344 Sheffield Farms Trail Lot 9� i .aro—.,.-.�:iN -•Y°' `5. ,:.,y.,... --Nv . �. .y-... o. , . .d 4'__ `. ..... '.y I.7.�5 IC i.
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344DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Subdivision Name: 51j !F/1fLA tZ
-Directions toproperty: RvOy 04,> iC> Section: Lot:
IMPROVEMENT
CT c-�J � t h=G C a�.r PERMIT Tax Office PIN:# �� /I - r�
Road Name: 'vh CG ILa f'µt f(�Zip;!
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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 l l of G.S. Chapter 130A, Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems)
***NOTICE*** TIM PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRO ALHEALNSPECIAT T DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
,RESIDENTIAL SPECIFICATION: BUILDING TYPE nti:i # BEDROOMS # BATHS Z # OCCUPANTS 2- GARBAGE DISPOSAL: Yeslor�D
-.
COMMERCIAL
� SPECIFICATION: FACB,ITY.TYP,E1 # PEOPLE # PEOPLE/SHIFr - # SEATS _ INDUSTRIAL. WASTE: Yes or No
LOT SIZE S/.�`tanc&TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE -
SYSTEM SPECIFICATIONS: TANK SIZE L CDQ GAL. PUpMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12LINEAR FT.
OTHER
'REQUIREDSITEMODInCATIONS/CONDITIONS: INST&LL- ON "%31-00e
IMPROVEMENT PERMIT LAYOUT - -
00'
S
Zf h �Mlw.i.
M, N
FRa,a r
**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: - ael�s
`TA,vK ,*c No�-!r
49 Sov,,o3
AUTHORIZATION NO. ISO OPERATION PERMIT BY��,� DATE: g_1110
*"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT - YSTEM DE RIBE ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION ,1900 "SEWAGE TREA NT 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 PERMIT & ATC
} Davie County Health Department R� j
Environmental Health Section D LS
P. O. Box 848
Mocksville, NC 27028 1 [IM r(704)634-8760,: "rJJ HEAL
**•*IMPORTANT**** THIS APPLICATION CANNOT BE PROCES D UNLE
ALL THE REQUIRED INFORMATION IS PR
10
1,
Name to be Billed
r t: L. ,4 L
Contact Person
Mailing Address
_`J Z Z P%?w.vt w
�% p w Di, Home Phone
7 / 2 - a8 / 5
City/State/Lip
s is", - c, /P,n
A76 2 7 / D 3 Business Phone
2.
Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3.
Application For:
& Site Evaluation
Q' Improvement Permit & ATC
!a Both
4.
System to Serve:
❑ House rif Mobile Home ❑ Business ❑ Industry
❑ Other
5.
If Residence:
# People Z
# Bedrooms `�
# Bathrooms Z
dDishwasher
❑ Garbage Disposal
ar Washing Machine ❑ Basement/Plumbing
❑ Basement/No Plumbing
6.
If Business/Other:
Specify type
# People
# Sinks
# Commodes
# Showers
# Urinals
# Water Coolers
If Foodservice:
# Seats
Estimated Water Usage (gallons per day)
7. Type of water supply:. ❑ County/City' W Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes lB-No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �o �C, i WRITE DIRECTIONS (from
i Mocksviile) TO PROPERTY -
Tax Office PIN: # '71 A'
Property Address: Road Name Sheet 1 cO (,q (Z yv� q�Q on
City/Zip NO kwtl4- 270 7 1 -
i c
If in Subdivisionprovidde� information, as follows: o/le6
Name:'ft�/GY Qriy%S �5��� CZ �°4r
Section: Lot #: %/YI
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. I, 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
and owned by t, d Jd4 e e' ,2% t 7llp6l to conduct all testing procedures
as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD (06-96)
:14.158 Acres P=.
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o
a o . -.:�: ,. ti gv-• .:: N srW2S"l .1737.25•
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Er
ink
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�l 6.0 Ac. 6.0 Ar
q 7• C• >t. s
5.0 Ac.`F14, �>xd :'Ac.
t ' A
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+ t E� + O
is4.or s 7 K t t: 5.4 'Ac
fitN
IUD
.��'°°`-' oo
10.001 Acres 5. A 5.7 Ac. 5.5 Ac. 5.7 Ac.'''
.57. �..1
{deo''
b 2}2.7Y -J�IIf 04.M�'sa'dby►
14 Av
ne.00 1e3.2e 69.45 21e.ee r
s soros• s•w aoa.,r N ee•sroo•�► -i a •�•ee•
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DA lee - 51
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DA lee - 521 • ,��
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DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section . SECTION LOT�__2'
Soil/Site Evaluation
APPLICANT'S NAME /�C IN )M ✓i b0f DATE EVALUATED / !j
PROPOSED FACILITY �r '/� , t � PROPERTY SIZE
SUBDIVISION C 0 Q,A—S ROAD NAME >4 mCCI GELD Qg!t S e0
Water Supply: On -Site Well ✓ Community Public
Evaluation By: Auger Boring___'.ef___ Pit Cut
. FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slope %
Za
HORIZON I DEPTH
fo
Texture groupGL
L
Consistence
r
SS
Structure
S
lc
Mineralogy
l
(:
HORIZON H DEPTH
Co
Texture group
C
Z
Consistence
er
F.- .5
Structure
]c
Mineralogy
(:
t4dLr
HORIZON III DEPTH
2 —
22 - y +
Texture group
CA
Consistence
r -555P
FrS35r
Structure
�b
MineralogyL
t
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATEp,
SITE CLASSIFICATION: 1 J (r' - EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: I� T OTHER(S) PRESENT:
REMARKS: K;0 G%-kY . [., I . (�Dp� ST41.�O—r
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
CONSISTENCE
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
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineraloev
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(01-90)