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409 Gordon Dr (2) }[�r ��;•'T�np ay.j+` �:uwtlrf y4::a� .,.c:.t b ",. L ',':4 +� �:t� ...i'.' r .,.r �..7'.+- -: .• ..k:.., i ,- .ry il`,l.t_'., ..-+ - „- j ,ter^ :J •'(4 � :.;ti+ • «.-!. ...7r . � Y 3v, .tri. .,Jr`b.R -0 "'"� �• 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 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 s.n PROPERTY ADDRESS � r0p N �/� • Zoe 6} DATE 3 `1 - LOCATION �J `� ��dc. �,aA �- ��. �� . ��. ' �'� c,c. �.t� Q► •� SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE ` # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS 'INDDUSTRIAL WASTE: Yes/Ko LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) O NEW SITE ✓ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIkJ00 0 GAL PUMP,TANK GAL. TRENCH WIDTH ROCK DEPTH �� LINEAR FT. a' 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 BEFOI INSTALLING THE SYSTEM. 7 I3 IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF N 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. 0.• 4 $ \ AERATION PERMIT SYSTEM INSTALLED BY S 1�e�m�aN U 'N cu �E�1 a 44 Q AUTHORIZATION NO. C) 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 136A, 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. DOHD 10/95 .Y � 'f.;; an•�:yati�4;;✓.1 `t'N ti a? ' ,A. .i; .a' r r �-- ` - -. ,. - •'° Davie County Health Department ENVIRONMENTAL HEALTH SECTION - P.D. Box 665 a- V D . o Mocksville, N.C. 27028 f . 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.*** NAME `R. Q S -T. DATE " , I C� AUTHORIZATION NINBER s ..� N2 NAME ON IMPROVEMENT PERMIT (IIf different than above) t SITE LOCATION avl- ?.I1 eJ COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **(NOTICE+" THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 kV. '* APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT y \ f (V Davie County Health Department AaAO Environmental Health Section P. O. Box 665 > Mocksville, NC 27028 qq� 1: Application/Permit Requested By�har lez 1 i Mailing Address bp,-) �`� rQ 1rg„' Home Phone �t l—sin") Business Phone cm- 2. -1�Z5— 2. Name on Permit if Different than Above 3. Application for: a General Evaluation peptic Tank Installation Permit 4. System to Serve: ❑ House Er Mobile Home ❑ Place of Public Assembly i ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # i ❑ Basement/Plumbing No. of People L4 ❑ Basement/No Plumbing No. of Bedrooms ff—Washing Machine { No. of Bathrooms eDishwasher 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: 2"Public ❑ Private ❑ Community 8. Property Dimensions / c;11Lo 6-F;?o CQ age Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? Q.-Yes . &►No If yes, what type?_CUAd QLI0 6*LrC%.. *NOTE: Improvements Permits shall be valid 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 IN>=ORMATION REQUIRED: l _ •� Tax Office PIN: #5WOQ-65-5593 PROPERTY ADDRESS, as follows: 1 \ Road Name: ioi-acs city: SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. -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 application. DATE SIGN TUBE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 2'1. 1 OWN the property. ❑ 2. 1 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 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. coaAQ� Y4 I flgtp DATE I SIGNATURE DCHD(1/93) ) i 003 Jo> (1.B6A1 6668 S 069 003 zza 0 003 13 11.91A) 9635 0672 003 (12.IA) 5593 z+a U• 039 s. 1 (1.00A) GOR 3066m SP �p49 Y 0 i pA� gP �p9 13.2a) 1 1 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Q NAME ��=� �_ DATE EVALUATED ADDRESS PROPERTY SIZE I �p - PROPOSED FACIILTY �� h^Q LOCATION OF SITE G e� Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH ' Texture group Consistence Structure Z '\Z- Mineralogy Mineralo HORIZON II DEPTH Texture group C Consistence v7s- - S Structure 'RZV- v;�k Mineralogy A HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS �$ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION -S LONG-TERM ACCEPTANCE RATE( o .y+ SITE CLASSIFICATION: y •S' EVALUATED BY: _ C LANG-TERM ACCEPTANCE RATE• "' OTHER(S) PRESENT: REMARKS: 4�Q\0_ •, 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-Vl:!-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 Mineralolzy 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 ■■■■.■■■■■■..■■■■■.■.■■■■■■■/■■.■■■■■■■■ ■EMMEM■ NOME■■■■ ON MOON■■ ■.■■■...■■■._■./■.■■■■■.■■■■■■.■■Neu■■. ■E.■ ■■■ M■■E■■■MME■■■■M■ iiiiiiiiisii■iiiiiiiiiiiiiiiiiii�iiiiiiii=i�iiiiiiiiiiiiiiiiiiiii ■■■■■■.■■■■.■■■■■■■■■■■...■■■.■NON■■■.■■■ ■■ a■■■■.■.■■■M■E.■■■■M■ ■.■■..■..■■■.■NNN■■■■.■N■■.■■..■..■.■.■■■.■■■■■MN■■NM■NM■■NM■.■N■■ ■N■.■■■■■NNN.NN■■NNN■■■■..NN■..■ N■.E......■.■■.■■ M/M■■■■■■■E■■■ ...........■......■........ .................■.■.■..�.■.......■.■■ ........................... ........................ .■■■■■■■.■■.■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�iii=i�i�■=iiiMiiiiiiMNo iiiiiiiiiiiiiiiiiiiiiiiii■iiiiii■■MEMO iiiiiii ■■■■■■■.■.■■■..■■.■■./.■■■■.■■■■MOM■■/■■■..■■■■.�.=■■ME.N■■..MMM.■■ MMiMMMMMMeui■MMMMM MEMNON ■■■.■■.N.■■■NNN....■.■■N...■■■.�N.■■■NN�■/M■NN/../■.■M■NEN■ ■E ■■■■■.■■■■.../...■■■./..■■■.■..■ NOMEE■ ■■ N■■■..■■■EMO.■NM■ M ME■..■■■/.■.■■//.■■/■■.N..■■■.MEN■ENN■■■■NN■■Oi�n■■■■M=mom MMEMME EM.■/■.■.■.� ■■■■■■■■■■■■MM■■■■■■■■■■■■■■■■■■■■��■■■MM�■■■�■■ M.M■ ■EMM■■■MM■ ■..MM■■■.■.M■■MMES.■..N■■■■■■■■.■M�:N■■•._=::■1■■M E..M■M■ ■■M■/.M■ ■/■.■■..O■■O.NMEMO.N■MMNN===_��-■■EMS/EMM1/■NNONMON■=■■M■M■■■ ..H■O■M■M■M■O■■.......■........�........0■■1�� N■NM■M■C■■.MMIC■ ..■ N■■M■MO■N■NNN■■.M■NOMN■MM■■■■■■■.M.■■Il■ OH■H ■■■■■O■N■■E■■/■■/■■■.■.■■■■■■■■■.M■■.■■■M■..■■■■■■■■■■.■EO/MMMMMN■MMM■M.■■.■.■■■N■■■O■■■O■■N N�■.H■.��N■./■NM.■■OO.■..MM ► l■►��•.a■.■'►�N� phl ......i M�■E0. 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