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370 Michaels Road Lot 121 578 DAVIE OUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pegittee'�S .> E`' Y 7 Name;*'!"' ame; *'!f j:'i~ %1 f� Subdivision Name: 'j1� / Direc-tIotis to property: Section: Lot: % IMPROVEMENT PERMIT ' Tax Office PIN:#k.. '.' /j " v ' D....I.7 TAT.. «..... /!VP **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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) s , ***NUT1Uh**" TH15 Yl;KM1T IS SUBJE' UT TU 1(hVUUA'11UN 1N' Jlih f PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER EN ED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE X47 # BEDROOMS - # BATHS -f) # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE L 6 k?'l TYPE WATER SUPPLY r DESIGN WASTEWATER FLOW (GPD) 40 NEW SITE � REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE G% U GAL. PUMP TANK GAL. TRENCH WIDTH _?4- 'ROCK DEPTH « -/ LINEAR FT. vie REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ID e��rop P',rA W fvei d a "eq Pei, ?' Z e SII 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. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: Irl A' f' nay 0sel�% alyp 0 s V Xle w �1 �e, AUTHORIZATION NO. OPERATION PERMIT BY: DATE: aenfv "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) A APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT In Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED n ' c ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed w�-�� v 1' rn'� Contact Person Mailing Address 1 rel, Oax -739 Home Phone City/State/Zip C o �,e J I , / 1'e, a-7014— Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: 3RDishwasher 6. If Business/Other: # Commodes If Foodservice: ❑ Site Evaluation ❑ House Mobile Home # People ❑ Garbage Disposal Specify type _ # Showers # Seats City/State/Zip lritImprovement Permit & ATC ❑ Both ❑ Business ❑ Industry # Bedrooms 3 ❑ Other # Bathrooms oZ� VWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: 8County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes WIN 0 If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: l00 x 3b0 Tax Office PIN: # 57 0t - /0 - 7 2- 0– I Property Address: Road Name ` I City/zip Moc1kPU#&_j a�oz8 If in Subdivision provide information, as follows: Name: k i�� I I Section: Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY - •� k 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 aC�-) � t�onduct all testing procedures as necessary to determine the site suitability. DATE -7—/4 —�8 SIGNATURE Revised DCHD (06-96) c APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIO Davie County Health Department i 19. E' +I H RK Secti n /r ALL, nvironmeO. n a ea o (/ (`� 1 P. Box 665 I , , Mocksville, NC 27028Lai mm D � r 1. Application/Permit Requested By r/i ah 'O �a✓Vrn SC. r e- Y Mailing Address �= - t : {_ r =* Home Phone Business Phone 2. Name on Permit if Different than Above 3. Application for: // General Evaluation a Septic Tank Installation Permit 4. System to Serve: ®'House O Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision '� tea` �6� Section _� Lot # No. of People No. of Bedrooms No. of Bathrooms f Dwelling Dimensions /100 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ BasemenUPlumbing ❑ Basement/No Plumbing ❑ Washing Machine /804 S �� ❑ Dishwasher i ❑ .Garbage Disposal 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 ,�d O �� s� COQ E Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? =17-4 ❑ 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: —� Plcjeolr / V C4 A -e This is to certify that the information provided is correct to the best of my knowledge, incurred from thi a plication. DATE I understand I am responsible for all charges SIGNATURE � CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED I?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 De�wwe Co my Health De artment to enter upon above described property located in Davie County and owned by s v Fath, �ecry;ie� Thr. to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. -iy.-�, s DATE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section ' Soil/Site Evaluation NAME / DATE EVALUATED ADDRESS �j PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE , J1�A/L l Water Supply: On -Site Well Evaluation By: Auger Boring Community Pit Public 41--l" Cut FACTORS 1 2 3 4 Landscape position ,L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 4_ Texture group Consistence r Structure !C !G 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: '& 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 Mineralozy 1:1, 2:1, Mixed Notes Ilorizon 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