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189 Bowman Rd v.+ _r.0� S."`%s.' int rM r,ei.:e�;.�,is.; °,w,,,:.;.y_•�ry—Fr n. .. .r 4 e n,.� ... „:: >.'... - . ...., ,-,., ..„ - .. 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 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) S NAME bo-,es. VIA �ftA k ' Ptx� PROPERTY ADDRESS 4010YnQYtj C=L C� , /•l0C�SDATE' �I'�o C�S LOCATION Q , N 1�,� 4t�► 4%" Mk N SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE n1,\�oTMQ # BEDROOMS # BATHS # OCCUPANTS 4 GARBAGE DISPOSAL: Ye No COMMERCIAL SPECIFICATION: FkILITY TYPE < , # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: C /No 14 LOT SITE *'qPE WATER SUPPLY,• DESI6N WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: IN, SIZE )CDC) GAL. TANK GAL. TRENCH WIDTH ROCK DEPTH 1�Nt� LINEAR FT. SGV OTHER 1 r REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE P NS OR THE`INTENDED USE CRANE._,YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. t •�bJ � �21}•) _, 51\0 MPROVEMENT PERMIT BY '�� _ ��"► . **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN—- 8-30-9:30 ETWEEN -8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OFINSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT - SYSTEM °INSTALLED BY (rl 4 1 Pic—, F AUTHORIZATION NO. O0 5 5 OPERATION PERMIT BY DATE �r **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 FICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 Y"+ � i+ b �7' ce� a�K liver;', v�t•,•i' r tv � >-;i - .:.r': A e... ,.. �, _' . - r _ Davie County Health Department a,-•1j" ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CXTRUCTION + (`'15 ued,in compliance with Article 11 of r TM•G'S. Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction.muat,be issued by the Davie County Environmental Het•� th Section prior to issuance of any Buil&ing Permits. This Form/Authorization'Number should be presented to the Davie County 8kj ding Inspections Office when apply in for Building Permits.*** AUTHORIZATION M14BER NAME �J O a DATE 1 _ c�5 t , NAME ON IMPROVE?ENT PERNIT'(If'different than abovei J grin e C SITE LOCATION COMENTS/CONDITIONS RIZATION,TO CM6TRUCT YWWTER SYSTEM 1 A" . **WIdf�W7HTS-AUTHQRIZATION FOR WASTEWATER SYSTEM RSTRUCTION I4 VALIDfOR A PERIOD OF FIVE (5) YEARS. `EWIRONIENTAL HEALTH SPECIALIST DATE DCHD 10/95 k. tin APPLICATION FOR SITE EVALUATION/IMPROVEMENT 5W Davie County Health Department D Environmental Health Section P. O. Box 665 CCT 2 4 10 Mocksville, NC 27028 �1. 1. Application/Permit Requested By k5o9ey PCA rMA n P Mailing Address ✓ Home Phone hectic "Yl Business Phone 2. Name on Permit if Different than Above V A M e--5 V T I12 - _V,:52 C2 E 3. Application for: gGeneral Evaluation ❑Septic Tank Installation Permit 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place'of Public Assembly I. ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # C ❑ Basement/Plumbing �. No. of People ❑ Basement/No Plumbing No. of Bedrooms 3 RWashing Machine No. of Bathrooms ?? �" 'Dishwasher :, Dwelling Dimensions S.— ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type d No. of People Served No. of Sinks No. of Commodes No. of Urinals r Y' No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public ❑ Private ❑ Community r i 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes eNo If yes, what type? E t I 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvement Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY INFURNE.ViON i • { Directions to Property: Tax Office PIN # r8/7- $9 3 Ft4t�t Road Name gaL )jIA pj 01 IV 4o Box # (if available) I f 70 V IV R ►�+ (J v I> pe✓ `� D IV city �1)7o e-k.syt i �4 6a de /V f y This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY C MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by.the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determin said site's suitability for a ground absorption sewage treatment and disposal system. t DATE 9IGNATURE ` DCHD(1193) •�1 't ��. .l•' 9�� f''� i .. (j; •w X��R tti•R'b.. ✓ • .tr. t \ �'kyt t+ri t fi " y \t .' � LWldi♦ :W^� � 'iu �� ,a,1' rMSk(r 8��` Lr• �, f' 1,�t �i".,pyj . _ U U� \:I Int NQS t°.i%;...4��.� �t�'d. '. !t ) yh� iq� •` >r' ,1rlks •�i Y n < n. r" I _`7 / L �`\\ , ,r �' n t r ;'�,. . `O�07� t1,�t� ftp S' � 'V J' •¢ J 1 � ^:• Cj,' .t{Y � �F} E�7t� ),7 t��Ct .� z �,cj.. � i,+ .�. �.c2, �! ' �.. �.i r� Y<L`, r rQ .Y r{. 'N rr�yL 5d A Jj r:• �" r�` .r. Eiji ' A Ott •5rr I + �� __t..- _ I N - ' ` p•)'4T. .:..r.l Y,ci 1 �,1� r l I rtl` i'{Yw { ' ` t - ��','l .. t 'y+��' t �f u �.y�r fh0$"'� �.''> � � 1" 4� � �t 'rt• f,y5 ��. .. � 1�['+y r` :' 4 `iS .v ,T i(t w� S r pfg. t i '�.` ��•t '}�t '�^` �`trr. t7 �,yt } •'i� Y IF" .. � t'. �\� S( `. IyM�,I� '' i 1. int 4'.. �'�� •. �'g�✓�W '�•�'..I .,,t t ,..i/ t I YLsi k a I10� :$ � � ,¢' '�A C- �• ' :i a� e Alt" TI 7 + } u L ��.perrr 'it A '�'rx r .`.I i d Y 'ri ¢" � co+d6�1�a'�,.r: k,j•j rG i'')"7 � , ff `� 7'u♦(:� .� zw �k�o � � W'Y I �i �.� t t, t � � -��.vG�I 4ra.6 �'; c t"�Y*Y'1 J .� �� F . ` r � �1 l .1t':, trt N W' �. °w IJi. , r :tv �` R �} i��a .rY '4try!•. ', + ' -ii4, ti '.• jC.V�V r! a+'t f�y:"'"` r s+r,,'t7�nN �. Ci�� s, 6 '.1.+ 'fi.� � A. ' t{ t'kt � 'Y-.: 'i•tr h"}" r h hi•i. ,n .�% L ' ' �•�' r e1 3n w k X v I "R \, R J•� '�2riL S'.P�w�Jl�' t nF ,r��t tC 11..1'tM'.. 'i 5 a`` ,,rp. T �y�'1� ^�• �\�� . .. } ` ��hL �• '.e �.�aj y�r Fp'•Tr �� ) 41't P; F4Y v VL 1... � jr'�r''yf�'^� r Iq _ 6/.a0.,r 4 x ! �'� •'.,ta a�j, , ..+ 0 N Atj,� tI�1 q tt 7 .. +` t to � i U J r }.) 1ti• 1{`L.'r r 'N'+' k rki r d • t � rtA J l y t k rL w 1 .A/ �±G � �i f � '1 � "arlyi .. �E � ..�. `r,f�; t�sr •. , t tt.3ff ajt y �, 1 ti. per. 1 -.. _ .1:. 11 S. .y Li .. 1�`41� '6b 5 I8�•-� � ��7��P1r I � ( �l.rr� • 353 (2 . 09A) 243 271 V 248 4499tu f7�+ Crn U) 9406 1435 259 -----259 27 18 01 ( 1 . 59A) � V 475 8 5301 3 428 _ _r " N ,Cn Go 32Q3 INDEXED ON 5013 o Z JA i-les L�ICiv �� .r • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation I NAME 00!� � ✓ °`� �� DATE EVALUATED Y ✓ 9� ADDRESS '!S 1p 1'x"9 PROPERTY SIZE PROPOSED FACIILTY �� o '(Y�ca LOCATION OF SITE ow Kr'AT� Water Supply: On-Site Well _ Community Public Evaluation By�t` Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S .S Sloe % HORIZON I DEPTH Texture group Consistence - =Z Structure Mineralogy ', 1 %\ HORIZON II DEPTH Texture group C Consistence Structure P k Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS s - RESTRICTIVE HORIZON r SAPROLITE — -� CLASSIFICATION ,S LONG-TERM ACCEPTANCE PLATEJ 3 1 - SITE CLASSIFICATION: .S EVALUATED BY: .3 LANG-TERM ACCEP ANCE RATE: OTHER(S) PRESENT: REMARKS: � LMEND 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-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, 2:1, 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 ■■■■■■■■■■■.■■.■...■■.■■■■■■■.■.■■■.■..■........■ ■SSSS■■■ ■■■.0.■ ......................................... ... . . ... ...... ■■ ..................................■..... 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