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287 Michaels Road Lot 330 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME C• c� [? e` Cel: V1 PROPERTY ADDRESS �� 1 1 t`. �'� G� N 1 - �C_ rI t'yI DATE v LOCATION SUBDIVISION NAME -=? 4� �� C ��-' LOT NUMBER :�� SEC. /BLOCK NUMBER I RESIDENTAL SPECIFICATION: BUILDING TYPE t�� ,��� ��� # BEDROOMS # BATHS -.t N OCCUPANTS GARBAGE DISPOSAL: Ye�lal COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE Iz`G ' Oy TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ` SYSTEM 5PECIFICATIDNS: TANK SIZE GAL. PUMPLINEAR FT. TANK GAL. TRENCH WIDTH �' ROCK DEPTH %� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: a *THIS PERMIT IS SUBJECT TO REVOCATION IF SITE SANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST f 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. OPERATION PERMIT AUTHORIZATION NO. SYSTEM INSTALLED BY .l 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 136A, 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 APPLICATION FOR SITE EVALUATION/IMPROVE 11ENTS PE Davie County Health Department Envircnment�.l Health Section P. 0. Box 665 N'.-cksviAc, NC 27028 APR { �. Application/Permit Requested By P f �1 Il'1Q/1 Mailing Address P. >< % g, ne IUC Home Phone 00 c -)24-29Y7 , ��d/ Flli4inn�c Phnn� ��p2��'1'�5S( 2. Nnmo on Poinih 11 DIlloront then Abovo a. Appllcnilon for: 0 Onnoml I-vnlunlion �'_l Soptic Tnnk Instnllatlon Pormft 4. System to Serve: ❑ House ® Mobile Home ❑ Pla f _,blic Assembly ❑ Business ❑ Industry ❑ Other ❑ Un`: "'et" f 5. If house, mobile home: Subdivision Section Lot # ❑ Ba: c ?fumbing No. of People P, _ Cl Ba:,ment]NoPlumbing No. of Bedruoms _ t1 W. ;king Machine No. of Bathrooms 'c�; C3 D! • •.vashcr Dwelling Dimensions Q13 X q L ❑ Gr 'gage Di. -^I 6. It business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks No. of Urinals No. of Lavatories _ No. of Water Coolers No. of Showers _ Water Usage Figures 7. Type of water supply: Public ❑ Private ❑ Community B. Property Dimensions 02 - <3 D X 3[n,_UT _ Sewage Disposal Contractor 9. Do you anticipate additionslexpansion of the facility this sytem is intended to serve? ❑ Yes f No If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. lmprovement� Permits a-3 subject to revocation, it site plans or the intended use change. Effective October 1, 1989. PROPERTY Ii,1012i�IA-IO;\? 16,EQ1JIR);'. : Directions to Property: Tax Of fice PIN 01f) j& raw Road name Pio:: # (if available) City —now -&—s U f ) This is to certify that the information provided is correct to the best lncutrnrl frnm ihts aPPli�.ntinn Mid , by know4edge, a enders d I nm rosponsiNo for rill chnrtlwi hlrnAl i• 1 TIT %�Iltlli, (Ill ll' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property, u- 2, l DO NOT OWN tho property. If you checked Box 42, the rest of this form MUST b;: completed by the owner or a person authorized by the owner: 1 hereby give consent to the authorized representative of the Davie JC Health e a en tq.enter p n above described property located in Davie County and owned by bit/ .S f1 //���K �/J t� % � to conduct all testing procedures as necessary to determme said site's suitability for a ground absorption sewag3 treatment and disposal system. r a�,_ //``��[[ DATE SIGNAT RE xt{o (heal X. ..., .; ._ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER w Davie County Health Department f Environmental Health Section JUL 2 11995 j P. O. Box 665 / f Mocksville, NC 27028 I � E T fEAITH Application/Permit Requested By r ok o 'avyn er'/;'Ce— C• f't o e- / �G Mailing Addresser_ /tl��'��`j%!� Home Phone to ` 9133 IY1 0 .46�,�/,/t� Business Phone ak I{ s2 ✓.S l 2. Name on Permit if Different than Above 3. Application for:General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: 2'H//ouse ❑ Mobile Home ❑ Place of Public Assembly J -. ❑ Business ❑ Industry nn. ❑ Other ❑ Unknown i 5. If house, mobile home: Subdivision ''T �"a' rc�B.� Section _�� Lot # A 7. 8. -11 i No. of People No. of Bedrooms No. of Bathrooms ��- Dwelling Dimensions i If business, industry, place of public assembly, other: Specify type _ No. of People Served No. of Commodes No. of Lavatories — No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ Type of water supply: ublic ❑ Private Property DimensionsQ©F Sewage Disposal Contractor _ Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ .Garbage Disposal Yes "o ❑ Community "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:DO /� - �� c �G B A- -S This is to certify that the information provided is correct to the best of my knowledge, incurred fr m thi�plication. DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED 9ROPERTY 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 representativ of the D, uwe Co nu ty Health De artment to enter upon above described property located in Davie County and owned by �.ii 5 rn1 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. -/9,515 DATE DCHD (1/93) r y ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME i;.dRJ DATE EVALUATED1.,7.��$'� ADDRESS PROPERTY SIZE / PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position A- Slo e Z HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH r- -v J - Texture group Consistence Structure s" Mineralogys 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: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: IcIa ll OTHER(S) PRESENT: 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 5 -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 5C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mi neraloity 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 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) Eo.o o ***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 when applying for Building Permits.*** \ o q e 2 . S �� CCc1 A N DATE `4 — G 9 do �AUTti- `ZAT0 3N1 0 ' NAME J NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION VN ��-� 'P,-A_S ? b F ESQ //J e_AQ Y-e.s = - COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM *HNDTICEH* THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95