3841 Hwy 64W Lot 15IMPROVEMENT
PERMIT
Tax Office PIN:#
Road Name: t �='�' Zip:.
**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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r `' '),+� f `. ¢) , a tr _„ , .. • ,f ! PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
,RESIDENTIAL SPECIFICATION: BUILDING TYPE f # BEDROOMS -:? # BATHS V # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE IWXJ TYPE WATER SUPPLY ` CJ DESIGN WASTEWATER FLOW (GPD) yT,:� l% NEW SITE // REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE z! fJ) GAL. PUMP TANK GAL. TRENCH WIDTH —P61 ROCK DEPTH _� LINEAR FT. 7715%2)
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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.
OPERATION PERMIT A&
SYSTEMtNSZALLED
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 ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS",
1227DAVIE
COUNTY HEALTH DEPARTMENT
'
IMPROVEMENT AND OPERATION PERMITS
PROPERTY INFORMATION
Permit a
r
br,2 r" ' � /�.
' "'�" `t"'
Name:
�!, �
...fit..
: Subdivision
Name: E` °s
�
-D1fe tionS to property:
ri:' 4411
Section:
�
Lot:
IMPROVEMENT
PERMIT
Tax Office PIN:#
Road Name: t �='�' Zip:.
**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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r `' '),+� f `. ¢) , a tr _„ , .. • ,f ! PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
,RESIDENTIAL SPECIFICATION: BUILDING TYPE f # BEDROOMS -:? # BATHS V # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE IWXJ TYPE WATER SUPPLY ` CJ DESIGN WASTEWATER FLOW (GPD) yT,:� l% NEW SITE // REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE z! fJ) GAL. PUMP TANK GAL. TRENCH WIDTH —P61 ROCK DEPTH _� LINEAR FT. 7715%2)
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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.
OPERATION PERMIT A&
SYSTEMtNSZALLED
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 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 05/96 (Revised)
AUTAO'RIZAXION NO: 1227 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permitte6's P.O. Box'848
Mocksville, NC 27028 e)
Name: ?-1-i nz L1. erj 2 Subdivision Name:
Phone #: 704-634-8760,
A
Directions to property: 4�< Section:— Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#:& -72- ele)e)
Road Name: zip:6
**NOTE** 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.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPI C12VIS DATE ISSUED
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department
Environmental Health Section FM 16 IM
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By /C Groom Wn5jYUCfl�/'1 /'Wmd
Mailing Address 06
0 ' Ll &Aole LQt)tHome Phone
WC d Busr ess�hone
2. Name on Permit if Different than Above ,,,,��//
3. Application for: �eneral Evaluation ,}46eptic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry /' El Other El Unknown
5. If house, mobile home: Subdivision Agunly)]) HEICs-Hr- , Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 Washing Machine
No. of Bathrooms Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type dA
No. of People Served No. of Sinks
No. of Commodes
No. of Lavatories.
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures,
7. Type of water supply: Public ❑ Private
8. Property Dimensions 160 X ADO x I d0 X 2 06 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes �<No
❑ Community
I
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementst Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Y1KUYL'K1Y 11Ni1Ui-111.11U1V i-lIqulKL'll:
Directions to Property: � 1 k f (01� Nf }prp x Tax Office PIN #i2 D 0 7 6100
1100 :� P"+ D U le AbcLcla►� Wd Road NomeLAAJ
F02, S4Ll l 61 0LOIIIZ� Box # (ir available)
5--2e. Q` McHeo City ffiXk6vI Ilelo Ahla7o--,�
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred frol/my phis application.
DATE SIGNATURE ��,,,.A,&///
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:
I hereby give consent to the authorized representa� lve o the DaZie County He th D partment to enter upon above described
property located in Davie County and owned by Nn2rl�
�I /i'►., C//y�Yr�r:' ��
to conduct all testing procedures as necessary to d to to said site's suitability for a round absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1/93)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION--/ — LOT l�
Soil/Site Evaluation
APPLICANT'S NAME gel&, DATE EVALUATED -7/ EAQQ
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well Community
Evaluation By: Auger Boring t / Pit
PROPERTY SIZE 245D „ z2zQ
ROAD NAME
Public L1__1'
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
46
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
L9(–
Texture groupC
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
.S77
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (0I-90)
EVALUATION BY:
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
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
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
SC - 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
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