151 Shady Grove Lane Lot 18r `Perim' /����,� '
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS ''.4 PROPERTY INFORMATION
1 ,
Subdivision Name. G is/' d it
fo'pcoperty: _-�. i%r fo%n l i, c . Section: f Lot: �.J
^� IMPROVEMENT i
PEST Tax Office PIN:# 11 1- 5 -1/0*
Road Name- ')i1ct
**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' "
constructionlmstallation of a system or the issuance of a building permit.
(In compiiance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE .;
y'%'�c,.1�5CS. / if ( 117 / M/17 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HP7ALTH SPEQIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS E # BATHS -,L # OCCUPANTS_ GARBAGE DISPOSAL: Yes or No
COMMERCIALTSPECIFICATION: FACITY TYPE # PEOPLE # PEOPLEISHIFI' ,�' # SEATS INDUSTRIA, WASTE: Yes or No
LOT SIZEIA
. &RO TYPE WATER SUPPLY (-c, DESIGN WASTEWATER FLOW (GPD) rc v NEW SITE REPAIR SITE
SY ITEM SPECIFICATIONS: TANK SIZE &P GAL. PUMP TANK GAL. TRENCH WIDTH �7Z ROCK DEPTH � LINEAR FT. YOv�
'OTHER"
REQUIRED SITE MODIFICATIONSXONDMONS:
IMPROVEMENT PERMIT LAYOUT
**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) 6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:��
09
AUTHORIZATION NO.. -0-0e OPERATION PERMIT BY: DATE: 2 —T— /
**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 05/96 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIJ
Davie County Health Department
�tsS V
Environmental Health Section
B o. Box 848
FEB 1 31997
Mocksville, NC 27028
(704)634-8760
L Name to be Bille
Mailing Address
City/State/Zip
V
****E%IPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
d D i �AL—(A Z20VS9i Contact Person
Name on Permit/ATC if Different than Above
Mailing Address _
3. Application For:
4I. System to Serve:
5. If Residence:
j�Dishwasher
6. If Business/Other:
# Commodes
If Foodservice:
8.
R Site Evaluation
* House ❑ Mobile Home
# Peopled
❑ Garbage Disposal
Specify type _
# Showers
# Seats
Type of water supply:
Z8 County/City
City/State/Zip
Home Phone 4 i D --qq/6-1616
Business PhoneQ l O — q Ci & --7-Z V
k Improvement Permit & ATC
❑ Business ❑ Industry ❑ Other
um
# Bedrooms L) # Bathrooms Z
Washing Machine XBasement/Plumbing ❑ Basement/No Plumbing
# Urinals
# People Sinks
_ # Water Coolers
Estimated Water Usage (gallons per day)
❑ Well
Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes' 4 No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: -Z7 Z, X I g I r X Z ZC>r X 110( t 1 WRITE DIRECTIONS (from
n Q I D y 1 Mocksville) TO PROPERTY:
Tax Office PIN: # S9 P'1 -3s 1
//�� 1 �1 �OuTtF 1't2��
Property Address: Road Name �N A r) 4 t.o� ��� 1
j�
City/Zip N- N)A �G _ 1
L� ot`I �IJ�� Wt�ls
If in Subdivision provide information, as follows: 1
Name: �l F✓� fll� lO��-J�
Section: Lot #:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. 1, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
n
and owned byyph(5 l 'e7A) S i . �7 �' J ���� �� i�S� to conduct all testing procedures
as necessary to determine the site suitability. n n r n
DATE -o9 - 13 -q7 SIGNATURE
Revised DCHD (06-96)
i� cr
0
j
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME I/,Wg%
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit / Cut
FACTORS
1
2 3 4
Landscape position
L;
Slope x
!9
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
YO ^
Texture grou
G .
Consistence
Structure
<
5 d
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 4
LONG-TERM ACCEPTANCE RATE: z
REMARKS:
DCHD (01-901
EVALUATED BY: .IIV`
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
Moist
VFR- Very 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
SC -Single grain M -Massive CR -Crumb CR -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/fta
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