1609 Underpass Road Lot 3DAVIE COUNTY HEALTH DEPARTMENT
�+ IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT 0Z i9Lr
**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 C���. p . \4 � PROPERTY ADDRESS % 0Q- �" a O DATE 3 '� S '
LOCATION g E - 1\� cm I S-
SUBDIVISION NAME LOT NUMBER 3 SEC./BLOCK NUMBER i
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS :. # OCCUPANTS ` GARBAGE DISPOSAL. Yes No
COMMERCIAL. SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE X :�OrJ TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) Q NEW SITE'V. REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE J6C)b GAL. PUMP TANK GAL. TRENCH WIDTH 3 "ROCK DEPTH LINEAR FT. � b
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MAST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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IMPROVEMENT PERMIT BY
**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 �n R Qy IAO ` `' " INNS
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AUTHORIZATION NO. OPERATION PERMIT BY o DATE `- 6
**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
Davie County Health Department
..s ., ENVIRONMENTAL HEALTH SECTION .J)
l7ZO(i P.O. Box 665 /b0. Ci0
Mocksville, N.C. 27028
AUTHORIZATION FOR MMASTEYATER SYSTEM CONSTRUCTION
(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 presented to the Davie County Building Inspections
Office when applying for Building Permits.***
NAME. �• s� DATE — ! AUTHORIZATION NUMBER
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
J APPLICATION FO ITE EVALUATION/IMPROVEMENTS PERM
PIE cE
1 Davie County Health Department D
Environmental Health Section
.pv q� P. O. Box 665 FEB 2 0 1303
IV Mocksviile, NC 27028
1. Application/Permit Requested By ��%rT� r!�i JU`7 e / Olt)�
Mailing Address l� 3 e/� e--, Home Phone
� 4iD AA— 7-7 606' Business Phone
2. Name on Permit if Different than Above
3. Application for:/ ❑ General Evaluation
4. System to Serve: ["/House
Q Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ In stry-s-T� ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision & Section Lot #
No. of People SPS• ��
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
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
❑ Basement/Plumbing
❑ Basement/No Plumbing
C�Washing Machine
Dishwasher
VGarbage Disposal
7. Type of water supply: C9' Public ❑ Private ❑ Community
8. Property Dimensions 1 Ili I
%
lWESTRIDGE SUB. Sec. 1
Filed 4/13/76
Recorded Map Book 5, Page 4.
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Penve 1'5Le? -6s
C/ISL- _ _—�—'---' •- ,
DAVIE COUNTY HEALTH DEPARTMENT
•' Environmental Health Section
Soil/Site Evaluation `
NAME DATE EVALUATED 1 ��
ADDRESS b PROPERTY SIZE % 1 X aa.O
PROPOSED FACIILTY oy LOCATION OF SIT
Water Supply: On -Site Well Community Public
Evaluation By&IZ, " Auger Boring ✓ Pit Cut
FACTORS
1
2
4
Landscape position
.�
S
Sloe Z
HORIZON I DEPTH
Texture groupL
L
C
Consistence
�'�
(' 'X
Structure
Mineralogy
:l
: I
HORIZON II DEPTH
Texture group
Consistence
Fa
Structure
- 8
4
Mineralogy
•1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
s
S s
RESTRICTIVE HORIZON
SAPROLITE
'�-
CLASSIFICATION
YJS
sl,
LONG-TERM ACCEPTANCE RATE
1
SITE CLASSIFICATION: -Y.5' .5
LONG-TERM ACCEPTANCE RATE:
REMARKS: -�
DCHD(01-901
EVALUATED BY: 11R�
OTHER(S) PRESENT: N CT*'D_
zt.� . 'Z - Zzo';;)rj►
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- Vc-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
Mineraloicy
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