3878 Hwy 601N�.rS•LI1.1 EtSiuv�� +.��v'!'i,:'." TaIY '•Tl+.1 Y.s,'�Y' .�!`_.:.:." Y."r:_ ,�,... 41. >'.' . .f.'v7,- ,f. a i S �. • :.3. r„ __�
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•_ 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 oust 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 u e W •� s AMS PROPERTY ADDRESS 1po N - 2 is -Z DATE 13- 9L
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL.SPECIFICATION; BUILDING TYPE V\N\16tM° # BEDROOMS # BATHS # OCCUPANTS ,�, GARBAGE DISPOSAL: Yesco
COMMERCIAL` SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/
LOT SIZE '-TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) t M0 NEW SITE "y REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. �'�QMP TANK ' GAL. TRENCH WIfTH 3 , ROCK DEPTH I LINEAR FT.
OTHER ,�..
u .J
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF.SITE PLANS OA`TME INTENDED USE CHANGE., YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. w
• s� w
1 1 . k -s
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:N-1:30 P.M. ON THE DRY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
If
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AUTHORIZATION NO. O y 2 .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 10/95
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9 �'- , t n , .'� i
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'�� � " � � Davie Coun�y Health Departient � � �
�-��,� _ • �
� � ENVIR�ENTAL NERLTH SECTIDN �
w ���� �' � ^� �~ , P�O.� Box 665 ;
,'`"` ' �-� Moc �vi11e, N.C. �7028 � d4, ,4 � i
k'�� . . . . .. ' . . �� � . „ . -�. . � � . � . � . � .
F, li :
� ` � AUTHDRIZATION'FDR HASTE�qTER SYSTDI (XINSTi�1CTI�l , _
a =LL
r; - �.: -
�,,� 4 (Isaued in co�plianre with Article.11 of
��`�; �� � G.S' Ghapter 130R, Wastewater Syste�s)
,..- • ,;,,, -. . . , .
�}' �+�*This fluthorization Far Waste►+ater 5yste� Construction �ust be issued�by the;Davie�Gounty Environ�ental Hea�t� 5ection priar� to
issuance of any Building Per�its. This For�iRuthorization Nu�ber should be presented to the Davie County Building Inspections
Dffice ,when applying for Building Per�its.+�+� `
' AUTFDRIZATION I�U;9ER
� �; � ,` m� �^ '2�, .��o , �°�� ��;5��
,NRME ON I�RRDUElENi PERMIT iIf different than above) � �
� SITE LOCATI�1 � � � � O�� ' '
COMENTS/(:OImITI�lS �hl RIJTHDRIZATI�N T0 CONSTRUCT WASTEWATER SYSTEM `
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f�TICE� THI5 AUTHDRIZATION F�R WASTEWATER 5Y5TEM CON5TRlICTIDN IS VRLID FDR A FERIOD OF FI4E `i�) YEARS. �
`� � �- � : Y9���� � �� � ,1 � . g b
� .� autRa�ra. �TM s�cir�is� _ na� , .
DCHD 10/95 � �F
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED 1
THE REQUIRED INFORMATION IS PROVIDED.
- i I - � --
1. Name to be Billed
Mailing Address
City/State/Zip O
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [ ] Site Evaluation
Contact Person
�D I 1F@F.0W[E
AUG - 61996
Home Phone 2 Z'2 30
Business Phone
City/State/Zip
[V]-rmprovement Permit & ATC [ ] Both
4. System to Serve: [ ] House [f ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People_ # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal
[y]"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: [A,-C--Ounty/City [411 [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [kT<O,--
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 OfficePIN: # aa: - �_ - rp.'i 7C> �iDl �✓ - PAs7' A1-1 �4AR.� D.w� sG%wG
7-uacry
Property Address: T oad Name & D /•J � C/ust A ('A.rik— � /naa /Pii't'
City/Zip omaGK Z 7 0 2i _Gt.esJ' (�ut.I ' 91%64044 �. P'1� c►P
If in Subdivision provide information, as follows: ni/��rt waw
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 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 /�n.� c r� r`rz,c��-v� to conduct all testing procedures as necessary to determine the site suitability.
DATE SIGNA
Revised DCHD (06-96)
693
460.02
291
36.2 Ac. 58 N ;
9.75Ac" (275 Ac.)
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2
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0 451,49
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47$.5 0 60 0 0
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(3.02 Ac) ` Loj 4,72 v 62453.88 34f.88 --_
+ as 4 Ac 2 24Ac C
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N 68
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ass
2.5 Ac o D 8Ac.
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6476
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation q I
NAME DATE " _ DATE EVALUATED '2 -'-
ADDRESS �_ `Q`cc�� PROPERTY SIZE �d Clcs�
PROPOSED FACIILTY �'� LOCATION OF SITE Lo ( N 4\Z
Water Supply: On -Site Well _ Community Public
Evaluation ByC'Z.L Auger Boring Pit Cut
FACTORS
1
2 3 4
Landscape position
Sloe Z
.- o
19-160
HORIZON I DEPTH
6,L1
Texture groupL
�-
Consistence
Structure
e,R
MineralogX+�
HORIZON II DEPTH
��
Z
Texture group
Consistence
Structure
Mineralogy
/' 1
`,1
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: Q S • EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: �� D
REMARKS: �� C>1 c1i13 Aft�z7�lAr`9�
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 c;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vcry 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
DCHD(01-901
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