137 Winchester Road Lot 3` . , • - i � , � i ; '���' v ''f`Lkrp�'�.nN6+�•'Yr „y�r�yi^+.�v ;r ;,!'"n" f
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^' DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTkND OPERATION (PERMITS • PROPERTY INFORMATION
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Name �:: !� �� J����� >.:�'"�; a� it Subdivision Name:
Directions t ;property:
j,4
v 'f,� i Section: .+� Lot:
IMPROVEMENT C
PERMIT iI Tax. Office PIN:#
nIZokd Name: wo. Zip;
' **NOTE** This. Improvement Permit DOES NOT authorize die construction or installation of aseptic 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 pennit.
(In compliance with' Article 11 of G.S. Chapter 00A, Wastewater Systems, Section .1900. Sewage Treatment and Disposal Systems) .
***NOTICE*** THLS PERMIT IS SUBJECT' TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. -YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:•BUILDING TYPE ',.
�_ # BEDROOMS #BATHS �I #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT �! # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE -1 TYPE WATER SUPPLY o DESIGN WASTEWATER FLOW (GPD) NEW sm-ko _' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�
GAL: PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR_FT. DO �
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS: C
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ii
SYSTEM INSTALLED BY:
JL
, I� f�J44
y
AUTHORIZATION NO.
E�S3t� ..OPERATION PERMIT BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE`
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEM:
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
DATE:
BEEN INSTALLED IN COMPLIANCE
UT SHALL IN NO WAY BE TAKEN AS A
11 •
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' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
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1., Application/Permit Requested By ,Z?IC14
�ND�i2.�ni1/
Mailing Address a S U)/o� L—J�✓ L� Home Phone 5C%— 7 7
b Cis V "Lw- h/ , C 7 Q Business Phone `Z � - 7.. -7
2. Name on Permit if Different than Above
11 3; ,Application for: General Evaluation YsepticTankInstallation Permit
A.', System to Server Houses ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5.' If house, ' mobile home: Subdivision f o� 9' �(O `'�y` Section Lot #
❑ Basement/Plumbing
No: of People ❑ Basement/No Plumbing
c� (f }LLL.C}1
No. of Bedrooms -7OA) ❑Washing Machine
No. of Bathrooms ❑Dishwasher
Dwelling Dimensions
6. If business, industry, place of public assembly, other:
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
Specify type
No. of Sinks
No. of Urinals
No. of Water Coolers
_ Water Usage Figures
❑ Garbage Disposal
7. Type of water supply: Public �i ❑ Private ❑ Community
8. Property Dimensions 4027--S C — Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
t
'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:
/S79 , _ rb C--u,v c( -u6 /Co :MArE
,✓2161q 77, nP,6W e-aXJ',0
-" This is to certify that the information provided is correct to the
Incurred from this application.
7-9-2s
DATE
of my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR aTr= 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 G unty and owned by
p
to conduct all testing procedures as necessary to determine said site's suitability Xor a ground absorption sewage treatment
and disposal system.
77- 9,59 -
DATE • SIGNATURE
DCHD-(1123)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 4
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
Evaluation By: Auger Boring
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Community
Pit Z /
FACTORS 1 2 3 4
Landscape position A—
Slo e
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH t li F
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 RATE
Public (/
Cut
SITE CLASSIFICATION: RS EVALUATED BY: &81, !�
LONG-TERM ACCEPTANCE RATE: i 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