Loading...
627 Jack Booe Rd �.r. ..i t.W...�-a,e-.-.:.•:.-. -.rev=... �p.'..::-,:..y.>..r v'•,..r':.ew s ... ... ._.tw " -.1 Tt,�.n-:. .....,:_ k ` ., ", - '� .... ,, ....-. .. _ _. DAVIE COUNTY HEALTH DEPARTMENT �S 1�7�-5 �,�i CX 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) NIAMEL(�%s?l-/ //�' PROPERTYADDRES5 !' ��6/ e��I DoZZf DATE rLJ/ LOCATION -._l/7/'J� �ID e SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE T# BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIIE s7-< TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 1//) NEW SITE t/REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE IN GAL. PUMP TRM( GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 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 BEFORE INSTALLING THE SYSTEM. S0�t► 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 SYSTEM INSTALLED B1� N AUTHORIZATION NO. OPERATION PERMIT BY l 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 Davie County HealthDepartment g�' R2 B a r �2S fl� ENVIRONMENTAL HEALTH SECTION P.O."Box 665 -rte 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 oust be issued by the Davie County Environmental Health Section prior to isivance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** � NAME � DATE _� � � NAL�FORIZRT��NUP:�a NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION CM ENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM f**NDTICE*H THIS AUTHORIZATION FOR WA TEWATER SYSTEM CONSTRUCTION IS VALID.FOR A PERIOD OF FIVE (5) YEARS ( ENVI AL`HEALTH SPECIALIST DATE DCHD 10/95 i • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY �.0,2['!v /� LOCATION OF SITE r Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH u .40." Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence / '- Structure / Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON- IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON I SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � �J SITE CLASSIFICATION: EVALUATED BY: �/ zz, 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-Very 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 SC-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/ft2 DCHD(01-901 CCCCCCCCCCCC■CCCCCCCCCCCCCCCCCCi�CCCCCC■C�■■CCCCCCCCCCCCCCCOEM ■■■■■■■■■■■■■.■■■■.■s■■e■■■■■■■■■■■.....■■■■■.■■■..■ ■■■■E■■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCC:::::CCCCCCCCCCC:CCNONE MCIMEMEMEMENO ■■■■.■■.■■■■EE■.■■..■.■a■■■■■■■.■E.s■■■■■ ■■. ■ ■ ■■■ ■■■■■■swims ■■ ■■.■■■■■..■■■.■■■■■.■■.■.■■E■e...■E.■■■■ ■■■ ■ MI mom mommom ■■■..■■■■..■■■.......■■■.■■■■.■ ■■M■E.EEM■■EEEEESE■■■■■■■.■■■■■■ CCCCCiiiiiiiiiiiiiiiiiiiiiiiiiiisC=CCCEiiiCCCCCUC■CCCCCCC=CCCCC�C ■■..■■a■■■E■■E■e■■■■E■.E■■■.■■■■e. .sE■■EM■EEn.■■■■�.■.■■ ■■Ce. _ ■■.■■■■■■.■■.■■■■■■■■H■■■■■■O■■■■tN■OM■■■E■EC�■■■■ MEM■■■■■■■■M ■.■t■■■■H■■■■■.■■...■■■■■.■■■■■■.■.■■■■.■■■H■■e MEMO ■■■■■■ ■ ■■EE.E■■■■E■E.■EEE■ES.■EE..■■■■■S.■■■■E■E�E.■■■E E�■■ ■■S.SE■EE■ ■.■■■.E■■■■■SSM■■■■■■.■■■.MM■■.■■..■■■e■����..e� ■■ ■.■.�M.EE■■■■ ■e■■■.M■.■■■■■■■■E■■■H■■E■■■■.■ .■E■E•_�..Eu�■O■■■.■■E ■■■Masa■ ■■■ H■■■.■.■H■n■■.■■■■■■■■■■'IEEE.■ ■■■e.E.■ ■/E.n E.■MB■. OMEN ■■■..■■■■■■■■■►!■■■■■■E■■■■�E.■■■e�M■..■SME IS E■C:U■■■e.■� CCCCCCCCCCCCCCCCCCCiwaiiii■CSCCC�CE CC IsCCCC �C 1011HMENEM ■ �■■■■l ■■ ■■■■EEl■ ■■■■■■■ CC�■CC�tCI�a■C®C Cn E CECCC■"EMEMEM■ ■.■■■■■■■■■■E■■■■■■.■E■M■EC■■■■■IS■■■■■ ■ EME.■■M■■■ ■.■..■■t■■.■H■■■■S■■.■■ES■E■■EES■... EE E..■■■E■ ■..■■■SEM■■S■E■S■.E.■■■■E..SOE■M=■=.�■ It ■■ ■H■■�■■ ■■■■■■■■■■■HH■■■.■tM■■■■■■■H■ ■ ■ ON ■E■■■ ■■ .■.■■■■■■SM■■EN■■Ott■��■........ �. ■■��■■... ■■■■■■■■■■■■H■■■N■■■ H=OE. _. No M■MM■ME ■■■■■■■■■t■■■..■■E■■■O■S.■■■EE■■ vLE_ - ---- ■H■H■■ ■■■ ■■.■E■■■■■■■NSn■Hn■ CCCCCCC�C® E ■■ME MEMNON■C ■■■■■■.■ESE■E..■■HEM.�E■EE■■n ■ ■ ■■ ■■■ ■ M■■E ■E.■■e■■E■■■■.■■ENE■■■■■■■■.■N■■ N .■ N■E■■■ ■ ■.■■■MESE■■EE...EESE■■EEE■.EEE■MI■ ■� MO■■■■■■ ■■.■EE■■■■E■■■■■■■.OEM.■EE.■..E ■ ■ . ■HE.■■ on immommm ■■■.■..O■■S■■,I/��E E■■■E■ME■E/11■ ■ N n■■■.E.■■■■ ■■■■■E■■E■E■■LfEeSCS■■.■■..M■►�iA. ■H■n.N■SS MMEMOEMO. =OMEN MMMM_ .. co0 MENmimmCCCCCEMBERSCCMUM MAIMS 0 . _: ■■:CME C:C ...............................■■EM . H■m■■u■■■■ ■■■■■■■■■■■■■■■■■.■■■■■..■■■■■.EE■■■H MEN �.EM■ ■■■■■■■■■■■■■■■.■■■■■■■■■■n■■■■�■.■ ■H■■■HE HE ■■■■H.■■■.■■■■■■H■■■■■■■■■.■■t ■ ■ ■ ■ ■ ■■■.■■■■H■■■■ ■■■■■■■■■■■■■.■■■■■■■s■■■■■■■■E■�■■C■C.CC ■■■■■■■■■■ MENEM MEMO. ■■■■H.■■ ■■■■■■ ■■■E■H■■ ■ ■ ■ ■■ rOMMMEMEMMEMMEMEM H■■ ■H■■■■■■■ ■E■■■■ ■■o■■■■■■CMI■■E■■■■■■■■E■■�M■ES■■■■■■� ■ ■■MM■ ■■ ■■MME■M■ ■M■MMEMMEME ■ ■Mt NEEM■■■ ■■■■■■■■■■■■■■■■■■ M■■■■■■■■■■■■■■H■■■■■■■■■■■■■■■ H■■■■■■■■■■■■■■■■■■■■■■EOE■EEM■ ■■■■■■■■■■■H■■■■N■■■■■.S.■■H■.■■■■■U■■■■■■■■■■■■■■■■■H■■■■■■■ ■■■■■■■■E■■■■E■■■■■■■E■E■E■■■■■■■t■■E■ EE■■■E■■■■■■■■■■■■E■■■S■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E■■■■■■■E■■■■■E■■E■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■M■■■■■EEE■■■O■■■■■■■N■■■E.■■■■■■■■ MEMMU■■■■ mmommmmmommmmommmommommmmommmmmommmsm MMUM■■■■■■■■■■■■■■■■■■■■■■■i■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■■■MMOMMOMEMEEMOMMMMEMOMMEMMMMEM■■ MMOMMEMEMENEMEMMEMEMM■■E■O■EO■E■■■E■■■E■■■■■■■E■■■■EMEMMMOMMMMMEMEMEMEMEEMMEMM ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ li■■.■■■■.■■■e■■■■■■■■■■■■■■■■■n■■■■■ ■ ■■■■■■■■■■■■■E■■■■■■■■■■■ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department tt i JC:s if W : . D 7 Environmental Health Section a, P. o. Box 665 FEB 15 1995 s Awa Mocksville, NC 27028 r. --------------- Application/Permit -----Application/Permit Requested By Mailing Address 01 6. Home Phone WO 7G4-OD 7G /VC ,?7//4 Business Phone 2. Name on Permit if Different'than Above 3. Application for: ❑General Evaluation CkrSeptic Tank Installation Permit 4. System to Serve: 2 House . ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry /1 ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision ���/9•� l'� f '� - Section Lot # [i?tasement/Piumbing No.of People ' " V ❑ Basement/No Plumbing g I No. of Bedrooms E� Washing Machine S Dishwasher No. of Bathrooms Q Dwelling Dimensions 41 X G p'Garbage Disposal ,f 6. If business, industry, place of public assem ly, other: Specify type No.of People Served _ No. of Sinks ;J: No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers f' No. of Showers Water Usage Figures 7. Type of water supply: public ❑ Private ❑ Community 8. Property Dimensions Jeta/ Sewage Disposal Contractor t 9: Do you anticipate additions/expansion of the facility this sytem 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 y revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: • i e- AWe -so,�, if cJ, o tia YR- 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 SIGPKTURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: I 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. DATE SIGNATURE OCHO(1(93)