270 Dublin Road Lot 15DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMAT[ON
Subdivisi Name', rote—, 1A
on
Section: Z Lot:�../s'
IMPROVEN11ENT
PERMIT
Tax Office PIN:#
RoadNarn6- )Ubli ziv:A,7o66
**NOTE** This Irnprovement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater systent; An,
-HON must be obtamed from this Department prior to the
AfJTH6RIZATION FOR WASTEWATER SYSTEM CONSTRUC
c trucdonfmstafladon of a system or the issuance of a building nit.
ons Perim,
(In compliance with Article 11 of G.S.. Chapter 130A, Wastewater Systems, Section . 1900 SewageTicatment and Disposal Systems)
***NOTTCEt** TEIIS PERMIT IS SUBJECTTO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE YOUR WASTEWATER
'SYSTEM CONTRACrO'R MUST SEE TMS PERMIT BEFORE
ENVIRONMENTALHEALTH SPECIALIST DATE ISSUED
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE At #BEbROOMS(-7 # BATHS #OCCUPANTS -j=MGAPBAGE DISPOSAL Yes orNo
COMMERCULLSPECIFICATION: FACILITY TYPE #PEOPLE .#PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE WATER SUPPLY /-1 DESIGN wAsTEwATER FLow (GPD) L7Xz') NFw srm—k---- REPAIR SITE
SYSTEM SPECIFICATIONS:. TANK SIZE
-ALZ—WGAL. PUMP TANK —GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE moDiFicAnoNs/coNDmoNs:
IMPROVEMENT PERMIT LAYOUT
**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.
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE
Davie County Health Department
Environmental Health Section APR - 3 1997
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760 7 1
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Bit led Vc 6�1 ContactPerson
Mailing Address 2— 5' S' 15— - Home Phone 8 — X Fir
city/state/zip A J- — Business Phone -7 1 1
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [L+4Me- Evaluation Improvement Permit & ATC ]Both
4. System to Serve: [IT90use Mobile Home Business Industry I Other
5. If,,Aesidence: # Peopl,_q # Bedrooms 3 # Bathrooms --'3— L�Vishwasher [ArGarbage Disposal
(L.] -Washing Machine [qSasernint/Plumbing Basement/No Plumbing
6. If Business/Other: Specify type # People_ #Sinks # Commodes
# Showers— # Urinals_ # Water Coolers_
If Foodservice: # Seats_ Estimated Water Usage (gallons per day)
7. Type of water supply: �-�bunty/City [ I Well [ I Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes [-Ko
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** 00ffm THE PROPERTY MUST BE
SUBMITTED WITH T APPLICATION.
S- :WRITE DIRECTIONS (from. ocksville)JOPROPERTY.
Property Dimensions: 2� oc
Tax Office PIN: # 9'7&9 - -7S L.'9 (-'3 Sr. ( lu.�41' 1
Property Address: RoadName 2-7� 'Z� - Z
city/zip A -4, C- 2�7
If in Subdivision provide information, as follows: _,,—v
Name:
Lot #: I S:,
Section:—
This is to certify that the information provided is corTect to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application i I s falsified or
changed. 1, also, understand that I am responsible for all charges incurred from this application. 1, hereby, give consent to th
e Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by 7K� , , � C� s, % —to cc nduct all testing procedures as necesW to determine the site suitabil ity.
DATE!nL-4 � 7 -7 SIGNATU
Revised DC14D (06-96)
THIS APEA MAY BE USED FOR DI?AWINC7 YOUZ? SITE PLAN:
iwt A�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
NAME
ADDRESS P--OC4 "�Ulp-o
PROPOSED FACIILTY
Water Supply: On -Site Well Commuri ity Public
Evaluation By: AugerBoring_ Pit C1___ Cut
FACTORS
1 2 3 4 5 6 7
Landscape po-sition
11�f — 1-11
Slope Z
�;o
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
I I
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Cons is tence___
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
.SITE CLASSIFICATION: — /"( — EVALUATED BY:
LDNC-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R -Ridge S7Shoulder L -Linear slope FS-Footslope N -Nose slope
CC-Coricave 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- Very 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