517 Angell Rd DAVIE COUNTY HEALTH DEPARTMENT �./
--- -' ' Environmental Health Section �4�I � '�3-G�J
P.O.Boa 848/210 Hospital Street `�:(�D
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000867 Tax PIN/EH#: 5840-17-7655
Billed To: Wayne Hutchins Subdivision Info:
Reference Name: Wayne Hutchins Location/Address: Angell Road-27028
Proposed Facitity: Residence Property Size: 150x259x151x2���
**N�*-Ttilb�mprov�me nt/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
. system. An ALJTHORIZATION 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 /I��S� #People�` #Bedrooms � #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��y� Type Water Supply G�/l� Design Wastewater Flow(GPD) ��� Site: New�Repair❑
System Specifications: Tank Size%j�Da GAL. Pump Tank GAL. Trench Width�l r�Rock Depth��7�� Linear Ft. C��
Other: _`,�rS��f 1��. V�i�,� ' ����18�
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLiJENT FILTER RISER(S)IF 6 K BELOW
FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie County Health Deparhnent 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.o a of installation. Telephone#is(336)751-87G0.****
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Environmental Health S ecialisYs Si ature: ��;(i1 �'�l-J�- Date: �c2 �
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DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
Account #: 990000867 Tax PIN/EH#: 5840-17-7555
Billed To: Wayne Hutchins Subdivision Info:
Reference Name: Wayne Hutchins Location/Address: Angell Road-27028
Proposed Facility: Residence Property Size: 150x259x151x.2��'
ATC Number: 2276
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 C NSTRUCTION IS VALI�R A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � Date: !� ��U`��l"
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation 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.
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Septic System Installed By: %�%�G'/�-
Environmental Health Specialist's Signature: Date: � � < `���
DCHD OS/99(Revised)
A PLICATI N FOR SITE EVAWATION/IMPROV�JNENT PEHMtT&ATC � �"`�`--�� O ``' �4=� _
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a. 71pp11aatioA toss it� nstion � Improv�t p�rait/1►sC 0 Hotb
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""'IMPORTAIV7Y'*"CLiENi��MUST CbMPIETETHE REQUIRED PROPERTY INFORMATION REQUESfED
BELOW. Either s P[.AT or SITE PLAN MUST BESUBMITTED b t6e eUent w�lt 11f13 APPWCATION.
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Property Dimen�iowt ��x�`���/`��/Y�� WRITE DIREG710N8(from Maksville)to PROPERTYs
Ta:081cePINs # -=�� � .� ,�u--� ��� �d �/�c��� �.-L/ ���1 ,PY�,�
Pcoperty Addreu: Ro�d N�me n _ � n� � l-o�f� � � �
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N�mes n ,� G.Y �A,•>.P�S�-�/yt�%�� N�'��, .
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&cHon: Blocks � Loh Date Property Ft��ed: i �'�' /(G �! /
T61s b to cerHh►that the InfbrmaHon pt�o�vided b con�ect to t6e bat oimy Icno�►ledga I anderatand t6at any permit(f)
lasaed 6eceafter are�abJect to�wpewlon or revoc�Hon,lt the dte pl�w or�ntended m�e c6wn�e,or if t6e InformsNon
�abmitted in t6b�pplicstton V filsifial or chan�ed. l,also,und�tstand t1ia�I am ruponst6la jor all cborgu lr�cumd froni
tlils opppcodo». I,6ereby,�ive con�ent to the Aat6orisisd Repneuntative o?t6o�Dsvie Cawty Halt6 DepaMment
to enter apon�bove dacttb�d property{ocated in Davie County�ad awned try
to eondact ap taHn�peocedora a�aee�A►tA�•e�•�!•�•+�•_��!:��•���;!;�
n��_ 1 )— 1 G�-- g I SIGNATURE CG � �
TH1S AREA MAY BE USE�U 1+'OR DRAWING YOUR$1TL PI.AN(Inciade a f t6e iolla�rin�s E�tinQ�ad prnpa�et�
property Una and dimen�ioa, �tructara, utb�¢kt, tnd�epNe IocaHow).
8tte Revbit C6ae�e
Date(�): .�
Cltent NoHBcaHon D�te:
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This map is for PERC TEST
and BUILDING PERMIT purpose
only. The Davie County
Tax Administrator's Office
assumes no liability forany
information contained on this m
.
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4 COUNTY-ID:F50000001104
' I
October 26,199911:38 AM
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Parcel Identification Number
i 5840-17-7655
�' � `� �' � DAVIE COUNTY HEALTFI DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 9900Q0867 Tax PIN/EH#: 5840-17-7655
Billed To: Wayne Hutchins Subdivision Info:
Reference Name: Wayne Hutchins Location/Address: Angell Road-27028 /�
Proposed Facility: Residence Property Size: 150x259x151x Date Evaluated: /�^�� �7
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring t� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo % L
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH '• �d�
Texture rou
Consistence � ,
Structure � ( '
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION ,E,
LONG-TERM ACCEPTANCE RATE 2 'Z
SITE CLASSIFICATION: w d� �`'y'�16���C fCf9iv EVALUATION BY: G
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
� / a c,
REMARKS: � P-,��Y • lp -- !CS� . � i CvU � l�✓��'7��-
LEGEND
Landscaae 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
tructure
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
DCI-ID OS/99(Revised)
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