288 Granada Drive... i.L. ,..... 1.'a,...,. tt,'-.-.'�.. n'.3:,f .f'':. ,{•. �:� 3 .. 43' il- ' 'r'�_
DAVIE 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
systema 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
6
NAME l E PROPERTY ADDRESS lTr'aY10.SI-0.- 1�%"% J o�►r/oy� DATE
LOCATION .7 "Aa Qr`
SUBDIVISION NAME X7,40,4a Zl—r--( LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS �,,? # BATHS # OCCUPANTS _1S:f—GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE f TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) NEW SITE, I--- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /�= GAL. PUMP TANK GAL. TRENCH WIDTH _14f ROCK DEPTH' LINEAR FT.
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���
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:38-9:30 A.M. OR 1:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. d OPERATION PE IT Y \� �� 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 13OA, 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
` APPLICATION FOR SITE EVALUATIONAMPROVEMENT PER
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Davie County Health Department 0
Environmental Health Section D
P.O. Box 848 AM - 51996
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed /I AW ` - / //A/ -E/ A 19, (fRO l/.s,47- Contact Person R V A% G7 iq LJ
Mailing Address Q Ti- G P 14 Am dA XD P- Home Phone % F(. 0
City/State/Zip 19 CIV&ME ,10 , 9 7,Oe L Xa39' B si��,e 8 86+11 C -7Q--
2. Name on Permit/ATC if Different than Above .S17his-
Mailing Address .S/a m C City/State/Zip
3. Application For: [ ] Site Evaluation [improvement Permit & ATC [Both
4. System to Serve: [ ] House PdMobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People S # Bedrooms 3 # Bathrooms_ W Dishwasher N Garbage Disposal
M Washing 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: w County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes L4 No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A FLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �' WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # S'Y %D - a -q - I q i a �il/0AA OA.) I � V -t-o �61t 1 +i n10 M C �2d.
Property Address: Road Name 9YY1 6kA A R J f!- Z,1;.. R i o k f- o N RR 1 h m o2C to 8a c h am D,
City/ZipdUq,QfC� 700(0 &RUQ'{ ftmn ed fo ka t9u;�y;
If in Subdivision provide information, as follows: � ri ► 4^hf U/U �.1) qG 1 A/ fig -ho ,-O/�!D 2Fi �2
Name: Gf/00 cL yR SO1IORIl- b2 +6 G P 1` &111 d 1i L.
Section: Lot #: /C1qht 0A) G A Q 6 D R +0 � �T,
R is li+ IA.) fo P12o,0E7-i+(,! A out a la n
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 c��%�G ✓Y oconduct all testing procedures as necessary to determine the site suitability.
DATE / SIGNATURE /iv/Q/lll./�c� 7/
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
i
NAMES4
ADDRESS
PROPOSED FACIILTY ///. V"/
Water Supply: On -Site Well
DATE EVALUATED ia'd
PROPERTY SIZE.o9G
LOCATION OF SITE i91+� lj h O d �JCt-/I�
Community
Public LJ
Evaluation By: Auger Boring ;,/ Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH t +�
Texture groupG
Consistence
Structure i .t' /
Mineralogyi
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION f'
LONG-TERM ACCEPTANCE RATE "
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY: ,ia /7
OTHER(S) PRESENT:
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
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