260 Ralph Ratledge 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)
NAME J// PROPERTY ADDRESS /ifll�`� � TiL �,�G� ` �C�.+ DATE j
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ,[ # BEDROOMS —,,?— # BATHS # OCCUPANTS #9 GARBAGE DISPOSAL: YeKq
COMMERCIAL. SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE fIC TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 5:Kj!� NEW SITE !/REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE " GAL. PUMP TAW GAL. TRENCH WIDTH �3'�" ROCK DEPTH /� � LINEAR FT. Dd
OTHER ' erx
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.
�I
Ft'
..........
IMPROVEMENT PERMIT BY C 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 D SYST INSTALLED BY
AUTHORIZATION NO. O 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.
DOHD 10/95
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 13OA, Wastewater Systems)
***This Authorization For Wastewater System Construction oust 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 Permit's.***
AUTHORIZATION NUKBER
NATE 4" rte,_t' j�' DATE �'��.�/'�� N2 0323
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION !ji f�/ �lLmezaP
COM WS/CDNDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**OVICE*** THIS AUTHORIZATION FOR STEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
162
ENVIRONMENTAL HUCTH SPECIALIST DATE
DCHD' 10/95'
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department APR 2 4 �99�
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Tye-' \eUMailing Address � Home Phone
e6 Business Phone
2. Name on Permit if Different than Above
3. Application for: a General Evaluation ErSeptic Tank Installation Permit
4. System to Serve: ❑ House M4obile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot #
2 ❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 2-Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions .Y 7lJ ❑ 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 2-Private ❑ Community
8. Property Dimensions A—,2 A!F-Y5 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes �o
If yes, what type?
'NOTE: Improvements Permits shall be valid No from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
PROPERT11 R Z U REb:
Directions to Property: Tax Office PIN: #
PROPERTY AbbRESS, as follows:
Road Name: ,,,,`�/�$'� Irad
eel City: &l11i1/e
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
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
MUST CHECK ONE: Plfl 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
DCHD(1193)
3
8 62A
0 29Ac.
h
o i
209 �)
)256 AC fVp� f
l/l0�10.5� 207 �`L
I
(39AC �rV y
/39.5 AC c �
10,
CEME-7 4✓l
4
/ns
a8 7
3 i
Zg� 3
G52'�8 lT 8
5c 2
P
N �Ip �� D /9 c
� �A6 Z Z � 21
dells � �A S aP
� ro Aga
90 E 3 8AC
qt
y E ^00- - T I Nry 331 1
OAC
n
' SAC
(1.37Ac)
'J °j 9.64B/.B ilAc) N
•• ; I �.4C) l3) (2) ~
(5) (I) \ 858 Q �SGZG) ry
90 ti Is5� s4a_> ' 23
13 /
G/4��' NaAc.� 79AC
14 /15 17
h
N
l
27AC. \
0
•: e °
25
/2B7
/OSAC.�-
t�
' DAVIE COUNTY HEALTH DEPARTMENT
r ,
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well �_� _ Community Public
Evaluation By: Auger Boring L'__1 Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope --
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 4- o
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
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: l/ EVALUATED BY:
LANG-TERM ACCEPTANCE RATE: J 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.ry 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
Mineralo►
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
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■■ ■EMENMENEMEN■EN■ ■■■■■■■
■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■..■■■.■■■.■..■■■.■
■■■■■■■.■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■.■■.■.■�..■■=.MEM■.■■.■..■
■■.■.■.■....■■..■■■■■■■■■.■e■.■..■■■.....■�■,■■.MIMMMMMMMEI■■■■MMMMMNSEM ■■
■■■■■■■.■.■e■■.■■■■■■■.■■■■■■e.....t..■.. ■.■ ■ ■ ..■ ■■■ ■■MINN
■.■.■■..■.■■■■s...■.■■.■....■.■..■..■.■■ ■.■ ■
■..■■.■■..■■..■■..■.■■■■■■....e■....M■.■.■■.■.... ■■■■■■■■M■■..E■■
■■■■■■■■■■■■■.■■■■■■■■■■■■■.■■. ■■■■■■..M.■■■■.■.■.■■..■.■■■■..■
■..■..■■..■■■■■.■■■■■■.■■.■.■e. ■■.■.■■N■.■■■.■...■■■■■■...■■■■
ENOMMEMOMu■MOMMEMEMEMMEN��
■■■■■■■■■■■■■■■..■■■■■.■■■.■■■■■ ■■.■NO■ .■NN.M..■■.■■■■.■■.■
■■■■.■■■■.■■..■■■■■■■u■■..■■■■■■.■N■■■.■..■.■..■■.■ ■EMO■ME■■■
.......■.......■....■..■...0.■.........Me.■E■M■■0 ONOMEMMOMEME.�
■■■■..■..■.■..■...■.■■■.■..■■■■.■■..■■■■.■■■■.■■� � .■�■NMEMEMM�
......................................... ....... ME ■OMM� ME■EME■
MEMNON■.H..■■..■■..■■■.■■.■..■■.■■.■■ .■ MMEMEMEM
MEMO■■■■■NEC■■■N■■■■ ■■.■MME■
■����■■�CCC��C�ii�i■������i■CCCCCCCCCrC CCCCCCM- - ME MEN SENN�NE_
C���CCCC�CCC�CCC��■ CCN%�■��a■mmo
IN
C�,■MCC �■ ���■■■ �
■■■■..OME■■■..■..■■E.■EHn■.■■■ .� ■
■..■■■■.■M■■■■■■.M.■■■M■■■■■■■.■.■■
ON ■■■ n■■ ■C■ ■■■■■■■
■■/:��.�il■.■.■�.■■■■.u■.■■■■nONE. ■m ■ ■EM U■.■.■■
■■ rl■1 ►�.■■■■ ■■■■■■ A...m:..i■■■■- ■ ■ 00 ■■■■■■MEN
'
ME MOMEMMEM
■■■■■■■■■O■■■■■■■■■■■.■■tl■■O■■■■C.CHME ■ ■■ OMEN No
■.■■M■■■.■■uu■.■E■OM■■tl■■■ u■ ■ ■ No ■■■■■ ■■
■■■■.■■ ■■■■■■H■■■N■■ ►■■■�■■■■■ ■ ■■ ■■■■■
■■■■■■■C■■HN■■■N■■■C�INH■O■ �. ■.0=E.O..��
........................��....... ■ .N■H . ■N■
............ ■N■HN■
Elm .... .�■E..■
NOMMEMMEM■■.■....■C0 Lo ON E■■■■■■Hu■ ■n■■■u\ ■■ ■■M ■■■■■■NC
■■■■■■.■■E■■■■■■E■■■..■■■■E■■EM■E■ H ■■ MMMEMC
■..■■■■■.■.■■■■■■■.■■■.■■■.■MEM ■ ■ � H■.■.M■
■■.....■■.■■■■n■M■■■■■■■■M■■M■�■ .� i■ C■N■■..
■E■.■■H■..■■HN■■EO■■E.■■■■■.■ .e ■ MEM■HMEN No■
■.■■■■■ C■MMCMMMMMMMMM■MIUIMU 1i . .■ ■HM . ■
....... ■. ...... ■N ■.
...■■.■ MO■CM■■■■■E■■■■■■■■■■■■■■■ ME ■ ■ ■N■�■
................................... . =a EM■UMM■■
MEN MEN ■. No
■...■..■■...M■■...Ott■■■EE■■.■■■�■■■ MOOMM■n.�.■■
■■■.H■■■■■■.MMMMMMMSN■■■■H■■■■■■■■■■MEMMOMMOMMMMEN■■■ ■CCCMENNOE ■ ■ ■■■■■■NN.EN■
■EM■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■ ■■■■■■■■■■
MIUMMEMMUMME
■■ MEMMEM/ MOMME■■NE■■NM■■■NONE■■ ■ MEMOME■MM
OMEN.. MINES.■.■ ME■MMMMEE .....■■■.MOMEMEME■ . MEN MCMMNMEM
.:on 0 MONSOON a EM■■■■C■■■■MH■■ ■ ■ . ..NNE so M■■MMCMHEMME■■■
MEMOMEMMEMEMEMEN
■NN■■ .. MEME■MEN MENEMMEMEMMU ■■= MEMNO■M .■...........EMEM■
.■■■■■■■■OE■■.e.M■N..■■■■■■■■■■■ H■■ M■MMMM■MSam MEM■MMEMM■M■EME■
..................................................................
.E■■ ■■MEMO■■■■N■E■■M■■■■■■■■■■■■■■�■■■■MEMO/ ■■■■■■■■■■■■■■■■■■■■u■■ ■
.■■■. ..■EMMMEMMEEM■■.■■■.■■■H■■■■■ . ........................