1595 Underpass Road Lot 5Ae
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT D za 7
**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 o'(��SO �1 �v ��a2�S PROPERTY ADDRESS
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE o v S2 # BEDROOMS 3 # BATHS # OCCUPANTS ? GARBAGE DISPOSAL: Ye /N
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE Q� # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE:'Yes/No
LOT SIZE �,Q1 X 0 0' TYPE WATER SUPPLY QA1 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE &0 GAL. PUMP TAM( GAL. TRENCH WIDTH .,,3 ROCK DEPTH LINEAR FT. 00
OTHER
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.
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IMPROVEMENT PERMIT BY�s�—J�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN u
8:30-9:30 A.M. OR 1:00-1x30 P.A.' ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT "SYSTEM INSTALLED BY
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AUTHORIZATION NO. OOPERATION PERMIT BY C,. DATE Ca 13_
**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 .19H '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
�,._. Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
02-0 7 P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
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(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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
1�Peermits.***
AUTtORIZATION NUMBER
NME v % KITt< DATE 2
J 7! ;.;
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION�^�-%�—s�
COIEMNTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
-**QVICE*H THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST- DATE
DCHD 10/95
a/lr�' / �y 41,-e SX.a.,e,
*' �) APPLICATION FOR EVALUATION/IMPROVEMENTS PERMID
avie County Health Department fl
I� i l/f �'► Environmental Health Section FEB z ����
P. O. Box 665
In Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 13-M () Ao2ps r U Home Phone VAO -`110 S6Ss
&IaLe, AC J 70,06 Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation optic Tank Installation Permit
4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision 4-14� XP -411-1 Section_ Lot #
❑ Basement/Plumbing
No. of People ? ❑ Basement/No Plumbing
No. of Bedrooms 3 ❑ Washing Machine
No. of Bathrooms a ❑ Dishwasher
Dwelling Dimensions �'s X� 2 ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: 2 --'Public ❑ Private ❑ Community
8. Property Dimensions 10 X Sewage Disposal Contractor r4Z9" K i F-aosoO
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o
If yes, what type?
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
This is to certify that t e information provided is correct to the best of my
incurred from t is ap�igation.
ATE
Tax Office PIN: #
PROPERTY AbbRESS, as follows:
Road Name: (/��%,eP�SS lF1 _
City: 4L'qvtGC;
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON AB VE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 0-2'1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUS be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Dvieunty Health Department to enter upon above described
property located in Davie County and owned by Cly°, L, /<, 'c e2
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE i SIGNATURE
DCHD (1193)
cam•►.
a•
J*Apsm 46
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R Soil/Site Evaluation
NAME ��x� �.s� V DATE EVALUATED
ADDRESS S '� �Q PROPERTY SIZE
PROPOSED FACIILTYLOCATION OF SI'T'E 'L,-)
Water Supply:
On -Site Well
_ Community
Publlc_�
Evaluation B&�zj_
Auger Boring
Pit
Cut
FACTORS
I
2
3 4
Landscape position
S
S
-.5
Sloe %
-
-90
O-8
HORIZON I DEPTH
"
Texture group�-
�-
Consistence
Structure
Mineralogy;1
HORIZON II DEPTH
2''
Texture group
Consistence
=
1
Structure
k
Mineralogy
1
:I
):
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
S
S S
RESTRICTIVE HORIZON
—
SAPROLITE
—
CLASSIFICATION
S
$
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION: %a* `'S•
LONG-TERM ACCEPTANCE RATE: —�
REMARKS:, c' ? � N%•\
DCHD(01-901
EVALUATED BY:Q_C�." t om►
OTHE RESENT: oN 4L
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
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