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2622 Liberty Church Rd (2) 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) WE �I/1�/S� )',+a/'/ja C PROPERTY ADDRESS Zile ell r,(l d K Xd. DATE LOCATION ��11 s�� ,�� //ll''!�/':/./�� ,�/� /a it'I'��'i�sr /r�.z, SCA J�ld�f,'�i1�•fi- ��/ SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL.: Yest COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY _�4e4l DESIGN WASTEWATER FLOW (GPD) ' d NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ej62_GAL. PUMP TAME( GAL. TRENCH WIDTH �� ROCK DEPTH A?" LINEAR FT.CkO� 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. IMPROVEMENT PERMIT BY 1 **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:WI:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. —j—j OPERATION PERMIT SYSTEM INSTALLED BY 5 �SNti ��E►� F EV[N - T AUTHORIZATION NO. 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 .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 1 "ort` '.S:.Cs� «Fi:i� w* a";,. y_....r r` ♦nT"• .-r ;7 r -"'"�,r r �t ;r i.- .. - .. _.,.,, rsF- Davie County Health Department y�..� ENVIRONMENTAL HEALTH SECTION Y ) P.O.' Box 665 f Mocksville, N.C. 27028 „�. ;• • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION . (Issued in compliance with Article�ll of, S.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 .K�(1 Y/� /�i� e DATE _ !�/S (� AUTHORIIRTI'ONNUMBER Y , NAME ON IMPROVEMENT PERMIT (If different than above) �'f SITE LOCATION .�: ��►U��.0 �lr "�j��ll � �� 2X_;1Z��1,11"Al �el COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEYRTER SYSTEM **MICE*" THIS AUTHORIZATION FOR STE TER SYSTEM CONSTRUCTION IS VALID FPR A PERIOD OF FIVE (5) YEARS. ENVIRMWUAL HEALTH SPWIALIST DATE' DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE M Q W IE j 1' Davie County Health Department Environmental Health Section P. 0. Box 665 NOV 1 7 10 Mocksville, NC 27028 I � r. I i 1. Application/Permit Requested.By tk r s Mailing Address Home Phone �.� r ' 17 C� aZ Business Phone 2. Name on Permit if Different than Above !; i 3. Application for: O General Evaluation Veptic Tank Installation Permit I 4 .8ystem to Serve: C3House obile Home ❑ Place of Public Assembly ❑ Business ❑ Industry C3Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot# i; ❑ Basement/Plumbing E No.of.People ❑ Basement/No Plumbing No. of Bedrooms /2- Washing Machine No.of Bathrooms �" ❑ Dishwasher } . I. Dwelling Dimensions ❑ Garbage Disposal t. 6. If business,industry, place of public assembly, other: Specify type No.of People Served_d' No. of Sinks No..of Commodes?, No. of Urinals t No. of Lavatories 2-- No. of Water Coolers No.of Showers Water Usage Figures i :._.7.,:-Type of water supply: ❑ Public ❑ Private ❑ Community i 8: Property Dimensions /19(, Sewage Disposal Contractor i 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. Improvementst Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTYE Directions to Property: Tax Office PIN I �. Road Name ' Lox # (if available) • / // city 51 r-3 i ,6 7. 03 . f 7•q-2 �c i 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. __LL_ 17- 9 91 ATE SI NATURE CONSENT FOR BITE EVALUATION IQ BE DONE ON ABOVE DESCRIBED PROPERTY MUST.CHECK ONE: V1. 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. /-- 17 - 95 DATE CPIGWATURE DCHD(1199) DAVIE COUNTY. HEALTH DEPARTMENT Environmental Health Section _ 0ol Soil/Site Evaluation NAME y(�C'//!.0 +� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTYy/1� �, LOCATION OF SITE •C,[� //j� Water Supply: On-Site Well _ Community Public Evaluation By: AugerBoring_� Pit Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC_ L 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 LONG-TERM ACCEPTANCE RATEl , SITE CLASSIFICATION: EVALUATED BY: _ '! ' 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 clay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V1_-.f-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 M moon ..........................................■.....................■. ...........................................�■..■....M■.■■■...■!■.. ...............■.............■.......■.■■. .■.■■..■ EE■■■E■■■■OEM ■■..EENEaaENEE■■.■/../SSSS.■.■./ MMMMMNMMMMMMM e■MMMMNMMMMMMNMMM■..■■EMOME.MEN ■ ■..■.■..■..■............■./ .■......../../.....�....I■EMMOME■■MEMO MMMMMMMMMMMMM ■■■aE■EEEE■■■aE.■E.EEEO■■EE.E■.EEaaSaaaOEaaEaa ■aaE.eN i■■iiEaiiEiEEiEi.iiaiEiEaiEiiaiaiNiNiEiOiOi■ieiENiiEiaEiaiiaiaaiaiiNEiiMiEiEieai'aEl�aa■aE.aaaaMM.a.eEa■EONENESS � NEiii '�MENO 00 Omiin ■ ■■■■E■■■■E■■EaaE■■E■■EEE!■■■!■■�■■Eaa....aEE..EME.E.■■S..E..aaM■ ■■■■M■■a■NaaaaEaaElNOlaE■E.aaaN■■Ea■■■aaEN.E.aa��.�eaaSHSaaS.E.S ■....■.■../.■.....■.■■EEEEEN..EEEEE■ ■/EMM! 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