278 Baity Rd DAVIE COUNTY HEALTH DEPARTMENT
,r✓ 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS 61J� iM' _ G'1 rld 9 c? DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLDG( NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEDFILE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE &2,6,e — TYPE WATER SUPPLY Oe DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /.� LINEAR FT. _��d0
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MIST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
r.�
r
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 SYSTfM INSTALLED BYtk(&S&lw
c
E; O
�o,.1 T
AUTHORIZATION N0. 004OPERATIONiERMIT BY �' �QCJ+AAP DATE 7 3 h
**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•1O/95
, A, Davie County Health Department
,-% j ENVIRONMENTAL HEALTH SECTIOAle
10
• _ -- .,� P.O. :Box 665 0
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
'(Issued incompliance 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 NUM%. R
MHAMEDATE `o 7 '9Z N2 09
NAME ON IMPROVEMEM PERMIT 11f different than`above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATI OR WASTEWATER SYSTEM CONSTRUCTION OVAL[,FOR A PERIOD OF &1f,& YEARS.
� 1
ENVI AL HEALTH SPECIALIST DATE.
DCHD 10/95 .
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM O M
Davie County Health Department ll
Environmental Health Section O
1 I _ P. 0. Box 665
Mocksville, NC 27028 MAY 2 4 1996
6 r
1. Application/Permit Requested By I or r �« "
Mailing Address 2761 RA17-/ RD Home Phone s^8' 7/?
fh0CK.5VtU-LC A15- 2-X ZS Business one ?GO �Ol�
2. Name on Permit if Different toan Above
3. Application for: X General Evaluation ❑Septic Tank Installation Permit
4. System to Serve: X House ❑ Mobile Home ❑ Place of Public Assdmbly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot # !
j ❑ Basement/Plumbing
No..of People 2 L�d ❑ Basement/No Plumbing
No. of Bedrooms J~"T" Washing Machine
1.
No. of Bathrooms .. Dishwasher }�}
t
Dwelling Dimensions ❑ Garbage Disposal (
f
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No.of Water Coolers i
No. of Showers Water Usage Figures !.
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions&C 3 A&PM) Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
E
If yes, what type?
'NOTE: Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989. 1
t
s
t
}
Directions to Property: PROPERTY INFORMATION REQUIRED:
�jpt At I 14J 'u izA(Ritail Tax Office PIN # S9.2,2 -D530
0 G'D pg;11,FIVAYRoad Name G .
Inn!L 1gDtr�i �� Box # (if available) —
�G S 1YppCity
Dowty DR!1c-5W4 y ' o
/WC,
AL
I
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this pplic tion.
J
D TE V SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: �. I OWN the property. Ason
. I DO NOT OWN the property.
ked Box#2, the rest of this form MUST be completed by the owner or a peuthorized by the owner:
ve consent to the authorized representative of the D vie oun�y He 1th Department to nter upon above described
cated in Davie County and owned by ��,Y/4_ f}'l�l�, ISG
all testing rocedures as necessary to determine said s' itability for a grou absorption sewage treatment
yste4m.
TE SIGNATOR
WHO(1193)
N° .75AC. p1 V r- i1.�♦ ,d ' .N
1.03Aasom`°Iss rzs (2Ac1 4zoaz )7.bf1
3X534"= A80.98 I, ,, �,•,�
ti ry '
5AG s7s 33
rn 8 n .. m33A , .con r t;cir.
a3.2ACv -35.01 a '^ t i I *2' S.I4 5 57 8 9 K 11 I 13 14 15
25500 045
210 6 "A2 .4 m V27&•52, 139 _
m , 04 405.16 722.70 - ,'3.37 892.08 '
324 '2Al
6 7 ,
�+
2. 2a N 1,y-
Iso N. ♦ " .�A.r r4
39 01
0P_ i0 2.09AC mml l u64
-.- - -
310
38' '72.01
.R
t� w
_
O N a 8' '-220 I)`r 1.16Ac 17.37A '
2 la v 7204 tow
K
g 43 42.10
�•1,r� m,.3q.03Ac v 616fAc� Rq�., '�r * t7a• e3 4t '.8-1'A.2�72.021.w
N
..��,�.• s
(5.
0.2 17 �H . 22.46Ac
4 rss176.o c 8s A
,0- • IIp ♦ 1�. 6'•.t0. 3 228.47 I • 75 �. ,>�M'
3j5 , . � 3j6 - 1 �I�C^ .,.... 5463-gy• .
J\ 3.02 AcO LZe ., 08A0 125 72 J. {d 73 , sxo it'p_ t + / F. .°
9AC. us' >LPO .1' H m 2BBAc R0.
r v ]. !P♦r • 3.O6Ac a - 204
m
I .',��.•P•a ' 4t3A. : z31 i
•
r;(89Ac) a
1 . g3' N q •ap -�,._. • �,. _ , 764.79
c 68 xxk° .3.8 107 il" s��
CIA �icl .• 9 101 3 9q. 161 l' �`r-'7k41.a, b A_.: ; r.
s61`; .r• 421 F.3,�.`•a n �r♦,`,i 7FY'�i'�,p. a { y -t m
1 $.R•y t{�.' t '�♦1t�?9 _ y 63 zte "> y,` _ },r ` .
61 I r Y `tee. g. 9 ,07212 ae. Tr 74
,8 f s4 4 '12'.05 ei t
_ r, - s. ♦A 1 " u III
26.33AC
we 10 , • t` 4 ♦• ':• 7- ., V: '1 1
M 4`69
4
m e`)+
m -
o - 23.74 Ac ,4• �. ���
33
♦y\ � '' t�> 11. - 4 t J�`' 'SC'^� .� '.
I
e,
�.,'. `.. ,, L.• 7 .; F ,.t ' E' 1.3 ;t 72.08
g
ry30 ` _ w '! 1 v-. � t'_ e. � Ya �y�♦�• 1.41.97 AC , .
220. +"•a:�'i, w�" - I }` k _- - _'% .513109 t.
2. 92 o% m !y� '•ly
>"s "s � pr' 2838.- ,y '• o .° � 0'
t r
8 72.07 t.
y _ '•,
.06
.Y• r0 12.0000 38.17 AC ,O
"'e
4)51(b
5 Ib0 - tt .iv ''�•!I -,' Yn V. �). (40.42 AC) .,
t' >t 4 1_a1 aj;� l. itt�t'''311 J °yh� N
03
16�n
2 95 02;' ,.�� +•atq`rLt v�t,,�-.n. ,. �' � ,
s e9503 <, n e ) �EEf MAP DeL
-3 `
r+� �� '�l`•' • �,. r `&f".
44
'213122 '� rri �,e v i -� 0,..t
t �a l -
87s20
a v t'ti
�. DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME 4 DATE EVALUATED
ADDRESS PROPERTY SIZE
!�G
PROPOSED FACIILTY e LOCATION OF SITE
Water Supply: On-Site Well l0 Community Public
Evaluation By: Auger Boring_// Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe 7.
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH a -,
Texture group
Consistence '
Structure rAx
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
. .Structure
Mineralogy
J SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: — EVALUATED BY: /
LONG-TERM ACCEPTANCE RATE: _� OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Footslope 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, I
SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-V?.-.ry 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/ftz
DCHD(01-901
■■■■■■■■■e■■■■■■■E■■■■/e■■■■■■■■■eee■■/■ E■E■■■■ won "No NMIN SEEM OEM
EEM■■■
■■■■■■■.■■■O■■O■■■E■■■■■■EEE■■■■ ■E■■t!■■
■ ■■��■�O■■w■■■O■■■O■O■■■■E■■
■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■■■■■■■�.M■ ■■N■■■■■NNE■■■■■■E■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■■■/ENN■fit/E■■r01E■■OEEi'i: ■■■M■NMONO
■■■■■■■■■N■■N■■U■■■■ME■■■■N■N■■■■■■�■■■N■■MAN EAE■■Mai■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■NEE ERA &1 0 Ell■E■■/■■N■■
■■■■eEEO■■■EE■EN■e■E■OE■■EE■UEEE■■/ E■VEE I%►%tau/■E EWE■EE■EE■O■
■■E■■■■NE■■O■E■O/■■ON■O■■■O■■ENE■■■eCe■►!■■■■►a� MEMO ■■MUMEMEMN MEI1M■■■■■OO■■
■■■■■■■■■■■■NN■■■M■■■M■■■■■■■M■■ 1111■■M■\■EO■ME ■ ■ ■MM"M N■■MN■O■
■NE■E■■EE■■■N■■■■EE■E■■N■■N■■■■■■■■■■■■M■■ .•E■■a. MI
_.� ■�■M■■■■■■■■
■eN/■■■/E/■■■■ ■■■■■■■■■■■■■■■■■ ■■NNs■/■ ■/ll■ ■ /■/ /■/■MEN /■
NO ME
■■EE■■■■■E■■■E■■■N■ME■EE■■CMMN■■■■■■■■■■■■■■■■■■■CMEN■■■■■■■■E■■■■
■■■/■■■■■■■■EN■ENE■/EE■■/EEE■■■■ ■■E■E■■■■M■■■■■■■■■■■■■■ns■■■■■
■■■■■■■■■/■■■■■■■■■■■■■EMEN/■oil NONEEE�N■EEEE■■EEO■OMEN■/EEOE■■
■■EEE■NEUE■OEEEEE/■■■eN■■■■N■MM ■■NNE■EN ■■nM ■ ONNHOM■MMM
■■■■■■■■■■■■■■■■■■N■■■■■■■E■N■■■MEN■■■NEE/■N■ECaaaMM
MMM
■■/E■■■//■■EE■■■/■E■■E■NEEEEE■■■■■E■ WEE E■ME■e ■E■E■ ■/ E■N■NI
■■■■NEEMEN■ENEE..■.■■■■■■■■..■U■■CEaamom MMIN�n■ ■E■■Ca■CO■M■M=
...■■■OOO■■■■■O■■■■■■■M■■NEM■EMNOM ME■■NO■NNE ■■■ MIN■ ■. 111111111 ■
■■■■■■■■■■■■/■eU■■■M■■■/■■N■■■■■..■■■■/■/u.■�W■ ■ ■■■e■/■■ I/ON
■■■■■■■■■■■■■■■■■■■■.■■N■■■■■■E ■■MESH ■WHE/ON■/■O■■ NNE
■■e/EE■EE■OEN■E ■:SNE/nMMOMMO■MEMOEHE/■EE■E/ate/■�■/EOmom/M■
■■■■■■■■■■■■/MONK e■N■NEEMEM■MNN■■■M■■■■■■■■■■■■■ ■■ ■■■�■■■■■■
M■■M■■■■N■■HNEEMMEN N■ONO/EE■■■■ME■N -- mom E■■■ N■■■■MI
■E■■MMM■■■■■■■EO■■ENNE■mom N■ENE/■■E■■EO■O■■■mom Ca■ ■uOOEMOMI
■■■■■■N/■■EME■MEN MMEN/OEE■E■OMONSOON N■EO■�■NONE aC ■�■Ca■■�O■E■M■■
■■■■M■■■E■■MOn ON mom NEON ■/■/■EN
EN
MMM■UE■■■■■■E■ENEOMENNEN■■EE■■■■E ■■t■MN■■�i ■t � ■N■■na
■■■■■■■■■■■■■■■■■E■ENE■N� �■ EEEE ■ E■eO■EI
MEN
■■M■NN■■■■MMMMMMMEN■a•■�•.N■■■■ �N ii� Caaa aN■ ■CMaION
OM■
EMENE■NEEM■=MME■N■■M■■■E� ■■■■■■=■■M ■M EE / SOMEONE
a
■■N■■■�■ ■N■M�■■■■■� ■■■■N ■■■/■I ■N ■ ■ �i ■■Es■■
■N■■EN ■■■■EN ■N■EE� �EEOE No N ENE ME
■E■■■■■■■ ■■M ME NO
MEMENEEN on 0 ME
■■■■■■■■■■■■■N■■■E■SEMEN E■NE■■E■E H ■■ ■E■NMNSE
mom N■■■mom■E■N■■■■a■E■��■E■ ■■■■_■ �■ ■ ■M ■■■■■ ■N
ENE■ME■NON■NN■■■■ N■11■N N . �. MN■■■aN
NE 111101111 ME Ea aaaaaaa5
No ME u
NNE MEMO
n■sNMEM■N■■
Ne/■■■E■■■■■■=MNUN■■En■o■No M
M■=■■� ■EH ■ ■ ■■■■
a■■■ONE CCn■ uu■■ ■■�■CiCC ■C■ HsC H ■ EE■■
H ■■■■MENEM
E■■N■E■E■EON■ ■■■■■/■■■■C■■■E■CC■ ■C " Ci■uEEE■
ONE ESEEMS EEEHWO■E■■■/N/� ■ H■
M■N/■MENOE■■ ■ ■ ME ON Nn■a�■■N■■0 CaCC
■■M■Nu■ ■M■■CMC■gN ■■
s■■■EaCa
MEE s■N M■M ■■■ H n■ ■n
■■■C■■■ C■■ ■EMNNE aC■nCC■■E ■ ■C ■■CC CCME
■EN■E■■ ■C�■■M■■■■■■■■■e■M■■■■ C ■M
M 0 ME ME
M NEON" ME ME ME
■■N■■N■MM■■■■■N■■■■N/■■■E■N U■■ ■■■■■■■ ■■NMCNNa
SEEM N■E■■E■t/ENEH■■/■EM■E■NEON
�iNaaC ■ E■EE■E■E■E■■EN
CC�CCCCaaiuE_ uiiaiiaaaaaauaas■�i aaE■E H/uiaiaaa�
SEMEE■■■ ■■■ ■■■■■■■■■■■■■■■M■■H N ■ /■H E■E/■NC
NOUN.. CCE■NEOE EHM■■ .■.... .. .. ■a ME
mom
■■E■■■ ■ ■ M ■■
■ E■ ■ ■■■E ■■M/■■■■■ ■ ■ a■ /■E■■■■■NE■■ ■
.■.. M■aC■i■■■■■■■C■■■■■UNH■N� ..� CNN. N■ONNB■■■UWEN
NONE
OEn/■O■E/NMN■■NMN■EM■/E■■O ' H■N ... E■U�..........■.■■■/
SEEMS ON NNEO■N/■ ■NE■E■W■E/MUFF ■■a■En■.■N/UN■EN/■■OEM■
■■■■■UM■■NCM■■■"ME■EC■■■■UMN■NM■■■■N■�/NN■■■E■EM■■■E N■EEHM■■■
■■MM■N■■■■■■■■E■■■M■■■■M■■N■E■■■■■■■■N■■EM■■■■■■■M■■■■■■■■■■■■■■■N
■■EEEEE■E■/EEE■ENNE■MEEE■■E=■E■■■■■■N■■■■■u■■■=■■■■■■MEN■■■■■■■■■
■EON EEE■/E■E/■■■EE■■■■■■■E ME N■■■M■M M■/■N■■■■■N■■■s ■
/m■/C■■N■■■N■■■■NNN■■M■■E■■e■■ ■■N■Ca/HEE■Ns■/■■N■■■■N■H■EC■
�I::CCa'NOMMEMME mmmmmm MMEMME �:C:CM ■CCCMCCCCaCCC�aCCCauCC0