144 Calvin Lane Section C Lot 18 B"2-) �'�
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pehnit�'s
Name: -f:.., xr'�:� .`.... tC.f,°�i�1 Subdivision Name:L.Lt/".r'tt' %rt
Directions to prgperty: !�t'1' ! n �c r" r rl Section: Lot:
IMPROVEMENT _z r ,--
. �- PERMIT Tax Office PIN:#
Road Name: Zip: c %'
**NOTE** This Improvement Pen -nit 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)
j f ***NOTICE*** THIS PERMTT IS SUBJECT TO REVOCATION IF SITE
!e' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIIfONMEfiiTAL HEALTH SPE f .LIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
,. _
RESIDENTIAL SPECIFICATION: BUILDING TYPE tAH # BEDROOMS -5 # BATHS G # OCCUPANTS GARBAGE DISPOSAL: Yes or Co
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE r X�ZYPE WATER SUPPLY �v DESIGN WASTEWATER FLOW (GPD) � NEW SITE ""r REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12— LINEAR FT. /w
OTHER 1 ;?l�"r� �U 1 1 0A��
REQUIRED SITE MODIFICATIONS/CONDITIONS: �'� � A Lj- O �) Ce'� 1yy `L , kizci V D 1'F
lo,�--14
IMPROVEMENT PERMIT LAYOUT
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P12cf'. L 10 E
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"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 (336)751-8760.
OPERATION PERMITA���
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. " +" OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED COMPLIANCE
WITH ARTICLE 1 I 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)
APPLICATION FOR SITE EV&DATION/IMPROVEMENT PERM do ATC --
Davie County Health Department
r . Env/ronmenta/Health Section
P.O. Box 848/210 Hospital street OCT 13 1998
Mockaville, NC 27028
(336) 751-8760
***nWORTANT*** THIS APPLICATION CANNOT BE PROCESM UNLESS ALL TH9- ---
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i. Mame to be Billed J f i /h Vel Contact person
flailing Address Io 4Rome pie
City/state/ZIP
2. Name on pe=It/ATC if Different than Above
Business phone
Mailing Address City/state/Zip
3. Application For: U Site Evaluation 0 Improvement Permit/ATC Oth
4. system to service: 0 House ikMotibile Home ❑ Business 0 Industry ❑ Other
a. If Residence: # People # Bedrooms # Bathrooms
O Dishwasher O Oarbage Disposal Machine O Basement/plumbing O Basement/No plumbing
6. If Business/indastry/other: Specify type # people # sinks
# Cammo4e2 # Showers # Urinals i Nater Coolers
IF FOODSERVICE: d Seats Estimated stater Usage (gallons per day)
�
7. Type Iof water supply: 0 County/City 0 Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No
U yea, what type?
***IMPORTANT"**CLIENTSrIlUSTCompLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN munRESUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Mee PIN:
Property Address:
to PROPERTY:
Road Name TI �)r[, in
City/Zip (hC S y M,
if in a Subdivision pro de informs ion, as follows:
Name:
Section: C = lock: Lot:
Date Property Flagged: /v l3 C/�
This is to certify that the information provided Is correct to the best or 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 lurormation
submitted in this application is falsified or changed. 1, also, understand that I am responsible for all charges incurred froar
this appCoadon. I, hereby, give consent to the Authorized Representative of the Da Co ' ty H tb Depa went
to enter upon above described property located in Davie County and owned bI
to conduct all testing procedures as necessary to determine the site suitability.
DATE 1 r SIGNATUR&&1i
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
til,
,1
Account No.
Invoice No. /
y ' � DAVIE COUNTY HEALTH DEPARTMENT G
Environmental Health Section SECTION LOT `
Soil/Site Evaluation
APPLICANT'S NAME P���ILL-YVON DATEEVALUATED 1,LI 6
PROPOSED FACILITY PROPERTY SIZE D X 600
SUBDIVISION X11.1 of� ROAD NAME
Water Supply: On -Site Well Community / Public
Evaluation By: Auger Boring Pit ✓ Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slope %
670
HORIZON I DEPTH
Texture group
L
Consistence
Cr:55
Structure
4�1t
Mineralogy
HORIZON II DEPTH
-
Texture groupC
Consistence
• S
Structure
Mineralogy
HORIZON III DEPTH
-Li
Texture group
Consistence
Structure
Mineralogy`
l ;
HORIZON IV DEPTH
t-1'(- 0
Texture group
jA
Consistence
fid
Structure
Gk
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
.t
SITE CLASSIFICATION: PS
LONG-TERM ACCEPTANCE RATE: O'Ll
REMARKS:
LEGEND
Landscape Position
EVALUATION BY:yeff- Im t,u4, 1/
OTHER(S) PRESENT:
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
DCHD (01-90)
R
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AUTHORIZATION NO: 1748 DAVIE COUNTY HEALTH DEPARTMENT
+�► : /' Environmental Health Section PROPERTY INFORMATION
Permittee's2 C_ �j n P.O. Box 848 J j
Name: , .t~-�'� #' I LLM - Mocksville, NC 27028 Subdivision Name:
Ac
Phone # 336-751-8760
Directions to property:
15 'To � c6;_ V -j Section: Lot:
AUTHORIZATION FOR
{�. WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: 1,Cj .'i Zip:�t
**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 11o f.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
A) ho IS VALID FOR A PERIOD OF FIVE YEARS.
8NVik6M PAL HEALTH SPE(dAU§T DAT ISSUED