P0417 Westview Ave ` 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 6.5. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME Aa—,lorvim_ ,
, l�/�'J,� PROPERTY ADDRESS _WNL_rV, c..J �� 91014 DATE �9
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOC( NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE f # BEDROOMS --9 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DE5I6N WASTEWATER FLOW (GPD) Sid NEW SITE L�REPAIR 5ITE
SYSTEM SPECIFICATIONS: TANK SIZE 112,90 GAL. PUMP TANK GAL. TRENCH WIDTH -?/,- ROCK DEPTH LINEAR FT. _tea
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
,r 1
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 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
F
OPERATION PERMIT SYSTEM INSTALLED BY
AUTHORIZATION NO. 1.1I ! OPERATION PERMIT BY DATE 6
**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 IRA, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL. SYSTEMS', BUT SHALL IN NOWAY BE TAKEN AS A r
GUARANTEE THAT THE SYSTEM WILL FUNNCTIOd SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
Davie County Health-Department
ENVIRONMENTAL HEALTH SECTION
P.0. 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 AuthorizatiWF'ar"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 foriBuilding Permits.***
P� �'— l-- AUTHORIZRTION NUP'BER
i°
NAPE DATE a 1
NAME ON IMPROVE]ENT PERMIT (If different than above)
SITE LOCATION �ISC
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*It THIS AUTHORIZATION FD ATER YSTEM CONSTRUCTION IS V FDR A PERIOD OF FIVE (5) YEARS.
ENVIkNMENTAL RIU9 SPECIALIST DATE'
DCHD 10/95,
} APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section
P. O. Box 665 ( 9 1996
Mocksville, NC 27028
1. Application/Permit Requ ted By
Mailing Address /` Home Phone
n
. /LJ Business Phone 02w-al f
2. Name on Permit if Different than Above N
3. Application for: ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms C ❑ Washing Machine
No. of Bathrooms / ❑ Dishwasher /
Dwelling Dimensions mon ❑ Garbage Disposal
6. If business, industry, place of public assem ly, er: 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: Pu�bllic ❑ Private ❑ Community
8. Property Dimensions f 0 6/1&00n Sewage Disposal Contractor �
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? El Yes 040
If yes, what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years 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:
Tax Office PIN i/_,�'7.3
Road name
Box (if available)
City
r.
This is to certify that the information provided is correct tfth;est ofmy knowleZaljndd I am responsible for all charges
incurred from t is a plication.
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 or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie C nt ealth Depa nt to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine sai e's suitability for round tion sewage treatment
and disposal system.
946
DATE
DCHD(1/93)
21.01 _
182.8 ' Ai 6 .. —' .• � (I) r
9768 82.5
99.74 r _ (04 51
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a loo loo
rn 47 300
acs I 46 46.01 4 ;
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83 °A" U 48 (7) (14) 415.0,9 186.71 M
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t
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME / � DATE EVALUATED
` PROPERTY SIZE f�C
ADDRESS
PROPOSED FACIILTY � ���y LOCATION OF SITE //. r'✓,�
Water.Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position .L
Sloe Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH t p t
Texture group
Consistence
Structure
Mineralogy ( c'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
t HORIZON IV DEPTH
Texture group
Consistence
1 Structure
Mineralogy
SOIL WETNESS
I RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
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 ;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 firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Nonplastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
,iC--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
DCHD(01-901
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