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191 Candi Ln I 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. -4In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) d ..NAME 4AA&I ,��/,�l/P"r PROPERTY ADDRESS (;,t�It.�'' � �'?/• DATE LOCATION ?4> SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE i`. ,r # BEDROOMS # BATHS # OCCUPANTS I, GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE !Y i TYPE WATER SUPPLY �& DESIGN WASTEWATER FLOW (GPD) NEW SITE L�REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/ /' GAL. PUMP TANK GAL. TRENCH WIDTH '< ROCK DEPTH LINEAR FT,cel li OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED USE CHANGE. YOUR WASTEWWATER SYSTEM CONTRACTOR MUST " SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BY � l **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 SYSTEM INSTALLED BY AUTHORIZATION NO. ' OPERATION PERMIT BY Q*� 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.;.., L CSC OMR APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department ,lU;J g 1996 Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By 'J o�� Vg-j! Mailing AddressJy,5 �.-,,X Home Phone Wc1t l p T/�C 9-90a Business Phone 70 3 3 —fie o ld 2. Name on Permit if Different than Above o 3. Application for: ❑General Evaluation Q-9-e-p'tic Tank Installation Permit 4. System to Serve: ❑ House "obile Home ❑ Place of Public Assembly - ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # �1 ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms - t1 ❑ Dishwasher Dwelling Dimensions 7 X ❑ 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: G0 Public L�Private ❑ Community 8. Property Dimensions / /<a �� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? . ❑ Yes 9--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. PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Off i ce PIN: # Sa a a- V/ , Y0-7� p�p j y10 � °� moss PROPERTY ADDRESS, as follows: �-2 w l/'"" Road Name: 6- 'yI L+ l� C i t y: nJ o c nYW SUBMIT A PLAT WITH THIS APPLICATION.. Revisions effective October 1 , 1995. M t9Q -t l7 This is to certify that the information provided is correct to the best of my knowledgLndnderstand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY [and ECK ONE: Q'1. I OWN the property. ❑ 2. I DO NOT OWN the property. cked Box #2,the rest of this form MU T be completed by the owner or a person authorized by the owner: ive consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by t all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment sal system. DATE SIGN UR DCHD(193) DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/Site Evaluation NAME � DATE EVALUATED �7 i PROPERTY SIZE ADDRESS. > j PROPOSED FACIILTYak LOCATION OF SITE .q�t/ i Water Supply: On-Site Well �/ _ Community Public 1 Evaluation By: Auger Boring Pit Cut i FACTORS 1 2 3 4 Landscape position (, Slope Z Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH i Texture group C" C Consistence Structure it- 7L Mineralo HORIZON III DEPTH i 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-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 SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-.V?..-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 Mineralogy 1:1, 2:i, 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 ■■■■■■■m■■m■■mm■■■■■OMENS■■/■■■■■■■■■■■■ ■■■■m■mME■■■■■■ ■ ■■ ■Mmm■mmn■■■mons■■■■■NeeEMMMMMMME■MMME■MM M■■■■mOeC■■■eMO■O■eeMOEN■ ■MMMMMMMMMMM MMMO■■■■■■mO///MONO ■mm■mM■m■■■■MEOW mMmm■mE■E■mMENEM ■■■■MNE■■■■■■EMONOME■E■enO■■me■e�iN■■■e■eCC■Ce■■MONO■M■e■e■e■■eM■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■m■■■■■■■■■■■■■mMEMEM ■■MeN■■eem■Nenommmmm�■E■■■eM■■■Mn■■EnneMnee■Me■■OM■■■■E■Eeeee■ESON ■■■■ME■■■■■■■■ Now en■■■■M■■■■■EEM■■m■OEOmm■H eMM■ m■mM■NMO■mm■■■■ No ME MENEM ■■■■■■■■■E■Msem■MN■mm■s■nONmNSNNHeee■■eo■NNmeNEmseeONE EnMEO MEMO ■■.■■■■■■■mm■■mmmmON■MNE■smomm■nsm■m■mO moo MEN ■MEM■M■EMEM■MM■M■nOMENEEM■ ....■■■ENUMMOON■. a■■■■■��■■.■NONE. ■■M■■M■■■■■E■m■E■■E■■■■M■■■■■■■■ ■mmmmmmm ■ms ■ ■ m■NCEM■EOON ■■ene■ene■nneen■n■ne■een■e=■Mee■Ceeenn■enC■nMC eCo=e■Eeeeeenn'C■■ ■E■■■■■■■■■■■■M■■m■■■■■■■m mmmmm■Emmmm■mm■m■meme■ MEMO on Mee■■nen■eemnenMe■e■■■M■■E■ee■e■ ■■■■■■ee■■e■■■■■e■■NONEeeeee■■■ ■■■■MOM■■■■■E■■■■■■■■■M■■mM■■■■ mM■N■EO■mmOO■mmm■YO■mO■mO■emmmO ■ENnm■mmOmmE■m■m■■■meOnMOenO■OOO■■■■■■■n■OOH■Ooo ■o■■eOH■■eesmomm HO■ MEN■Nee■■■O■eO■■■■■eeeeeeeeeM■ee■■eN�H■eeNo MONO CH■■■e ■ee■■Ce■e■■■■e Mom m■■M■■H■■■■■ns■■■■■EM■OONEO■MO ■ ■■eO■ OONY emeeNN ■ N■OE■ C ■■E■■■■■■■E■■■e■N■■n■eeee■e■eccSON C■eee■■eeeen■e=000■��o�eo0NC ■■■E■■MM■E■mmNme■■■■eumN■■■■■■EEOE000■MMON■Osmmem Mmm■esOO nEC ■■■■■■■NEmme■ememMEMO ■YsmsmsmE�NEMOENH eOO■OOnnOOOe■eOs■CEOs ■■O■sO■e■N■Oem■ ■NOemH■MONO OOM■OEEen■eO■E■eOCeNeo■eeOneeO■nME MEN■MnmO■OOnNUMEO■nCsoon NONEe■Oe■■EEEMENEM■OOm■■mm� EE■Een mnn ■■Mmommn■ C No ■■■....COMENS neeMOENenenMENEMen■MNONE nMee mMOmC . ■umom ■■OOmmC mom.....MENEMEseNONEMO■■MENEMeeO■OMEme■H cum■CC . .�.. ..■..■. OEM meNmONM■M■mo■■■e■emMMOEMe■MemM■■e,•�p mCmMH■ ■ EC■■m C■■Nene■ mom No ■■■■■mY■w■m■■■■�■uur' i■E■e■HC■YUM■eCCM■E■■■■■ on NoMEN ■neMH■OOOOn CwH■OonOOenee0 NNE NEON enn■eeeM ■ eM ■eeemom ■■ mom EEemN■e■NmaumNM■NneeunN■nWE ■ eenn ■ ■ Mee enn■e■C MEN NONE enc■ m■em■N ■ ■m ■N■MN ■■■■Ee■■■a■eN■ECC■N■eC'iCC■eeeeeC ■ Ce C CCCC CMn Cee■■ ONE memm■ne■EeeneM■emMNmmeeme■mm��en H ■■ ■die■■■■eC ms■Ose MENNEN nmsHM!:�;; ON■■ �po'j ON� ■MOOD■ wo ■■O■mem■■mm■m■eOOOOYesI ■ ■ENHeeONne ■ ■ OWE NONO OmenEm CCCC------CCiM'CCmom u■ 'C■i�C ■n memmmmmm CCCmom'CCCOO��CCCC CC INMERE No C �Ce' ■ es mu ■ ■■ ..■■mM■mMM■semmNOON mes■Y��i�M� OC C■NmmmCC .mom mm mom m■■uo■ NOO N.. u■.Y . ... ..■■■....CYe■.. 'HNC... . ■s■■ .CECT... ■■■■■■M■■ eH ■eYu■ ■H ■ Ye ■ OHOe■ ■ ■OO■mwO ■ e■■C Yee■ ■■N■■ O ■ MOM ■■■■NYWHEM■■ uMM■NEEso ■ ■■■EeMEN■■ ■ =m■OHO■ WE mom EE■ Neu ■■sgOCHmu'Hw■eOmeMn■"mnnnEeOe°OnCOMe SlEmom mom C MOEN M NOON MM nOCC 'o MEMO..... ...■■.■■.■.MUMMMUMN........... . . 'CC NOON: ■■mOHmm■MNNmOOeeum■mme■■m■SONO ■ N ■ m■mmmm■■■Nm■■■ ■■ ■■N■■■m■■m ■DCNm■■■mens■m ■ No No■ sO■OH Hem ■ ■ s■■s■emYe■eCOmmmmemE■ NOON C ONN ME■OMENuC■�nOEOmm mom MOEN so■■■Om■N■ ME mO■■MMeemmsmm■msmmemO■ ■■mMC■mmOO■O� E■Emmen■m■■am 0 MOEN an on so ■■■■m mumm a ON mom mmom No USE smO■■M■mmm■mm■Emm■■O■■mmmOmmm■OENm■■Oon No ■■■Deem■e■He■N■EOeemmMN■ ■■EeoEMNNEon 0 ■M■ONm■■E■N■EEN■M mOOssm■e■m ON No ■ MA■■ NONNM■uMON■■/M■M■M/■■■NMN■ Nm■mom NNu■■■■■■M■■■■■■u■■C■ of■m■sen■MEN smm■mMEm■meN■M■YON■�eEOmmm■EMM■MM■■mmmMOE■■■■■■■MONO ■■■m■ EM■■Em■m■E■MM■■ME■■m■mOHMOEsm ■ mom NONE nO■m■me■■mmmSEEN Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 i Mocksville,,N.C. 27028 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.*** L/ �A�UTHORIZATION NUV3ER NAME �[1rJ/I!1 ,f L �l�tDATE /�� i y o 04,0 9 NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION /I COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*H THIS AUTHORIIATION FO WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. a� ENVIR016WAL HFATIrSPtCTAI IST DATE . DCHD 10/95 R, -