3218 NC Hwy 801 S Lot 14 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)
NATE )AU PROPERTY ADDRESS �O I�• j ' "' � • A 706 DATE
LOCATION �9 E
SUBDIVISION NAME 2R,�1{ l�Z(AN^• 1��.�YS LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE N a # BEDROOMS „ # BATHS # OCCUPANTS 3 GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: FKIa ITY TYPE - # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTEt,Yes/No
LOT SIZE • 1 `� TYPE WATER&PLY ,r , c., DESIGN VASTEWATER FLOW (GPD) 30 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE'
GAL. PUMP TRF6i 6�. TRENCH WIDTH 3 ROCK DEPTH _ LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:'
***THIS PERMIT IS"SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHAFE. YOUR USTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. `
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IMPROVEMENT;,PERMIT BY � nn
**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.
i rF.
OPERATION PERMIT SYSTEM INSTALLED BY
/0101
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AUTHORIZATION NO. '1 OPERATION PERMIT BY DATE _ `1 Y
**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 I
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 /
Mocksville, N.C. 27028 /00 0
' - AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
E
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to
hissuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County,.8 ilding Inspections
Office when applying for Building Permits.*** '
' NWE Av 1 d 2CZ�,o 0 �R DATE 9 AUTHORIZATION NUY,9ER
(`�° U 4 L 5
NAME ON IMPROVEMENT PERMIT (If different than above) `
SITE LOCATION 0 I �: l2 O c-1\
COMIENTS/CONDITIOrIS ON AUffHORIZATION TRUCT WASTEWATER SYSTEM
fmfNDTICE THIS AUTHORIZATION OR WASTEWATER 5Y5TEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
DCHD 10/95
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PEI 19.
Davie County Health Department
Environmental Health Section
P.O. Box 848 AW 191 +
Mocksville,NC 27028
(704) 634-8760 ENVIRONMENTAL HEALTH
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Contact Person ��*J?/a
Mailing Address Home Phone
City/State/Zip � Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ] Site Evaluation [ ]Improvement Permit&ATC f Both
4. System to Serve: ,pQ House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other r1
5. If Residence: (#People #Bedrooms #Bathrooms4-1— [Dishwasher[ ]Garbage Disposal
r
Washing Machine QJ1 Basement/Plumbing [ ]Basement/No Plumbing
6. usiness/Other:Specify
--type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply County/City [ ]Well [ ]Community
8. Do you anticipate ad itions or expansions of the facility this system is intended to serve? [ ]Yesf No
If yes,what type? C
PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �`/�—L'l J G K R S WRITE DIRECTIONS(fro ocksville)TO PROPERTY:
Tax Office PIN: # Z
YEE
Property Address: Road Name '
City/Zip G X00
If in Subdivision provide information,as follows:
Name: C� C
Section: Lot#: ;
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. 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
.r
by Z17h conduct allting ro edures necess to de
DATE the site suitability.
SIGNATURE ,
Revised DCHD(06-96)
w: ere y r ;t icey e su ivui n
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the u divs�o� ,R�q�ilnh fQrovte Courrty, this p
the:Qgordfof Cd.unt Commissroriers for-'recordtn �p`ihe Rag�ster of Oeeds of Dove Coutc
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
\ \ Soil/Site Evaluation
NAME Qv Q \may •�o�. DATE EVALUATED a� '
ADDRESS J �C�� PROPERTY SIZE
PROPOSED FACIILTY �� LOCATION OF SITE �'� 'a•r'
Water Supply: On-Site Well — Community Public
Evaluation Bye kA' Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe % d„ � -3bu
HORIZON I DEPTH
Texture group L Cl-
Consistence -
Structure C C_
Mineralogy VA
HORIZON II DEPTH 2" 21,
Texture group C C
Consistence _�-
Structure Ca Q \L
Mineralogy 1 . 1.
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S 5 S
RESTRICTIVE HORIZON —
SAPROLITE —• —
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: •� • _ EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: � OTHER(S) PRESENT: ` V) O N'P
REMARKS:
� - J 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-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
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
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