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11 4'cDAVIE COUNTY HEALTH DEPARTMENT - -�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION 4*D
: ee's
Namet
Name: � � /""� Subdivision Name:
Directions to property:IMPROVEMSection: �d Loth
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6a f lr °� rj ) - ✓1 �,
�y) 1 dita � PERMIT Tzx Office rIN.# - T�n . � .w
Road Name: ZiR !O'
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
3 ` -1 1n -►9► -9
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS �— # BATHS ',S # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �i�/ DESIGN WASTEWATER FLOW (GPD)_ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE v GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. �-
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
Gkcty\ zc;'�Ct'P �
�o°� G,� •
- ----------
"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
SYSTEM INSTALLED BY: W �� (i Q rit la ke
r APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
n C� rt J jd
�Lxl° Environmental Health Section
� �L P.O. Box 848
JMocksville, NC 27028
I-) W (704) 634-8760
****IMPORTANT****
-r—� _r.« r ---t-- _ ..
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL 1 a' LF q
THE REQUIRED INFORMATION IS PROVIDED. NO�
Name to be Billed i-) � � ` r?L YYna i?—
Mailing Address NA -)12 i3 4) L-11 V) Q re-
City/State/Zip N)U) oN
2. Name on Permit/ATC if Different than Above
c
Contact Person ff 1 ��
Home Phone Q �� W
Business Phone
Mailing Address - -A.. L4 'qt' City/State/Zip
Application For: '[4] Site Evaluation [Improvement Permit &ATC
[ ] Both
4. System to Serve: -W House [ ] Mobile Home[ A50 [ ] Industry [ ] Other
�o
5. If Residence: # People_ # Bedrooms# Bathrooms_"1[y] Dishwasher ]Garbage Disposal
--q,] Washing Machine `J Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [ ] County/City 'f-4] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes "N No
If yes, what type? `1K\0'CQ-1 C,L 6
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***.>��',%AW OF THE PROPERTY MUST BE
I-7 SUBMITTED WITH THIS APPLICATION.
ti
Property Dimensions: GOx r C% � �� �WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # ��o - Z" - ; 'r Q�*� M6CJCQ b JL,L-�- -TO
,a � i T
Property Address: Road IYameK10 9' i-1 imm Ab
City/Zip --TL) e rg L tl ,- 6 g-4 C'T i rnd it,
If in Subdivision provide information, as follows:,rA I �x / GO �4 aY1 ILE
Name: V V- Lt -�T Q� N O IV L
Section: Lot #: t(21 V E W41
This is to certify that the information provided is correct to the best of 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 information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by,_'!D $ , � L -)L Y-A'Zk-- to conduct all testing procedures as necessary to determine the site suitability.
DATE 1 C1 SIGNATURES u Le
Revised DCHD (06-96) /
THIS AREA Mtt DF-
r DAVIE COUNTY HEALTH DEPARTMENT
1 Environmental Health Section SECTION LOT.
Soil/Site Evaluation
APPLICANT'S NAME
PROPOSED FACILITY
SUBDIVISION
i
Water Supply: On -Site Well 1<
Community
Evaluation By: Auger Boring I/ Pit
DATE EVALUATED ��"�' A�
PROPERTY SIZE
ROAD NAME ,,4
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Sloe %
`?
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
i
Structure
Mineralogy1
HORIZON III DEPTH
r
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
r'.
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
EVALUATION BY:
OTHER(S) PRESENT:
REMARKS:
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
on LIE -1-1- ..l .,ter:,. D - V1 t;, VP - Vani nlactir