141 S Angell Rd DAVIE COUNTY HEALTH DEPARTMENT
. .
Environmental Health Section � ��
- P.O.Boz 848/210 Hospital Street �
. Mocksville,NC 27028 �i� �-� � � �`r� - �
(336)7.51-8760
, �
IMPROVEMENT/OPERATION PERMIT
Account #: 990000920 Tax PIN/EH#: 5840-00-9363
Billed To: Deborah Roberts Subdivision Info: �1� �, ,q,U9e�/ r
Reference Name: Deborah Robe�ts Location/Address: Main Church Road-27028
Proposed Facility: Residence Property Size: 18.2 Acres
**NOTE���iisgmpro?emendOperation Permit DOES NOT authorize the construction 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). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
�
Residential Specification: Building Type /�� #People_� #Bedrooms�� #Baths�_
Dishwasher: IA Garbage Disposal: ❑ Washing Machine: � Basement wlPlumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size L' Type Water Supply�_ Design Wastewater Flow(GPD)�?�D Site: New�Repair❑
System Specifications: Tank Size�QOrD GAL. Pump Tank GAL. Trench Width 36�`Rock Depth�� Linear Ft�9��
Other:
Required Site Modifications/Conditions:
1MPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
. /'
, � � � -�a
Environmental Health Specialist s Signature: Date: ���
DCHD OS/99(Revised)
, 1
;
� :
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990000920 Tax PIN/EH#: 5840-00-9363
Billed To: Deborah Roberts Subdivision Info:
Reference Name: Deborah Roberts Location/Address: Main Church Road-27028
Proposed Facility: Residence Property Size: 16.2 Acres
ATC Number: 2292
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA CONSTRUCTION IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: Date: 1�.�--''j��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
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.
Septic System Installed By:
Environmental Health SpecialisYs Signature: Date: � "� `a�
DCHD OS/99(Revised)
V _ a APPLICATION pa i County�Health pepa�ENT PEAMtT a AT � � t� a�j �
D �s
' Envirvnmeenlnl He�/th Se�dfon
r.o. so: 848/210 �ospitsl 8tr��t DEC 2 81999
. �ocks,nii., Hc z�oze � .
(336)7'S1-8760 �
***Z1�QR�+�• THtB 71B8LIC�ITION �1�0? P� PROCCBB�D UNL�88 71LI.� RaD
INa'ORbATION I8 pROVID$D. R�l� to th� ZN1'ORMATIOai BOLL�TIN !os instruations.
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a. _! tzasid�acs: � B�opl� �, � Badrooms � _ i Bathrooms �
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e. Do you�aHcipate sddiHau o�e�andoas of the lscWty thb mtem b intendal to recveT O Ya �_
V yes,�vhat type?
. **�'IMPORTANTR**CWEN79 MiJ�STCbMPLETETHE REQUIRED PROPERI'Y INFORMATION REQUE3TED
BEIAW. Either a PLAT or SITE PI.AN MUST BESUBMITTED b the eltent w�ith TLi1S APPI.ICATION.
Property Dimenf[onl: j�n.2 a c,r� R+RTTE DIRF.CtiON3�Mocic�lle)to PROPE1tTY:
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T6b b to certity t6�t t6e in[ormsHoa proRided is correct to the beat oi my knawled�a I underrtand th�t sny permit(�)
tssaed heresfler are�nb�ect to�mpeaeion or revoc�don,if t6e t[te plan�or iatended aae c6�nQe,or U t6e InformeHon
�abmttted ln t6b appltcation is talsifted or chan�ed l,also,andirstaRd tlkm 1 om rrsporatbte jor aU cbagu lncamd jro�n
tbls oppUcadon. I,6ereby,�conaent to the Aathorized ItepraentaHve oi We Davie Coonty Halth Dcpartment
to enter npoa abare deacctbed property loa►ted in Davie Coantq snd m�ned by
to condoct�11 tatfng procedara�u neeea�ry to determlue t6e�ite tabWty.
DATE �a"a��.� SIGNATURE � � `����.5
1'HI3 AREA MAY BE USED FOR DRAWII�G YOUR S1TE PLAN(Inclade all of the foUominas F�iatin�and propoecd
prop�rty llna and dlmen:iow, �tractar�s, setbacic�, and Kpti¢locatlons�
Sih Revbit C6ar�e
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Client NotiHcaHoa Date:
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DAVIE COUNTY HEALTH DEPART'MENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000920 Tax PIN/EH#: 5840-00-9363
Billed To: Deborah Roberts Subdivision Info:
Reference Name: Deborah Roberts Location/Address: Main Church Road-2702$
Proposed Facility: Residence Property Size: 16.2 Acres Date Evaluated: / �3•Q�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � / Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osidon
Slo % o�
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH •' S �'
Texture ou -
Consistence �
Structure ( S f�
Mineralo ,'
HORIZON III DEPTH
Texture ou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture u
Consistence
Structure
Mineralo
SOII.WETNESS
RESTRICTIVE HORIZON � � .
SAPROLTTE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATTON: � EVALUATION BY: .�g=���
LONG-TERM ACCEPTANCE RATE: � 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 "
GONSISTENCE
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
truct r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
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-gaUday/ft2 ,
DC�ID OS/99(Revised)