320 Oakland Avenue Lot 113DAVIE 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME 1 ,,�< : PROPERTY ADDRESS &700,J ( 144 - a 70 29/ DATE
LOCATION
SUBDIVISION NAME 7����/5��YS� LOT NUMBERSEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS -Y # BATHS 1, # OCCUPANTS , GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE / TYPE WATER SUPPLY A//A DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE !2?M GAL. PUMP TANK GAL. TRENCH WIDTH �f • ROCK DEPTH LINEAR FT. L
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 _J!!!�
**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) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY ^o %CZ A;111,R
U S 'S 0 tJ
AUTHORIZATION NO. O'L,L\ko OPERATION PERMIT BY C DATE 0 —9 -9L
**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 10/95
***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 pikk!nted to the Davie County Building Inspections
Office when applying for Building Permits.***
AUTHORIZATION NUKSER
NAME !l Cl0 -1a � � ?/ DATE
NAME ON IMPROVEMENT PEERRMMIT (If
�different
lthan above,),f
SITE LOCATION �/��/f,>�-// /7`C°i �1 `/ r 40—r a g
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIODENTAL HEAL SPECIALIST DATE
DCHD 10/95
-
--� °•=` i
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
�u
'
P.O. Box 665
Z
Mocksville, N.C. 27028
..�:
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
I�L6
(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 pikk!nted to the Davie County Building Inspections
Office when applying for Building Permits.***
AUTHORIZATION NUKSER
NAME !l Cl0 -1a � � ?/ DATE
NAME ON IMPROVEMENT PEERRMMIT (If
�different
lthan above,),f
SITE LOCATION �/��/f,>�-// /7`C°i �1 `/ r 40—r a g
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIODENTAL HEAL SPECIALIST DATE
DCHD 10/95
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
-`1NAME .S�O�+/ DATE EVALUATED
PROPERTY SIZE ����99i✓'U� �f
LOCATION OF SITE
ADDRESS
PROPOSED FACIILTY
Water Supply:
On -Site Well !/ Community
Public
Evaluation By: Auger Boring(/ Pit Cut
FACTORS 1
2 3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
& / -C
Mineralogy .-/
7"
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
i
SITE CLASSIFICATION: /'� EVALUATED BY: , a,&
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+2. -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
Mi neraloocy
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
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department a �%
Environmental Health Section D
P.O. Box 848 251996 51996
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS SS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed POk u+ �! R D501i
Mailing Address ) I I = to i "q n)L")
City/State/Zip m0CS,5Qt 0C M0i o))b4r
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [YrIsite Evaluation
Contact Person
Home Phone q l g- _? 75
Business Phone 4� a — 7C1 i"2 0
City/State/Zip
[ ] Improvement Permit & ATC
4. System to Serve: [ ] House V Mobile Home [ ] Business [ ] Industry [ ] Other
[ ] Both
5. If Residence: # People # Bedrooms_ # Bathrooms ^2 [ ] Dishwasher [ ] Garbage Disposal
[ q] Vashing 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 [vJ'Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes LefNo
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: WRITE/ /DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #`� % `T k- 95_ - �Q YV� -A0 &,U, a&2i� 6,1
Property Address: Road Name G(1 / ail 4il Az,, C'9 41-7aAz JPW 1JA44, 11AA IM W
City/Zip Zn o 02 ; (QU a6gA t1- . L� J
If in Subdivision provide information, as follows: �.({ � /M h�
4
Name: ()a ,0(1 17�(
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. 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 nduct all testing procedures as necessary to determine the site suitability.
DATE �� a^%_ SIGNATURE
Revised DCHD (06-96)
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