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P0251 Duke Whitaker Rd 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) PROPERTY ADDRESS � /)C4- ° DATE LOCATION 0&16' SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS # BATHS �' # OCCUPANTS -5--GARBAGE DISPOSAL: Ye COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH a " ROCK DEPTH 49 LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: WTHIS 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 ✓ ? f / **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 vF' NSTALLED BY .asr— ry r J � yo F �_ H6M 10 AUTHORIZATION NO. 0 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 .1980 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS-, BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FlNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 :.. a<�, S ,- + rh •.�- i . � ..:.v�' r^ ':y. ,} 4x"M1 - ,' x , moi:'. ` F Davie County Health Department ENVIRONMENTAL HEALTH SECTION �# Y P.D. Box 665 Mocksville, N.C. 27028 r AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) *,V*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 NUI3ER NAME .rf X0,0ycP �/� �iS'or DATE V2 � �� '� NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION )/i.k�,� COMMENTS/CONDITION ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **#NOTICE***THIS AUTHORIZATION`FOR TE WATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD QF F1E tSI YEARS y " 'ENVIROMEMALiHEAL SPECIALIST' DCHD 10/95 m j' ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE f Davie County Health Department 1� 1 �(,,/ Environmental Health Section /� uA P. O. Box 665 MR 19 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address D w,,- Home Phone sd Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House j Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People -� ❑ Basement/No Plumbing No. of Bedrooms "l ET"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 ePrivate ❑ Community 8. Property Dimensions1a ��'�'�-S Sewage Disposal Contractor —/ 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes I" 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: �' CAJ v;IL o 6�lj tu4pj � 3 S•�e � 9 F�ooelts DG/o�-e44 0?~3 r)A, t lPS 'u2►✓ /S /IA � t- es >v t- k CIN nxi�e P,4sfC�tC�e� hous.Fs� ��x�1�G'• �//yam"= r1J 7/ 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. 3-/9-9G DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: t11 i. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well 411� Community Public Evaluation By: Auger Boring t/ Pit Cut FACTORS 1 2 3 4 Landscape position 4 .0 L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r Structure Mineralogy 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 , Y _y SITE CLASSIFICATION: ,J EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 7 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.-y friable FR-Friable FI-Firrn 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 Mineralomy 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 ■.■..■■..■■■..■■■■■.■.■■■■......■■■O■■.■ ■■■■■■■■.■.■■.■■■■■■■ ■■■ ■■...■■.■..■■■■.■■■■■■■■■■■■.■■■ ■■.■.■■ ■ ■■■/■.■.■■■■■■■■■■■ON ............................................................■.■■■. ..........■..■■■■■.■■.■■.■■.■■..■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■ .........................■......................... 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