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P0440 Hickory St DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERM T IMPROVEMENT PERMIT 3 �� *ATE}* This improvement permit DOES (dT authorize the construction or installation of a septic tank system or any wastewater Oystem. 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 -Iret,: S�• j`t DATE LOCATION �'t// ',�'i,-s� S.•c��'Y SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE 9v # BEDRWM(S # BATHS # OCCUPANTS_c GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE r TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) LS. /� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE � GAL. PUMP TANK GAL. TRENCH WIDTH {r •' ROCK DEPTH LINEAR OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT 1S SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE.CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. .. fit.. IMPROVEMENT PERMIT BY Z/,,,-7 / s **(XNJTACT 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 DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY '144 F G7 AUTHORIZATION NO. (/l OPERATION PERMIT BY / DATE n/:! **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 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Pi Davie County Health Department Environmental Health Section P. O. Box 665 Ja 19 19� Mocksville, NC 27028 1. Application/Permit Requested By. , Mailing Address n ^ / Home Phone CPhone mIeeIr Po- of r7t) Business Phone— 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation 12 Septic Tank Installation Permit 4. System to Serve: ❑ House C+T Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# 2 ❑ Basement/Plumbing No. of People > ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher / Dwelling Dimensions ❑ Garbage Disposal 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 No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this s em is intended to serve? ❑ Yes ❑ No If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to. revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFOFSIATION REQUIRED: Tat Office PIN Road Name ./i Lux ,P (if ava.!.:table) /� i City —S�IPPrvrn �� a7bl This is to certify that the information provided is correct to the of my knowledge, I runnd I am responsible for all charges incurred from thpplication 7�Zg r�� JI dam. DATE ZjGNXTURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: El 1. 1 OWN the property. I� 2. I DO 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 herebygive consent to the authorized re resentatiyy��of # D yi ount Ith Depart anter upoy�abov OAS ribed propertlocated in Davie County and owned by�7'L®!/Iq V (� i✓T� �`G/yl/7� .9 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage tre nt and disposal Syste� w n/ v[I c r � a*" DATE VSIGNATURE DCHD(1193) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section l/ Soil/Site Evaluation ^� / NAME /( DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY eezAl LOCATION OF SITE Water Supply: On-Site Well Community Public C/ Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position J, Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH sr +' .Texture group Consistence Structure ,C Mineralogy �• /•' 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: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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.ry friable FR-Friable FI-Finn VFI-Very finrn 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 SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo¢► 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 a DCHD(01-901 ■■..■■.■...■■■■■■■■..■■■■.■■..■■ ./■■/...■■■■.■■■■■■■■..■■■e.■■■■ ■....■.■..■■.■.■■■.....■■■■ .■■.■■■■■■■■■.■■■■■�■■■■�■■■■ ■■■■■■■■ ■............■.....■.■■■■■■...■.■■.....■...■.■ ■■■■■■N ■■.■■■■■■■ ■■■■...■.■■■■■■■..■■■.■.■■■■■■■■■■■■■■■■�■■■��■ ■ ■■■��■■■■■■■n■■ ■■■■■■■..■■■■■■.■■....■.■■�■.■..■■■..■■■ ■■■ ■ ■■■ ■■■■■■■■ ■■ ■■...■■■■..■..■■.■■.■■■■■.■.■■■ ■.■.■..u.e.■■..■■..■...■....■■■ ■■■■■...■..■■■.■.■■■......■.■■■. ■..■.NN ■■■ u■e.■■■.■■■ ONE ■.■■■■■■■■..■■■■■.....■■.....■..�■■■■N■.■� .N ■■ ■■■■■■■■■.■■■■■■■■ ■■■■e.■■u.......■■..■.e/.......■..........■N■..� ■■■■C..e.■■�� ■■■■■■■■.■■■■■■.■■■■■■■■■■■■■■■■■■..■■■■■■■■■■■■� ■■I■u■.■■■■ ':iiiuiiiiiiiiii'N'iiiiiiiiiaiiiiiii:eei:asiiii■'Ci�iii■iiii�iiiiis'si ■■.■e■.�■■■■..■■.■.■■est......■.u.■■.■u ■■■■HIM 0 ii Mii' =i:i'■■' ■■...../1.............11■■■■■■■.■■■O�■■ ■■.■ ■... Elm■■.....■� U■....■ ...... ...■n■ ■■■■■. ■■■. ■■.=i'i .e. 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MORMIN :�ii:ii:C:■ 'AMNON :: ::::::=:C:O::::::::'.':�:::_::N:::C.::::::::::::::::: ...............N.■■■■■■■■■■...■ .............■.■.......■■■■■■■■■ MONO iiii�.iiiiiiiiiiiiiio■:iii''i'■eiisie::iiiiiiiiiieiiiiiii�ei=i .k• i :J1 r'�. t' � Y Davie County Health Department ENVIRONMENTAL HEALTH SECTION r P.D. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Q i i (Issued in compliance with Article 11 of G.S. Chapter 13OA, 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 NUKBER NAME DATE ' a 0 440 NAME DN IMPROVEMENT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FDR TEWATER SYSTEM CONSTRUCTION IS VALID FOR R PERIOD OF FIVE (5) ,YEARS. ENVIRDMFNTAL HEAMSPECIALIST DAT DCHD 10/95