123-129 Deer Trail (2)DAVIE COUNTY HEALTH DEPARTMENT 3.
- IMPROVEMENT PERMIT and OPERATION PERMIT ►
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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 A // R �' _ o_ <-ZG!� ,��!/y!/7ry �yJ ilt/Q di1� PROPERTY ADDRESS �t1 �� _ -.�i •-j PATE f'
LOCATION
SUBDIVISION NAME
LOT NUMBER
dti J-
SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE,� # BEDROOMS # BATHS g, # OCCUPANTS � GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SILLY DESIGN WASTEWATER FLOW (GPD) NEW SITE 4Z REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE AW GAL. PUMP TANK GAL. TRENCH WIDTH ?4 ROCK DEPTH f,2 • LINEAR FT. :7,614 1
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 2�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. OPERATION PERMIT BY ;ZL/� 2e 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 10/95
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Davie County Health Department
' ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization ror� 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.***
NAME /' DATE s �7 1 /a?—/S'" �G'.I� AUTHORIZATION NUMBER
Nw 0195
NAME ON IMPROVEMENT PERMIT (If different/than above)
SITE LOCATIONDD7 / .C. fie ✓P
CONSTRUCTION SHALL. NOT BEGIN UNTIL IMPROVEMENIS PERMIT HAS BEEN ISSUED.
Home Phonp-1 T - V6 0 4 _
I., Permit Requested By —12�m.� _� i tic ij q--� _ _ tiusinpas Phpne
2. Address ..�+ ll3�'�L .. _ b.✓s_�i,�1. C �2� 0 r!
I PrOP". Owner if Different Lhan Above
Address
4. Permit To: a) Install-Lef"After Repair--' -
b) Privy Conventional—.._ Other Type—__
Ground Absorption ' 3 "
C) Sub-C4vision_'7')1±- Sec..___...___ Lot No
S. System used to serve what type to ility: House—_ Mobile Homess
Iridustry____ Other—_.
b) Numtw of people
8. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms_._ Hath Rooms.. _—_'L__ Den w/Closet _
b) IIBusiness, Industry or Other, State: Number of persons served __...
What type business, etc.._,
Estimate amount of waste dally (2-1 hours)—__—__..—_._._.__._. '
7. Number and type of welter -using fixtures:
commodes Imo.-._ urinal;;__ __—..._ garbage disposal
lavatory ._— showers washing machine L-,"
dishwasher sinks
8. a) Type water supply: Public_______ F1riv.Ue__1k0_'_0_ Community -
b) Has the water supply system boon approved? Yes—__ No_t '
9. a) Property
b) Land area designated to'building sittr
c) Sewage Disposal Contractor_
10. Do you anticipate any additions or expansions of the facility this sewage system is Intended to serve?
What tyoe?
This Is to cortify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPON:;IBLE FOR COM^I_IANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 says for processing
Directions to property.
rr>vvrrov�rorn-mra-appncauorr. - -
DATE
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
[,roperty
UST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described.
located in Davie County and owned by
o conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
nd disposal system.
DATE SIGNATURE
It
ri/
A
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Mrix
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NAME — (&//
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED
PROPERTY SIZE Aoi�
LOCATION OF SITE
Water Supply:
On -Site Well _
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1 2 3 4
Landscape 2osition
Sloe %
�-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
i S6
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
-7, 7
SITE CLASSIFICATION: EVALUATED BY: i1; 6Z
LONG-TERM ACCEPTANCE RATE: 1 ( — 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 :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
Iforizon 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(01-901
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