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331 Michaels Road Lot 28�f..a % 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 G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME `- \ f�C�QNc J (� �1� nF�c�l PROPERTY ADDRESS � �/GrT� �� - tTE LOCATION SUBDIVISION NAME �� \"�. C1 C \Z �.S LOT NUMBER SEC. /BLOCK NUMBER RES IDENTAL SPECIFICAT ION: BUILDING TYPE C(\. oYrn #BEDROOMS# BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye�No COMMERCIAL SPECIFICATIONo`'FXILITY TYPE _. # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Nes/No LOT SIZE IOO k 3 b o 'i:,_TYPE WATER SUPPLY n DESIGN WASTEWATER FLOW (GPD)NEW SITE ✓ REPAIR SITE` SYSTEM SPECIFICATIONS: TANK SIZEJOfly GAL., PUMP TANK%GAL. TRENCH WIDTH ROCK DEPTH ��} LINEAR FT. b y d .. OTHER L ; 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. F 1W 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 g 1 OD \`L a XSYSTEM INSTALLED BY f'r1'- Vf— � S', 7e-yr%cn-t_, s- � � Ib� 1 1,W F AUTHORIZATION NO. Q OPERATION PERMIT BY (W a -A DATE S" 2 y- 9 G **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEK 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. DOHD 10/95 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 L_ AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in"6impliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) b, -X'-d ***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.*** j14 ` c C AUTHORIZATION NLnER NATE 1 1► c o J �, t CM kx DATE 1 ;� NAPE ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION \N\\ COPIENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. 'ENVIRONMENTAL NEALTH SPECIALIST, ' DATE DCHD 10/95 1. Application/Perm Mailing Address (a APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMWr I' Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, NC 27028 2. Namo on Pointll II Ullloront limn Abovo . 3. Applicntion for: ❑ Gnnornl Evnluntion U Sop tic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry n ❑ Other ❑ Unknown p 5. If house, mobile home: Subdivision �a llI L ir'iC� S _ Section Lot # �12� No. of People No. of Bedrooms No. of Bathrooms 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 ❑ Basement/Plumbing i. ❑ Basement/No Plumbing I I Washing Machine t ❑ Dishwasher ❑ Garbage Disposal ' i No. of Sinks No. of Urinals i No. of Water Coolers Water Usage Figures 7. Type of water supply: Rf Public ❑ Private ❑ Community 8. Property Dimensions 3 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? t 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementt Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Office PIN # P/0 (p _ Road Name j�,(*, PJ.. Box # (if available) City mnk-k U,) l a This is to certify that the information provided is correct to the best of incurred from this application. q-�s DATE edge, an5tmder5" I am responsible for all charges TU CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: El 1. 1 OWN the property. p-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 avie ty Health Department to enter up n above described property located in Davie County and owned by '(/ ' V) r f= U. - to conduct all testing procedures as necessary to determirle said site's suitability fora ground absorption sewage treatment and dispo:�al system. "L DATE NATURE DCHD (1193) *�•► APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM[ Davie County Health Department E ' t IH 14k CM; nviron I " a ea ec ion JUL2 11995 �r r P. O. Box 665 Mocksville, NC 27028 FAUH 1. Application/Permit Requested By f 95�0k7 'U '_arm �7e_r_�/ � C•ejartece- Mailing Address J� "—t" Home Phone ��.�,. �d�, /%� Business Phone �, 7 s2 5s 1 2. Name on Permit ifDifferentthan Above 3. Application for: General Evaluation D Septic Tank Installation Permit 4. System to Serve: ®'/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown I n vf-�IS r� 5. If house, mobile home: Subdivision —�'� 'T CJS a� W16D Section _� Lot # —2e I? No. of People No. of Bedrooms No. of Bathrooms 1 Dwelling Dimensions / �0 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine /goo S � ❑ Dishwasher ❑ .Garbage, Disposal No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ❑ Private 8. Property Dimensions OZO Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes C9-iQo ❑ 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: -71- 491 71—o ws 9-7-V l _S V � B �a S This is to certify that the information provided is correct to the best of my knowledge, incurred from thi plication. .s F-7 ✓?� , DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED FIROPERTY 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 Dewe Co my Health DDeepartment to enter upon above described property located in Davie County and owned by:�4 �IGodn� �ecril;iP_ to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. � J C ,.Z% -- DATE WHO (1193) Q] • � DAVIE COUNTY HEALTH DEPARTMENT E T ' Environmental Health Section Soil/Site Evaluation NAME , ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE CfiL!C'��P— Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit_ Cut FACTORS 1 1 2 3 4 Landscape position �. Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH O « 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 f ,� SITE CLASSIFICATION: U/ EVALUATED BY: ,A!�.'// LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND DCHD(01-901 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 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 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