:
Road Name: ��dtrbtno Tro ��S
city:
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charges
incurred from this application.
7/ I /%
DATE URE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: I N(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 determine said site's suitability for a ground absorption sewage treatment
and disposal system.
bb � '!
DATE SIG RE
DCHD (1193)
NAME
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
1y4vCir
lle�Ieu5_t
DATE EVALUATED Z_7/711?le
PROPERTY SIZE
LOCATION OF SITE �i-�` l` �%1 lJ
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group CA
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure f /
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: T EVALUATED BY: 114. 4_
LONG-TERM ACCEPTANCE RATE: 212 OTHER(S) PRESENT:
REMARKS: 7-e- —
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- Vc-y friable FR -Friable FI -Finn 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
Mineraloicy
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
C•J
CL
}
J
W
Q
a
LX
a
A
oa
D
2
A
w rnr••- aat i +� r.r •rr
.a •r•..••.� .�� rte. • .� r
wr.•..w .« r.. awe tines r �.+
.• �wr•w.wr*
carte
.�. �_:- � -���'. .�fi-."."•2�, ' �� ' ' -''"�. Vis: ... _
=ter y._r w rr•• �`+ ...� r. w�.., f w.
wrrrwa r.. w�www
.a+r�rw• war rw. w^r,r.ra
•y •n��a Y r.�
=ro.en . pc= v
.« r r ...... �• �«r :'�ww�..r �:r�w :raw+
r r..•.r•r r.���• r .
� �••,w, a��i� M Nam
rov
c�nnof ca��+•
~t •
ti*
��— \'��' ��
.� ;ice
1.976 Ac. \
I
2.208 Ac.
26
� .. a. 'i .-!'`'iii '1•.'... ^. J' ' � ..! _ +(-�
� 1— .4.�3� .
1:892 AC.-^,.--��
. - � - �.-`•'moi' -
., •4.a - . _ i<'w ; _ - •.
�� ��
00,
V
.rr•.�.a�rsw.•�r�a. _
:rar
ago P—*Aw
rd
N` qlk 2.897
S01,10—
;17
T
_ Y i� /
S4 It%% l24
ti 2.627 Ac. ° fl L3, � ',''' ;/ A,K •'
2.515 Aq. �� 3.436 hC. I R 4 ��0
-o:
2.105 Ac. 4ti• 2.109 Vic. } 2 � .ta► �, s
s I
qA
lk
[� W �_ 1 au• ,soar a.sr 'I
Rd — S.R. 1453
e rid,
�5,,.,,, f,,orme
x: _OaL
..- �rigfiIL
j
I