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442 Oakland Avenue Lot 72k DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION tttee's Name:. "+ `�� ci r/r U Directions to property: x J. Subdivision Name t % �' f ! )A /' Section: ` Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: & k ,wv C #' Zip: "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) _ "1\V lil.G" li- L7 i-GiU'111 L7 AUD,�GI.l 1 V zur V WA-t%11VL'q JLr 711L' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS --�? # BATHS .2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE L'%r�TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ��✓ �/ NEW SITE REPAIR SITE �O SYSTEM SPECIFICATIONS: TANK SIZE <1G) GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FF. 16 REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENJERMIT LAYOUT Ail **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 SYS LED BY:.f AUTHORIZATION NO. Ik3 OPERATION PERMIT BY:� 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 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) AUTHaRIZATION NC. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P�rmittee's / Q� ,_ / P.O. Box 848 :� f Na3ne: r . f, 'P' � i�'` .�r'�� fir+' Mocksville, NC 27028 Subdivision Name: ty Phone #: 704-634-8760 Directions to property: Gam. r �t �:'•� Section: Lot: AUTHORIZATION FOR.{f ,r� / WASTEWATER Tax Office PIN:# �` Dl - (J lid SYSTEM CONSTRUCTION -yy Wo 6 Road Name: QA/l%1� n/Cl Zip **NOTE** 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 applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1 , / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r- �' r,'4,� � : , '"` ., s�/, • ,: )� ` �.� IS VALID FOR, A PERIOD OF FIVE YEARS.. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE J Davie County Health Department l! Environmental Health Section P.O. Box 848 + 1 3 1997 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PRO/VIDED. 1. Name to be Billed LContact Person d Mailing Address O'dHome Phone /G}�slo —d46, 37 City/State/Zip � L-�S� i 1 l �f , I— I L%a—$ Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip_ 3. Applicatio: l For: [4,nitte Evaluation [ ] Improvement Permit & ATC [ ] Both 4.' System to ;ierve: M40use [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: � # People # Bedrooms_ # Bathrooms [016ishwasher [ ] Garbage Disposal [,,�ashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Busine; /Other: Specify type # People #Sinks # Commodes # Showe.. # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons perday) _ 7. Type of water supply: [0160—unty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No If yes, what type? i EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:*** IMPORTANT ***.aC0:2&T OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Ina aG°d WRITE DIRECTIONS (from 1 ocksville) TO PROPERTY: Tax Office PIN: # - 0(e �— � Property Address: Road Dame 951 w e %1y -PN T a 20 --� N� City/ZipVJ ; If in Subdivision rovide information, as follows: �) 1.� 6-1 C Name: 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,susoension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, -:iso, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Repr/Iesentat;ve of the Davie County Health Department to enter upon above described property located in Davie County and owned by Gam. �^\J to mptitirt all tF n roced s as necessary to determine the site suitabil.. DATE I ` i . ^_ Cl SIGNATURE t' Revised DCHD (06-96) U THIS -:. iA MAJ 13E USE) FOR I)RAIVINC YOUR SITE PLAN: .i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LoT,22 Soil/Site Evaluation APPLICANT'S NAME �.C/�� ' / DATE EVALUATED 111—,Ir PROPOSED FACILITY PROPERTY SIZE Anlj"eo SUBDIVISION CJ/�l� �/� /J 1 A V ROAD NAME Water Supply: On -Site Well Community Evaluation By: Auger Boring f Pit Public /l� Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group, Consistence Structure / S 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: % EVALUATION BY: ./ Uy 4Z LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: DCHD (01-90) 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 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