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111 Winchester Road Lot 1IMPROVEMENT PERMIT DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) -_-._.•.e NAME PROPERTY ADDRESS 6UYi Cl:i7,700 L DATE LOCATION [ �r.� /r ./� d l b V� fly eshe SUBDIVISION NAME� 7�r>.�.s` _� y� LOT NUMBER ,f SEC. /BLOCK NUMBER RESIDENTAL.SPECIFICATION: BUILDING TYPE Jt # BEDROOMS .2 # BATHS JYP # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEZZL GAL. M TANK GAL. TRENCH WIDTH 7< "' ROCK DEPTH A9 " -LINEAR FT. _?60 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. 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) 634176O. 1. OPERATION PERMIT SYSTEM INSTALLED BY 6Q. AUTHORIZATION NO. Q) 'A 3P a 13 r - OPERATION PERMIT BY R� 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 13OA, 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 t -'X6 ow ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By ��/C/C Ham/©Ei2.Sd Mailing Address a S �i.Ul y/�✓ L/1f • Home Phone �49a- 7 7 % �b CSSy iLt� J . C -? -7e') Q k Business Phone `� � - 72 -7 ej 2. Name on Permit if Different than Above 3. Application for: )(General Evaluation Septic Tank Installation Permit 4. System to Serve: HouseS ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision f �a7 � ��� Section Z Lot # ❑ Basement/Plumbing No. of People LP �(� UB 40. /t%E,650 1-2 ❑ Basement/No Plumbing No. of Bedrooms a ❑ Washing Machine C(,%/LLQ-/� No. of Bathrooms .0 Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6.1 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, No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions` CIC — Sewage Disposal Contractoi let 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes ❑ No ❑ Community '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: -5 aJZ/220U 00-.0 8Y�- This is to certify that the information provided is correct to the Incurred from this application. 7 DATE my knowledge, and I understand I am responsible for all charges 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 Davie County Health Department to'enter upon above described property located in Davie County and owned by !.0 - D -W-�rrAl t/ SOIP lcCF to conduct all testing procedures as necessary to determine said site's suitability Abr a ground absorption sewage treatment and disposal system. 4�L DATE SIGNATURE DCHD (193) • :' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section - / Soil/Site Evaluation /� NAME 1J�O�S'4l" DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY Water Supply: On -Site Well Evaluation By: Auger Boring LOCATION OF SITE Community Public Pit Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH S/d4- /Of Texture group 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 RATEI q SITE CLASSIFICATION: � EVALUATED BY: /�!'C� /Z LONG-TERM ACCEPTANCE RATE: r OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS-Footslope 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- V}_ -.-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¢y 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 ■ME■ ■ME■ ■on■ ■ Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.D. Box 665 Mocksville, N.C. 27028 vjCo �D AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION J (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 pr nted to.the avie ounty Building Inspections s Office when applying for Building Permits.*** �f�(/�►�5�/L AUTHORIZATION NUVBER NAMECi l' ��/S'�/! DATE 0 n NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM