158 Winchester Road Lot 7DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improvemett,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)
/ 7161,
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NAME s il'/�� ,.%�1lSa PROPERTY ADDRESS 1161/��e11�sY,�i'= r��iDATE r
LOCATION
SUBDIVISION NAME f!(/r�Y�'�-t' 110: �` LOT NUMBER „� SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ,-7 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye'
COMMERCIAL SPECIFICATION: FACILITY TYPE _ # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY l:l DESIGN WASTEWATER FLOW (GPD) GDG NEW SITE '---JREPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE.l6 � GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH -�' � LINEAR FT.
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.
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) 634-8760.
76
OPERATION PERMIT SYSTEM INST LED BY
/GD
AUTHORIZATION NO. / OPERATION PERMIT BY DATEL f J
**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
�XD
Davie County Health Departeent
r" ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in cospliance with Article 11 of
G.S. Chapter 130A, Wastewater Systeas)
***This Authorization For Wastewater Systee Construction Bust be issued by the Davie County Environeental Health Section prior to
issuance of any Building Persits. This Fors/Authorization Nusber should be presented to the Davie County Building Inspections
Office when"'applying for Building Persits.***
AUTHORIZATION NUMBER
/�
NAME'S / i Gni' ��l/I /S'O it DATE �/— - i v ° 0 2 ? �7
NAME ON IMPROVEMENT PERMIT (If different/than above)
SITE LOCATION iT''G��a �D i�� ` D 1�i �7 (7� E_
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
j pQ.kril•'lle., A`�'j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM LS L5 U U
Davie County Health Department
Ik'',
D
i
��4� Environmental Health Section
P. O. Box 665
JAN 2 9 1996
��
6 � Mocksville, NC 27028
,f1'
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r
Application/Permit Requested By 31Ce
I PIN1.
Jo G
Mailing Address ��s WrZJt, f fA✓EA) L N
Home Phone
O f,Ce S U'e t.t-0 /(J C �2 70 Z ti
Business Phone q 9 5' - 7a 7 9
2. Name on Permit if Different than Above
3. Application for: C3General Evaluation C3Septic Tank Installation Permit
4. System to Serve: 2"House ❑ Mobile Home
❑ Place of Public Assembly `
❑ Business ❑ Industry ❑ Other
❑ Unknown'
_
5. If house, mobile home: Subdivision 2���� �P7:.� 7
Section _�� Lot #
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing
No. of Bedrooms „�
❑ Washing Machine
No. of Bathrooms
❑ Dishwasher ;
s�
Dwelling Dimensions
j:.
❑ Garbage Disposal }
i
6. If business, industry, place of public assembly, other: Specify type
?,
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
I.
No'. -of Lavatories No. of Water Coolers
_
No. of Showers Water Usage Figures L
7. Type of water supply: .Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
z
9.. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
'NOTE: Improvements Permits shall be valid from date issued. Improvementsi Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
FRUPERTY 1REQUIRED:
Directions to Property:
c-cB A A40
This is to certify that the information provided is correct
incurred from this application. /
DATE
Tax Office PIN #
Road Name IV/ uC 1+15 S �C1J
Box # (if available)
City
of
my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT
CONSENT FOR SITE EVAL ATION 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:
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 SIGNATURE
DCHD (7193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
1
NAME /%h,
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE/moi �C
LOCATION OF SITE
Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4
Landscape position
L
Slope z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
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
,�-
SITE CLASSIFICATION: EVALUATED BY:
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
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-Fimn 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