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112 Winchester Road Lot 14IMPROVEMENT 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 AUTNRIZATION 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 PROPERTY ADDRESS 1. /74 Che--: I' A— —A9 'DATE LOCATION SUBDIVISION NAME ,�!��l�.-S n:,., LOT NUMBER ,f'�/ SEC./BLOCK NUMBER a RESIDENTAL SPECIFICATION: BUILDING TYPE �� # BEDROOMS,.7 BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye6 COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE /r'/C' TYPE WATER SUPPLY ('C DESIGN WASTEWATER FLOW (GPD). s'�/ <� NEW SITE a -<PAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE DP GAL. PUMP TANK GAL. TRENCH WIDTH ',a� ROCK DEPTH /�� LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INENDED USE CHANGE. YOUR WASTERWAER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FO FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. �EL ONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM 10. AUTHORIZATION NO. L'9j 7j OPERATION PERMIT BY Aa4� DATE I <Q **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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 0 -Davie County Health Department ENVIRONMENTAL HEALTH SEfTION P.O. Box 665 Mocksville, N.C. 27028 xZ1 AUTHORIZATION FOR WASTEWATER. -SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of Chapter I30A, 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 NMER NAME DATE '� /� ' l' 0, v 0 2 �) WE ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION >'P�r vl�.',� .4ai,� ��} ,✓✓ �jG�� 7�C �1S {� ,�✓l COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM 1W� rC,C� X/JOPISO o�o`�.SrG��;•r� �a �e � . APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM �� QAC Y Davie County Health Department %' `I'��' /tJ,��)- P. Environmental Health Section -AP Moc svilille, NC 27028 1. Application/Permit Requested By /-►aJl�2$c;,�/ l ��%�� .L ,U G �/ Mailing Address ��� L� 'Va-- f/A✓E'-t) GN Home Phone /Z0 fCe S t/, t_t-Ar /(% 2 70 :2- Business Phone Y;= I 2. Name on Permit if Different than Above r' 3. Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit t .t 4. System to Serve: 21House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry �❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section _� Lot # Z!$� ` ❑ Basement/Plumbing . No. of People ❑ Basement/No Plumbing k No. of Bedrooms ❑ Washing Machine I No. of Bathrooms L2 ❑ 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 _ No. of Showers Water Usage Figures . 7. Type of water supply: ZrPublic ❑ Private 8. Property Dimensions Sewage Disposal Contractor 9.. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes ❑ No ❑ Community t '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. FRUPERlY t Directions to Property: This is to certify that the information provided is correct incurred from this application. DATE Tax Office PIN fir` n Road Nance W V r- *Z5 ST Box # (if available) City best of 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. I 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 to conduct all testing procedures as necessary. to deLeraid site's suitability for a ground absorption sewage treatment and disposal system. s DATE SIGNATURE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT L/ Environmental Health Section LDYIT Soil/Site Evaluation NAME �� �e�1S4�✓ ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well Community Public t -"- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH JVP vf- A/6 ~- Texture group Consistence Structure .0 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 RATE SITE CLASSIFICATION: L—_ -) EVALUATED BY: Xyll l/ LONG-TERM ACCEPTANCE RATE: r/61 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- 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 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