110 Shady Grove Lane Lot 1�. _ _ ,✓moo
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NGE++:.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 Articlee/&1C-' il of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME [/ 7", 1-044 r7 adv PROPERTY ADDRESS �I �Gl e— r- I ��7- • q� DATE
LOCATION / rr Al
+,. SUBDIVISION NAME ✓e LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE Aare # BEDROOMS # BATHS # OCCUPANTS _ GARBAGE DISPOSAL: Yes/6
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE.._;'# PEOPLE/SHIFT _ # SEATS _ INDUSTRIAL WASTE: Yes/No'
LOT SIZE j/TIL TYPE WATER SUPPLY _ 46 _ DESK) WASTEWATER FLOW iGPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TAW _ GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.yj 1 �
OTHER
REOIIRED SITE MODIFICATIONS/CDNDITIGNS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SIE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWAER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
**CONTACT A REPRESENTATIVE OF THE DAVIE CMINTY 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.
OPERATION PERMIT SYSTEM INSTALLED BY 42W
F
AUTHORIZATION NO. OPERATION PERMIT BY DATE .
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL ,INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
i ARTICLE it OF G.S. CHAPTER 130A, SECTION .1900 'SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
I GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665 -
Mocksville, N.C. 27028
WMIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater'Systems)
***This Authorization For Wastewater Systei'ConstiucU6 oust be issded bythe Davie County Environmental Health Sectio
iAsuan6'af any Building Permits. This Form/Authorization Number should be presented to the Davie County Building I
Iffice when applying for Building Permits.*-*(
NAME- ),I X DATE' y�9 9L
4
NWE ON. -IMPROVEMENT I PEAfT—(If different t . han above)
SITE -7 14
LOCATION ; 1 11�ze L,� e -
ON MIX]RIZATION TO CONSTRUCT WASTEWATER SYSTEM
prior to
RiMIZATI& R
142
ENVIRONMENTAL HEALTH SPECIALIST,Uwit
DUID 10/95
L i. I
h
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address
0
Home Phone Ciqi� - y 3q 9
AA Vct_nne ky o27coG Business Phone
2. Name on Permit if Different than Above
3. Application for: . ❑ General Evaluation
4. System to Serve: House
Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ShQ (-)rmje Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 2Washing Machine
No. of Bathrooms Z Dishwasher
Dwelling Dimensions 57 X 3� houSC�SZ"'�Cxu❑ Garbage Disposal
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
7. Type of water supply: p-rublic ❑ Pr'v to
^ >< 19�.So x I67.C_J
8. Property Dimensions Q?o< b , D / X %�o. g� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Q1<0
If yes, what type?
A
❑ Community
-NOTE: Improvements Permits shall be valid IalAl*=WnWxWNp� from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: Tax Office PIN: # 5799 — Lisoiol I
PROPERTY ADDRESS, as follows:
Road Name: C8,11 m4ccs Rot
City: Advo-oc ,
SG$MIT A PLAT WITH THIS APPLICATION.
Revisions effective October I, 1995.
This is to certify that the information provided is correct to the best of my
incurred from this application. _ Q
DATE
I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
1 hereby give consent to the authorized representVivf the Davie County Health Departmen toe ter upon above de$cribe,4
property located in Davie County and owned by Vth/tl 'S LO�fsinlXJM . Ina ? �YnnCX cx"SriuCti
to conduct all testing procedures as necessary to termine said site's suitability for a grou absorption sewage treatment
and disposal system. /�
a3 q to �� cr�f oma+._ q �k� �t
DATE SIGNATUR
DCHD (1183)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Communri-ty� Public
Evaluation By: Auger Boring Pit l_/ Cut
FACTORS
1 2 3 4
Landscape position
Slope b
b Jew
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
G/
Texture grou
C_
Consistence
Structure
_54 P
Mineralogyc
�<
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: t 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
Moist
VFR- Vc.-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
Saprolile - 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