153 Winchester Road Lot 5✓Xb
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 (�//,t� l�/i� /��s'O /I PROPERTY ADDRESS %� 7l C F1 �r 7� �"" %✓i�" . o� r�a �' DATE
LOCATION
SUBDIVISION NAME �L'/.ire y'i'ps- /.!�; ,i D� LOT NUMBER S� SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE / til S r # BEDROOMS (-7 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes Io
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE �k/%4 TYPE WATER SUPPLY C oDESIGN WASTEWATER FLOW (GPD) _ iJ NEW SITE I/ -REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /W0 GAL. PUMP TANK GAL. TRENCH WIDTH .tel ROCK DEPTH /-2- LINEAR FT. dd
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
6:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) E34 -87E8.
OPERATION PERMIT SYSTEM INSTALLED BY
AUTHORIZATION NO. O
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OPERATION PERMIT BY \ - 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 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL. SYSTEMS", BUT SHALL IN NO WAY BE TAKEN,43`A
GUARANTEE THAT THE SYSTEM WILL FLNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
Davie County Health Department C 3�
ENVIRONMENTAL HEALTH SECTION
N_ 4, t . P.O. Box 665
w Mocksville, N.C. 27028 '
t
AUTHORIZATION FDR WASTEWATER`' SYSTEM CONSTRUCTION
(Issued in coapliance�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 presented to the Davie County Building Inspections
Office ;hninapplying for Building Permits.***
AUTHORIZATION NICER
J� /i� /�i��SC� o✓ DATE J' ,, t
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION %U s7 ��'ri �: ' -_ /__ S — I/l // 7!C`1 �S`- /yY'•
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**+NOTICE*#* THIS AUTHORIZATION FOR.WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIROMENTAL HEALiVcmcrmLIST DATE
DCHD 10/95
rCLl �n�BlSOr�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
PERM
QUCY Davie County Health Department
TTi` k' Environmental Health Section
u k e'
JAN L 9 1996
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�7-S�
, ,,1,6� P. O. Box 665
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W Mocksville, NC 27028
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1: Application/Permit Requested By
Mailing Address —2 v? s U V C f/A�/�,rJ N
Home Phone
_JD f C S ✓� c: t /(1 C d2 7U
Business Phone
2. Name on Permit if Different than Above
j
3: Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: 2 -*H ouse ❑ Mobile Home
❑ Place of Public Assembly !p`
❑ Business ❑ Industry ❑ Other
❑ Unknown
5. If house, mobile home: Subdivision 2 pa vzcc UC7�'� 7
Section Lot # J
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing :
No. of Bedrooms 3"
❑ Washing Machine
1
/2
No. of Bathrooms C�
❑ Dishwasher
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply:
8. Property Dimensions
Public
No. of Sinks
No. of Urinals
No. of Water Coolers _
Water Usage Figures _
❑ Private
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Garbage Disposal
❑ Yes ❑ No
❑ Community
'NOTE: Improvements Permits shall be valid from date issued. Improvementst Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
PROPERTY 1REQUIRED:
Directions to Property:
This is to certify that the information provided is correct
incurred from this application.
q6
DATE
Tax Office PIN #
Road Name tulUc1+Z5S7' C �p
Box # (if available)
City
best of my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALWATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
C(3
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 detLeraid site's suitability for a ground absorption sewage treatment
and disposal system.
DATE ISIGNATURE
DCHD (1 193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ,'�� e'er !
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
Evaluation By: Auger Boring
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Community Public
Pit z---- Cut
FACTORS 1 2 3 4
Landscape position
Sloe Z L
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH f �!
Texture group
Consistence
Structure J'hl,-
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: /DS
--s
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY:�/
OTHER(S) PRESENT:
LEGEND
�s
C_
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 clay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Ve-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
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