580 Ratledge Rd It, i i :.a. .. coy ,.,... . _ v.
DAVIE COUNTY HEALTH DEPARTMENT
* ' (1 j ;av e (` �} IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVD4T PERMIT �QS"S� /7�7
**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 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAMElS�o �p�l, J PROPERTY ADDRESS t'� E. . 1�1619'W DATE
LOCATION
SUBDIVISION NAME ..LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT ✓ # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE/� �A TYPE WATER SUPPLY APe// DESIGN WASTEWATER FLOW (GPD) NEW SITE !r REPAIR SITE
SYSTEM SPECIFICATIDNS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z� LINEAR FT. � �
OTHER _ &410 dSlPS
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.
13 A5"
F
IMPROVEMENT PERMIT BY �Q /
**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 0 # IS (704) 634-8760.
OPERATION PERMIT 3 STEM INSTALLED BY .i
ri
r
AUTHORIZATION NO. 3�I OPERATION PERMIT BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE I1 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
41
; Davie County Health Department `
,�F "•
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
' 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.***
AUTHORIZATION MXBER
NWE ///i /�c" �/� J�/7 P - DATE N2 039- 1
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*H OTICE*§* THIS AUTHORIZATION FO 5 WATER SYSTEM CONSTRUCTION IS VALID F R A PERIOD OF FIVE (5) YEARS.
/
ENVIRONMENTAL HEALTH CIALIST DATE'
DCHD 10/95C.
' + APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Sz:)
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
1 Application/Permit Requested By
Mailing Address z? �'� �/v.< �`,-t' Home Phone
9/a ?73-iz8Y
.? /w yded ,, Business Phone
2. Name on Permit if Different than Above
.3. Application for: ❑General Evaluation WSeptic Tank Installation Permit I
4. System to Serve: 9vouse ❑ Mobile Home ❑ Place of Public Assembly
P
❑ Business ❑ Industry ❑ Other ❑ Unknown �� w
5: If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing k
7 No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No.of Bathrooms ❑ Dishwasher
i
Dwelling Dimensions C3 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
I No. of Lavatories No. of Water Coolers
j
No.of Showers Water Usage Figures
7. Type of water supply: ❑ Public AMC nvate ❑ Community
.- yr! /��-� Gj1v
� 8. Property Dimensions Sewage Disposal Contractor
' 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0-19�
`y If yes, what type?
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: PROPERTY INFORMATION REQUIRED:
I Tax Office PIN: #5-126-D2 —
t PROPERTY ADDRESS, as follows:
/ V� n
Road Name:
i SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
I.
,
This is to certify that the information provided is correct to a 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 ONBA OVE DESCRIBED PROPERTY
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 determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME !� ��, DATE EVALUATED � �
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY Z4QLOCATION OF SITE
Water Supply: On-Site Well f/ Community Public
Evaluation By: Auger Boring I Pit Cut -"
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH 7i,i
Texture group- &
Consistence
Structure
MineralogX
HORIZON II DEPTH511111y
Texture group
Consistence _ lei
Structure k
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: _ EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: '- _ OTHER(S) PRESENT: Gti.
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.-y friable FR-Friable FI-Firm VFI-Very fine 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
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Davie County Aealfl Department
and .dome Nealt§r 9.f" ency
I
210 HOSPITAL STREET/P.O. BOX 665 {
MOCKSVILLE,N.C. 27028 11
PHONE:(704)634-5985
March 29, 1996
Mebane Enterprises, Inc.
2727- Old Town Club Rd. ` z 11
Winston-Salem, KC 27106
l
Re: 5 Site Evaluations
Tax Office PIN: #5726-08-6718
Ratledge Road/Sites 1-5
Dear Client:
As requested, a representative from this office visited the aforementioned
sites. on, March 26, ,1996. Based upon the information provided on the
application(s) for site evaluation(s) and after the evaluations were
completed, site 1 was found to be provisionally suitable for the installation
of a modified, oversized on-site sewage disposal system. Sites 2, 3, 4 and 5
were found to be provisionally suitable for the installation of an on-site
sewage disposal system on each lot.
Before any permit(s) can be issued the appropriate application(s) must be
filled out and the house location(s) staked off. .
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure(s)
cc:. Jesse Boyce, Zoning Officer