Loading...
228 Trestle Ln Lot 5 ., . '.".:. +S+?S t .i. r,Y r•✓.. ,4' .x A'+.',,.,: n :it n.. .a' :,`: J 5. - a.. __ Davie County Health Department 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 NUMBER NAME /�/'lc �,r; //ialfl.� DATE .� /r NQ u l 14 NAME ON IMPROVEMENT PERMIT (If differenntt�than above) SITE LOCATIONox? JLT COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM *"NOTICE*" THIS AUTHORIZATION - R WA TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRMWAL HEALTH SPECIALIST DATE' - DCIID 10/95 y DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **MOTE** 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 ,WWX,41 PROPERTY ADDRESS DATE LOCATION SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS _? # BATHS # OCCUPANTS 't?! GARBAGE DISPOSAL: Ye�5 COMMERCIAL SPECIFICATION FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE r C TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) _� NEW SITE !.'REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE�,� GAL. W TANK GAL. TRENCH WIDTH J/, , ROCK DEPTH /1 LINEAR FT. 5 DIJ OTHER REQUIRED SITE MODIFICATIONS/CMITIONS: ***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. ol IMPROVEMENT PERMIT BY l **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 INST Y 5° r-- 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 F(KTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD' 1O/95 ISO IE -;` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER V Davie County Health Department Environmental Health Section NOV 2 71995 P. O. Box 665 Mocksville, NC 27028 l 'LA(1 Application/Permit Requested By n J Home Phone Mailing Address / r/ s d LL t`: C, Business Phone -A, V 2 ,Name on Permit if Different than Above 3 :Application for: General Evaluation fdt'Septic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ElPlace of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑ Basement/Plumbing No. of People C3Basement/No Plumbing No. of Bedrooms 3 Washing Machine No. of Bathrooms I' 1 ❑ Dishwasher Dwelling Dimensions ❑ 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 t: 'No.of Showers Water Usage Figures TType of water supply: Public ❑ Private ❑ Community a 8::Property Dimensions �ti A Sewage Disposal Contractor ' 9: Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No • If yes,what type? I 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvement§ Permits are subject to s revocation, if site plans or the intended use change. Effective October 1, 1989. c PROPERTY INFORMATION REQUIRED: n i Tax Office PIN // Directions to Property: ' Road Namd/U,Sd � C J V/V C7!a/� I AN A 16-q fi Box # (if available) 01V 1-57 All �'� Al It 17 T , ( 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. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. j 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. ��� a� 'DATE SIG ATURE ' DCHD(1193) i . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ` DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY 00 LOCATION OF SITE �,L'I✓'"I ACS / Water Supply: On-Site Well _ Community Public �A), Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG 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 RATEe,3 SITE CLASSIFICATION: EVALUATED BY: 6/ LONG-TERM ACCEPTANCE RATE: 3 OTHER(S) PRESENT: REMARKS: LEGEND 1 r 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-Vc.-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 Mineralocy 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■■EN■■■..■■■■■..■■■...■.■■■ ■.■■■......■......■.■..■■...■..■■.■■MM.Mt■■■MEN M■■■M■M■■■■Eoo■■oo■ ■■■■.■...■..M.N.■.N..E■■.■..M■..■M■■M.■MMMtCSEN■■MM■�NM■■■■■■■SEM■ ■■■.■...■M■MM.■.■■■■...■...■...■ ■EM■.■■tee■■■.■.EEM■.■■.■■■■■■■■ ■.SMeM■S■■S■EMSe...MSS.N..M ■EMSM■/■eMEMSMM■Se■ ■■NS MMEMMEMMEMMEM SSSS EeSES■■■ ■■■■■■■ES■■SSS■SSMM.■■MNEE.MSSSS.NMMNMEeeE,M'e■e=�■� CS■SC EeSES■N■■ ■.■■■■■M■■.Se/ES■SSEMM.SMNEMM.e.eeteM■N■ eNN ■ ■S■■MNH No ■■■■..■s.■e■■N■■E■■eES.■SMNEeeEE.MMEe■eSMENON■S■ NN M ■■■■N■E■E■■MNM■■ ■.■■■..E...N■■■S..MMN■MMM...■..■�e.ee.eet/■e■.es/eeeeett■H■/.e■■ ■......■■■■■NMN■t■■NEe.MMM■■e...e..■Ce.Ht■Cee.■e■ ■■NEM MEMOMMENEXIMEMEMINC ■M■MSSS■.SMMEME■MMMSMMNOES■MM■eee■ ■tN■S■ESSEHS■e ■ .SNE■ .■ eE ..............................■MN■MM■■E■SM■Noil MNECEC■MME■MMM =MM SEE ■■MM..■■MEM■■MMM..SSME/■.EMMS■OM ���aMS■..■ ■E HEMEeNSNS■■OMMMS■ MEN ■.■...■.NN■■MMMM■■.tM.■■..MMMMMM■MM■MteMMMMHEe� �.Ne/ tee... C ■.eeE■■■ME■eES■■■■E■M■■ME■■■EM■E.N■MeEM■EE■E ■E= eMCen/■■eee .....n...........................NMEMN■NCMONSOON NoCM■■■CC■■■emom mommoom N■■ ■■Me eM■MNONCC� ■NNCe ■MEN■Me mooNN ■■■■■■■ NONE MMM■M■M■MMEM■MMMMMMMMMM■MMMM_ M•euN■■MMM■■ MUMEMMME= ■MMME■■t■■■■■t.ee.■■■■..UN//_":iii�C � / C e ■E■■■■ ■/.Me■■ME■■eO■■■■�.■SM S/NM■.■EM ■ ■ � ■ ■e■ =.ecce NOME M■M■MMEM■MMEM .MEM ■.NNE■■■ ■ ■ MM MMM. ■■■eee■■■■■E■■■■■■■■■M■■N■EMNON-■MM ■■ /NEECE n■■ �■ ■■■■OONC CCM■MM■M MMMM■e ■■■■■M McMEM/ , eee. ■H ■ eE■ ■■■M■■ ■EE mom CZ.M■E■■�■■ME.MCCCE■■■■�■■.■ i. ■ MN■.RMEMMEMMME■■■ ■EMOEN/EMENEeEE■■Ee■eNN1\M .M■EE■NNNNN ■ ■E ........■EEEESSS■MEMSEe■�tNS■■MM■MENNEN C SNCM■e ■■■■■S■■ ■.■..■MMMMMM■M■M■M■M■MM■MME■■■NMESH ON ■■o■E■e■ OMEN MNOON M■M■MMEMMM M■■■\`MM■M/�C"�n - ■ EM MN■M■ ■■ M■M■EME■■■■NEM■■E■CSSE■M�N►-N CNCNN MM NN■M■CN■ ■M■■NM ■M■M■E■■■■■NE■ M■■Q■■CM ■ eC =■■MEMCC ■E■■■■CC■.NEMMM■OM■MMCCCNNO■M ■ ■ EMM■M ■■■M■■■■e■■■M■MME■MMMM■NMEMSM■■■ NEON ■ NMM SOME■■■■■Me■■=■HEHu■ ■.■=ME■�► ■ ■■NS NC■CCN■M MEMO OMEN e■E N■H■EE■ ■■■ /M■r.�►.M ■E SHSSe ■ ■EME■N■S■C■■E■■M■NH■ EHMN■�/r. ■/ NN■ MEMMEN C ■■■■■■■■eMMEEE■■■HNNEM mom SOME N NO nMM■M■ ■E■MMM.■t■■■M■MEMEMEME ■ .eEOEN■ NC e■■M■e ■EMMMEMMEMEMENNMEMM■MMEMEENM■■■■N ■ iM �NSMME ■E■MMENEteMMEMMUMMOMEMENEMM■M■■o■■■■■■■■eM N■ ■ SOMEONE ■M■MM■MM■ME.E CCCMUMENEM EMENC CC=E NNMN_eniii10010 ■M■CM■■ OMEN MENEMCMEM■MENH C Mi .MCC" C'M ■■■ SM. ■■ .Mete■ MMMMMEMNN .. ....... . ■C MeeNMMEENe■ee.e0eMMOEN ME N MENEM MEMMEM 0 ■N ■ MMEMMEMMEMMEMMEMINMEMO ■■■t■ME.tMEEM■.NEeMeEMeM■NN■e■M"MME 0ME■M■NMNONE ■MEMNEMEM■o■o■■oN■■■.MMM■MMMM■ ■==CM ■ ■ MMeM.EE■NMEN■ ■■■M■■EMMOMEM■MMM■MM■■■MMMMEES.MCeM Me.e■.eMMM :%CMM MEMMNNMCCCCCCCCCCCCCNCCCCNCCCCC ■ :CCCMC:CCCC MMMeSNNCN EN■■■. ■ E■E■■■. ■MEM.■ ■MEM■t■nM■ ■■M ■ eMNSNS ■oM■oM ■o■■■ ■■■ EME■M■CMME.■HEM ■ . . .CE .HMMCEMEMo■EMEM MOMMA■ MOONCSM■CM MEM■MMOMMOMMEN No ■■■ .■ ■.■MMEMM■MMOM■ee ■■MEM ■ EMMEMM■CMMEMEMEMMEM . ■CME M■■.E■ ...■..■...■E■eMON E.MMMMtHNEEMEMM■MMEMMNNM■.EMMMMUNION■C■■MMEM■eHMMN■NEMM■MEMM■M■■ ...........NE■■■NE■■MEENMEEH■■■■MNo�■MMEMO■MEMM■MNENEMMMMMEMt ......■...EEE..n■.■.oEo..E.■■■.E■Eo.■ .tots■■moo■■ooets■EENEME■ .................................................................. ■o■.■oN■■■■MMM■■MEMMEMMMMEMEMMEMEMEEMMM■■■MMMMMMMMe _MMMeseEENENe■ ■MMMC■ENNINE■M■S■o■■MM■MME■MEMMEMESOMMEN■NEEMEM■■CMMEM■MMEMMEMEM■MMEMEMMEMMEMEMMUMMUMMIN.MM■..ME.EMNM MEMEMEMMMEME■■MEMEMEM■ ■Eo■■■■M■eE=.MEMM■MMNEMEMMMEMeNMENeNCN CIMMONSMmommoommommommu■C MEMEMMEMEMCCC�C�eCCC�w.CCC�.CCEMMEM CCCCC