P0192 Turkeyfoot 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)
WE V(zIjkl 4W PROPERTY ADDRESS �lf e,('��760' 0 t lfd- DATE
LOCATION -
o�T.sr. •h..�nros a �' � - 17 sa.R"'o� c ►. �''d`' - �. o ^o•- T
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE �•�a mQ# BEDROOMS -'I- : Yes
- # BATHS # OCCUPANTS '� GARBAGE DISPOSALNo
F ,.
COMMERCIAL SPECIFICATION. FACILITY TYPE "r' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE i�5c,u•�� TYPE'WATER SUPPLY V' DESIGN WASTEWATER FLOW (GPD) ��b NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SINE a°a YGAL.':—PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH �'` LINEAR FT.
N
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. r
,t
IMPROVEMENT PERMIT BY .
**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 INSTALLED BY
t
Eu ,
SEL v r
AUTHORIZATION NO. OPERATION PERMIT BY DATE
**THE ISSUANCE OF THIS ORATION 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
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665 a S 160.00
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIOMI
(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 `� `kms \'�\`A N \�Z AN\\X 0 DATE 92*
�. _
MFYE ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATIONy
i
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5). YEARS. -
ENVIRONMENTAL HEALTH SPECIALIST'—'Y DATE-
DCHD 10/95
s
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PEV
;
�
Davie County Health Department v .
Environmental Health Section
P. O. Box 665 FEB 2 9 1996-
Mocksville, NC 27028
1. Application/Permit Requested By e 4 /7��� �2h•� G./ti
Mailing Address A-9 S7bA)Cy8&0De d Ude, Home Phone 916 `,9i z '08L3
IV/,u s�o.V S.a RA. /{�a .2 9 io 3 Business Phone 9/0 - 3'100
.2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation eptic Tank Installation Permit
4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
i 5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms '2 Cashing Machine
No. of Bathrooms .2 L�Kbishwasher
Dwelling Dimensions x 70 Er-Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
i
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usa a Figures
7. Type of water supply: ❑ Public_ Private ❑ Community
8. Property Dimensions s p e Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EJI o
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.
PROPERTY INFORMATION REQUIRED:
Directions to Property: � y IN
UJ Tax Office PIN: # Y002049(1
16 o'27.��i %� P.ag��' �•`f/��, PROPERTY ADDRESS, as follows:
` Road Name: T—,A-/!
TD
/-4,R4•J.�ll /'ov J� Cit,: �6.cK� y!/xa
OA) q p Tui-kiry p l SU13MIT A PLAT WITH THIS APPLICATION.
Te 14 SMAII W/�ifx��icKS� J oNQ Revisions effective October 1 , 1995.
y'o4c--, ,�fje ova wAy p LL oN L of�.
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 fro this application.
d2 a969e-
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.
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 Davi Co my Health Department to enter upon above described
property located in Davie County and owned by 22 ��
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(1/93)
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DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation ` �(
NAME v U DATE EVALUATED
ADDRESS PROPERTY SIZE ✓� G.r.3�s'�
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well 1/ _ Community Public
Evaluation ByC-4Q,-\,_ Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position 77 <1 S
Slope R -o - b b
HORIZON I DEPTH '' ('
Texture groupL CL
Consistence -
Structure
MineralogX N1'1
HORIZON II DEPTH
Texture groupC c
Consistence L
Structure B
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS -5 -S
RESTRICTIVE HORIZON --
SAPROLITE
CLASSIFICATION .S S
LONG-TERM ACCEPTANCE RATE 1
SITE CLASSIFICATION: � • EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: a OTHER(S) PRESENT: oNQ
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-Very 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
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