1726 Angell Rd �� >> DAVIE COUNTY HEALTH DEPARTMENT �'•��- S�=ad
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)75]-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001120 Tax PIN/EH #: 5821-82-4976
Billed To: RiCky McKnight Subdivision Info:
Reference Name: Ricky McKnight Location/Address: Angell Rd.-27028
Proposed Facility: Residence Property Size: 208.70 X 419.4
**NOT�*��liib Impro4e�ment/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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 PERMIT BEFORE INSTALLING SYSTEM.
/
Residential Specification: Building Type /�'j ,K/� #People .S #Bedrooms� #Baths�
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �I�J� Type Water Supply i,� !�Design Wastewater Flow(GPD)� Site: New� Repair❑
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System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�� Rock Depth/�� Linear Ft:���
Other:
Required Site Modifications/Conditions: •
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6°�BELOW
FtNISHED GRADE. ****NOTICE: Contact a represen ative fthe Davie County Health Deparhnent for final inspection ofthis
system between 830 a.m.to 9:30 a.m. or 1:00 p.m.to 1: 0 m.o the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: • � '�J� �=�'"L� ' /� � Date: ,��� y�L��
DC�ID OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001120 Tax PIN/EH#: 5821-82-4976
Billed To: Ricky McKnight Subdivision Info:
Reference Name: Ricky McKnight Location/Address: Angell Rd.-2702$
Proposed Facility: Residence Property Size: 208.7Q X 419.4
ATC Number: 2404
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � `�.� �A.�� ' �Date: `S'—`� `G��
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicat he s tem scribed on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.C apter 30A ection.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a aran ee th the system will function satisfactorily for any
given period of time. � �� I,�
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Septic System Installed By:
Environmental Health SpecialisYs Signature: __����� Date: ���` � �
DCHD OS/99(Revised)
, ,� �
' � `' ' APPUCATION FOEi&�TE EIlAWA910N/oMPR�VEMEM'PERMIT& t-5 � � � " �
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Davie County Health Depar[ment
Envinvnment�/Hea/tfi 5ec[ion � � 4 2000
P.O. Box B48/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 ENVIRDOVIE�COUNTy ALTH
***II�ORTANT*** THIS APPL2CATYON CANNOT �E'PROCESSED TJNI,ESS ALI� THE REQUIRED
INFORI�ITION IS PROVIDED. Refer to the 3NFORMATION BULLETIN for instruction�.
1. Name to ba Hilled + � � t.- ' � Contact Peraon `
Mailing 7►ddreas �`7� V p r� Q� , _ Home Phone (�vlp �'� �
City/State/2IP �( ,,�('�j���/�i N,�� y�� (� Suaineas Ph ne�� _
�-,JG/ �1[ICA. 7��,-10/n�� J�2 t(�_Y' _ __ _
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2. Nama on Permit/ATC :.! Differont than Above
Mailinq Addresa , City/State/21p
3. Application For: ❑ Site Evaluation ❑ Improv+ement Permit/ATC � ot'a
4. Syatem to ses,►iaa: � House �Mobile Hom�a ❑ Business Q Industry ❑ O�..her
s. if Residence: N People �_ � Bedrooms _� q Bathrooms �
F�Diehrasher f-1 Garbage D.'.sposal lK Waehing Mactiine II Hasement/Plumbing fl Hasement/No Plumbing
6. I! Buaineae/Induatry/Othar: Specify type � People � Sinka
� Commodea / Shoxera � Urinals # Water Coolcsra
IF FOOD£ERVICE: # Seats Estimated Water Usage (gallona per aaY) �
.. :y�, r�� wa�ar r,uppiy: ll Coun�y%Ci'�;� �'Well 0 COm�muriity
e. Do y�oi�anticipaae ad�ditions or eapansions of the facility this system is intended to serve? ❑Yes �o
If y�es,what ty�c;?
***IbtPOI��''ANT***CE.IENTS MUSTCOMPLETiE"i'HE RE�UIRED PROPERTY INFORM!yTlal��►�QUESTED
BEL�JW. E�21her a pL.AT or SITE PLAN MUST BF,S''S161I7TED by the client with TH6S,QP?��ICATION..
Property Dimensioaas: o(� ,4 � WRITE DIRECi'IONS(from 11�Eacksville)to PROPERTY:
Ta�a Office PI�T.��� 5��I �O o�-��� ' �f>�
` �—
Fr�perly Address: Road Naroe �L�P,��.�, � � � (Yl L��S (�� 1 e 1 1 _
Ce:ry/Zip��'.�S�J/�� /�C 1 ,1(_S�t .
,a�1Qa.�
If in a Subdivision provide�nfore.ation,as follows:
Name:
Section: Block: Lot: Date Property Flagged: ,�� l/�� �
This is to certify t6at the information provided is correct tQ the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocatioa,if Che site plans or intended use change,or if the information
submitted in this application is falsified or c6anged I,also,understanJ tha[1 am responsible jor oll charges incurred jrom
lhis app[lcatlon. I,hereby,give consent to the Authorized FtQpresentative of t6e l�avie County Health Department
to enter upon abQve described property located in Davie C::;+mty and orvned by �o�� PY1. F'Q v-e.b P P
to conduct all testing procedures as necessary to determine t6e site s ita�^a'
DATE ��/�"�� SIGNA �
THIS AItEA MAY BE USED FOR DRAWING YOUR ST:'E PLAN(Include a.17 of the following: �zisting and proposed
property lines and dimensions, structures, setbacks, and��ptic��:.'.�o��).
,
► � �i►e Rewi3it Charge !
' Date(s):
Client NoNfication Date:
EHS•
Account No. ���
Revised DCHD(07/99) Invoice No. 7 ��
482 517
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(384) 2252
319
290 396
205
(30.84A)
4976
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0768 (12.32A) v o
3767
7713
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2502
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(399) 327)
DAVIE COUNTY HEALTH DEPARTMENT
.. . . � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001120 Tax PIN/EH#: 5821-82-4976
Billed To: Ricky McKnight Subdivision Info:
Reference Name: Ricky McKnight Location/Address: Angell Rd.-27028
Proposed Facility: Residence Property Size: 208.70 X419.4 Date Evaluated: ,�`/-�_
Water Supply: On-Site Well ✓ Community Public
Evaluation By: Auger Boring - Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition � �.
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �' � �'
Texture rou G
Consistence
Structure /L -� r
Mineralo ;
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � �
SITE CLASSIFICATION: � EVALUATION BY: /
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-Tenace 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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloav
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
DCHD OS/99(Revised)
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