881 Gladstone Road Lot 2DAVIE 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 it of S.S. Chapter 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME �lll/7n U b��u ./S/b PROPERTY ADDRESS GI Q -a5 / h d DATE �-5-
LOCATION
5lD1DIVISION NAME LOT NUMBER SEC./BLOCK NUMBER f
RESIDENTAL SPECIFICATION: BUILDING TYPE llelvrr # BEDROOMS _ # BATHS # OCCUPANTS _ GARBAGE DISPOSAL: Ye/ o
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ # PEOPLE/SHIFT t SEATS _ INDUSTRIAL WASTE: Yes/No,
LOT SIZE �� C TYPE WATER SUPPLY 4f DESIGN WASTEWATER FLOW (GPD) F4, d NEW SITE1,,'0' REPAIR SITE _
SYSTEM SPECIFICATIONS: TANK SIZE AD GAL. PUMP TANK _ 6AL. TRENCH WIDTH .36 " ROCK DEPTH 12Z 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.
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 17041 634-8760.
OPERATION PERMIT
INSTALLED BY
2
AUTHORIZATION NO. /jZ2 . OPERATION PERMIT BY DATE A "%
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE it OF G.S. CHAPTER 13OA, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS% BUT SHALL IN NO WAY BE TAM AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
—AV
j Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
9UNIORIZATION FOR WASTEWATER SYSTEM CONSTROCTIW
(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 presented to the Davie County Building Inspections',
Office when .applying for Building Pereiis.+**
: /`9� N2 0379 R
0 3 7 9
NAME 1[ /P/7,(ZUI : /i� LATE.
M
SITE
COMMENTS/CONDITIONS. ON AUTHORIZATION TO CONSTRUCT WASTETATER SYSTEM
wDAVIE COUNT! 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,CON5JRUCTION,must be obtained from this Department prior to the
construction/installation of a,system or the issuancefof'a bui l8ing permit.
(In compliance with Article it of G.S. Chapter 130A, Wastewater Systems,; Section .1900 Sewage Treatment and Disposal Systems)
'At)
NAME Al" �� E7iu /�: b PROPERTY ADDRESS ��at�� %l�)rl C� . ' �7�v'�� DATE
LOCATION
SUBDIVISION NAME �/%/�i>/>O.J /�'/"ir%! /S� LOT NIA�EA 6%_ SEC. /BLOCK NUMBER
� s.
RESTDENTAL $PEG FICATION: BUILDING TYPE f # BEDROOMS A'BATHS 2 #OCCUPANTS _ GARBAGE DISPOSAL: YeV
j
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ # PEOPLE/SHIFT M SEATS _ INDUSTRIAL WASTE: Yes/No
LOT SIZE " l TYPE WATER SUPPLY 1<17 DESIGN NASTENATER�FLOW (GPD) ?_o';d NEW SITE // REPAIR SITE_
SYSTEM SPECIFICATIONS: TANK SIZE 1A0 GAL. PUMP TANK _ GAL. TRENCH WIDTH -r/ ROCK DEPTH IJ LINEAR FT. bio
r
OTHER
REIXIIAED SITE MODIFIf.RTI0N5%CDNDITI(1N5:
Li
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THEINTENDED USE CHANGE.
SEE -THIS PERMIT BEFORE INSTALLING THE SYSTEM.
O
YOUR WASTERWATER SYSTEM CONTRACTOR MUST
:
�.9qG
IMPROVEMENT PERMIT BY A,
**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. jT�ELEPHONE # IS (704) 634-8760.
OPERATION PERMIT YSTEM INSTALLED BY ew �% n
j.
c t� j
I
I
AUTHORIZATION NO. r}37q OPERATION PERMIT BY `1��� DATE
i*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 UW(EN 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 ;
/ Soil/Site Evaluation
NAME /J /! �%I DATE EVALUATED
ADDRESS ' PROPERTY SIZE GJ
PROPOSED FACIILTY LOCATION OF SITE
Water Supply:
On -Site Well
Community
Public t�
Evaluation By:
Auger Boring
Pit
Cut - -
HORIZON I DEPTH
"
FACTORS
1
2 3 1 4
Landscape position
C
Slope %
HORIZON I DEPTH
"
Texture group
S'
Consistence
Structure
Mineralogy
HORIZON II DEPTH
t
+
Texture group
Consistence
i
Structure
/
Mineralogy/.'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mine ralo gy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY:
i
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 clayloam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist - .. ..
VFR-Very friable FR -Friable FI -Finn VFI-Very fine 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
SC -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic -
Mineralogy
1:1, 2a, 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