323 Michaels Road Lot 29✓XG
DAVIE 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 G.S. Chapter 138A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
✓INT12- LiZ1414 t/ PROPERTY ADDRESS _1 �/l G�NA��C;� 11 �. r/1 rldA ° DATE Z
LOCATION
SUBDIVISION NAME C2 l/, r Ac LOT NUMBER O SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE. # BEDROOMS Vf # BATHS _-?_ # OCCUPANTS GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE /IZII 6C TYPE WATER SUPPLY AlDESIGN WASTEWATER FLOW (GPD) NEW SITE l,' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE YY� GAL. PMP TRNK GAL. TRENCH WIDTH ROCK DEPTH ��LINEAR FT --? .,P6
OTHER
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 HEA
8:30-9:38 A.M. OR 1:88-1:30 P.M. ON THE DAY OF I
OPERATION PERMIT
FINAL INSPECTION OF THIS SYSTEM BETWEEN
HONE # IS (704) 634-8760.
BY
AUTHORIZATION NO. Q OPERATION PERMIT BY Av//'Wj 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 136A, SECTION .1900 "SEVIAGE 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
VX0
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
Gr 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 a in, for Building Permits.*** I
AUTHORIZATION NUV3ER
NAME DATE
NAME ON IMPROVEMENT PERMIT
(If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICES THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
z2f
EN ROMlEMlTAL WA#sPECIALIST DATE
DCHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER 15 2 L5 OUR
2 O (� /7 2
Davie County Health Department
Environmental Health Section
P. O. Box 665 JU;V 1 91996
Mocksville, NC 27028
1. Application/Permit Requested By.
hh 7
Mailing Address . V r73 /�/1 Home Phone
�t•v , /UC Q 70 Business Phone— -7CV
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation 2-S- eptic Tank Installation Permit
4. System to Serve: ❑ House Lg'fNobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ocu, Section Lot #CQ9
No. of People
No. of Bedrooms
No. of Bathrooms -
Dwelling DimensionsCAYa
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks _
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers.
No. of Showers Water Usage Figures,
7. Type of water supply:Publiicc El Private
8. Property Dimensions �-19 )� 3 D i' . 0r1 Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ Yes ET -/No
❑ Community
"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:
This is to certify that the information provided is correct to the
incurred from this application.
DATE
PROPERTY INFOMIATION REQUIRED:
Tax Office PIN
Road Name
Dox ' (if available)
City
my knowledge,
for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 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 Daxe County Health Department to enter upon above described
property located in Davie County and owned by FpnS'O M L tiiCe—JX--
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system. /) n 1 t, //J _
DATE — v 7/ SIGNATURE
DCHD (1193)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI O
Davie County Health Department
Environmental Health Section
r f P. 0. Box 665
IMocksville, NC 27028
1. Application/Permit Requested By r oh o -Ser_J;e— C• ekntoce_ M an
Mailing Address �_i! �f_ t:�• t! i�,?: Home Phone
�T0 Zi %� Business Phone ;Z `7s
2. Name on Permit if Different than Above
3. Application for: General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: ®'/House ❑ Mobile Home ❑ Place of Public Assembly)
❑ Business ❑ Industry ❑ Other ❑ Unknown
n ss %vf-q-<
5. If house, mobile home: Subdivision a ✓'T e -a— uJ6� Section —Z Lot #
JUL 2 1 1995•
"? ❑ Basement/Plumbing
No. of People
No. of Bedrooms
No. of Bathrooms c r
Dwelling Dimensions poo
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ublic ❑ Private
8. Property Dimensions I-0-0 Fly 41931�� o F Sewage Disposal Contractoi
1-11
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/No Plumbing
❑ Washing Machine
❑Dishwasher
❑ .Garbage Disposal
❑ Yes "o
❑ Community
"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:
�a 5
This is to certify that the information provided is correct to the best of my knowledge{
incurred from this application.
±>
DATE
I understand I am responsible for all charges
SIGNATURE'
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY
MUST CHECK ONE: ❑ 1. 1 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 representativ of the Dpie Co my Health Department to enter upon above described
property located in Davie County and owned by ;i 5e) Ay j j& >ed'v; CPQ
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
/y.-/`4 5
DATE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME Z:�Q_
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE 1 9 6V_il
LOCATION OF SITE �lj�. ' f
Community
Public f/
Evaluation By: Auger Boring Pit / Cut
--v
FACTORS
1 1 2 3 4
Landscape position
Sloe Z
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
y�r
Texture group
Consistence
Structure
5121<1
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: EVALUATED BY: ^�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 ;lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V? ---y 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