863 Gladstone Road Lot 4DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENT PERMIT and OPERATION PERMIT lPJ
IMPROVEMENT PERMIT IP
**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
c6struction/installation of a system or the issuance of a building permit.
(In compliance with Article it/of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME SCJ✓nne4 eloiei / �� PROPERTY ADDRESS ��AF� �G �'-10aDATE
�y ,
LOCATION /5-1&lVe A,-'7 Cl // II//
SUBDIVISION NAME �/l7%3YiYOr+/ /i/C4, C- LOT NUMBER � SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE 1104, M BEDROOMS i BATHS A OCCUPANTS _ GARBAGE DISPOSAL Ye '
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ N PEOPLE/SHIFT _ 8 SEATS _ INDUSTRIAL WASTE: Yes/No
LOT SIZE 9S��DD TYPE WATER SUPPLY el
DESIGN WASTEWATER FLOW (GPD) JV40 NEW SITE L `REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,_= GAL. PUMP TANK _ GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CDNDITIONS:
***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.
i
IMPROVEMENT PERMIT BY h� W
**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 11 IS 1704) 634-8760.
OPERATION PERMIT
1,
SYSTEM INSTA
9S
yv
AUTHORIZATION NO. ,a OPERATIC! 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 G.S. CHAPTER 130A, SECTION .1990 '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.
DCIID 10/95
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C., 27028
W)THORIZATION FOR WASTEWATER SYSTEM CONSTRICTION
511,
ilssued in compliance with Article 11 of ..
S.S. Chapter 130A Wast water Sgste.ms)-1i
***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.***
/ / AUTHORIZATION NUMBER .'
E Aon IIL.I �/u/� b DATE
WE N2 0722
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COM ENTS/CO)OITIONS,IN AUTHORIZATION TO CONSTRICT WASTEWATER SYSTEM
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section �}
P. O. Box 665
Mocksville, NC 27028
Home Phone �9f�' A193
Business Phone,
2. Name on Permit if Different than Above
3. Application for: ❑ General
Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: 1, House
❑ Mobile Home
❑ Place of Public Assembly
❑Business ❑Industry
❑ �yOther / '
❑ Unknown
5.. If house, mobile home: Subdivision �AeJ/io�
/D�'i�l�
Section Lot # —2L'
j)
❑ , Basement/Plumbing
No. of People
❑ Basement/No Plumbing
1
tNo. of Bedrooms
❑ Washing Machine
No. of Bathrooms ;&
❑ Dishwasher
Dwelling Dimensions
❑ Garbage Disposal
6. If business, industry, place of public assembly, other:
Specify type
No. of People Served
No. of Sinks
No. of Commodes 9
No. of Urinals
No. of Lavatories s
No. of Water Coolers
No. of .Showers
Water Usage Figures
7. Type of water supply: Public
❑ Private
TI Community
I l
8:. Property Dimensions % f �C
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.
ti
This is to certify that the Information provided is correct to the best
Incurred from this applic ---/��
DATE
and I understand I am responsible for all charges
al d�
CONSENT FOR SITE EVALUATION TO BE DONE QN ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 160 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.
DATE SIGNATURE
DCHD (1�13
DAVIE COUNTY HEALTH DEPARTMENT �r
Environmental Health Section
Soil/Site Evaluation
NAMEDATE EVALUATED
ADDRESS PROPERTY SIZE �� ��f ✓^
PROPOSED FACIILTYLOCATION OF SITE
S Aal
Water Supply:
Evaluation By:
On -Site Well
Auger Boring -
Community
Pit Z�
Public
Cut
FACTORS
1
2 3 4
Landscape position
Slope R
HORIZON I DEPTH
e.
Texture groupL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
h
y
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: T� D EVALUATED BY: Ala /Z
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 clay loam, SIL -Silty loam CL -Clay loam. SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
-------------
- Moist
- VFR-Very 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