141 Norma Lane Lot 18DAVIE 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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) Otis,
V-JU-A r1606
PROPERTY ADDRESS DATE
LOCATION
SUBDIVISION NAME ��l�lJ'/�e LOT NUMBER /1S SEC./BLOCK NUMBER _,Y
RESIDENTAL SPECIFICATION: BUILDING TYPE A121-11 f te # BEDROOMS # BATHS # OCCUPANTS Z- GARBAGE DISPOSAL: Yesto
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY �_ DESI6N WASTEWATER FLOW (GPD) -7X'& NEW SITE _L/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/ GAL. PUMP TANK,(= GAL. TRENCH WIDTH � ROCK DEPTH 1�1 • LINEAR FT. 6
OTHER -/; rS/ /Sn
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.
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IMPROVEMENT PERMIT BY f
**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�w TUSTLE BY
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AUTHORIZATION NO. C� 3�' OPERATION PERMIT BY
DATE 1` 1 b
**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
i Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
M. P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER 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.***
�-- AUTHORIZATION NUMBER
NAME 1 �'r' ,49 a 2 V" S DATE Z ;;2
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION%/�do�li°'� .��!' ie'
COMMENTSKONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS V�ALIIDD FOR A PERIOD OF FIVE .(5) YEARS.
VIRONOWAL WAMSPECIALIST _ DATE
DCHD 10/95
1. Application/Permit
Mailing Address
Home Phone _
i M
Posted By /
2. Name on Permit if Different than Above
3. Application/Permit for:
FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ${. 0&
Environmental Health Section /�� i 1�
P. O. Box 665
Mocksville, NC 27028
',e(,1RAtl AAW Po 'I q I/ ShV71 J2
ls
-! 'e )Vee- 2 700 G
3
Phone
* General Evaluation
Tank Installation
4. System to Serve: A House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ( ❑ Other ❑ Unknown
5. If house, mobile home: SubdivisionIA t� �+ P Section Lot #
No. of People 3
No. of Bedrooms 3 n11 jjn
No. of Bathrooms
Dwelling Dimensions I SysS� Cfle��
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: f19 Public ❑ Private'
8. Property Dimensions 79 ,6 L 1 Lego Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/Plumbing
❑ Basement/No Plumbing
A Washing Machine
0 Dishwasher
❑ Garbage Disposal
❑ Yes P( No
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date IssuedAmprovements Permits are subject to
revocation, If site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
ljwy (P()/ /J4,9. l� ��J/�lGtx�G a� s-•,: [CI d ` `vJ /�' f �!
This is to certify that the information provided is correct tZ
st of my knowledge, and I understand I am responsible for all charges
Incurred from this applicatio .
PO.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION !Q BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 0�,1. I OWN the property. ❑ 2. 1120 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 Da 'e County t ealt Department to enjer upon above described
property located in Davie County and owned by . 2 - -c. 4U
M I A
to conduct all testing procedures as necessary to determine said sit 's suitability ground absorption sewage treatment
and disposal system.
DATE
(12.10)
30' 8"
278.67'
TM C-7-10
TL 18
NORMA LANE
WOODLEE
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• 25' 4..
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1102 1 0'
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NORMA LANE
1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME'yA, DATE EVALUATED �S�
ADDRESS PROPERTY SIZE vpE xlc3�rO
PROPOSED FACIILTY ,�Z, Y LOCATION OF SITE 4100clie-Q— -/—of 19
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4
Landscape position P P
Slope Z 2
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group )-.e .9Lell 7
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 0 S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 171111—
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
EVALUATED BY: /� &
OTHE/R(S) PRESENT:
/D T
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