288 Armsworthy Rd � -
DAVIE COUNTY HEALTH DEPARTMENT ��//�`Z��
. ` Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000816 Tax PIN/EH#: 5861-66-6110.02
Billed To: �olet Arms�nrorthy Subdivision Info:
Reference Name: Wayne Frye Location/Address: Armsworthy Road-27006
Proposed Facility: Residence Property Size: 1.5 Acres
ATC Number: 2231
**NOTE** This Improvement/Operation 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
PERMIT 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 {7� #People #Bedrooms � #Baths�_
Dishwasher: U Garbage Disposal: ❑ Washing Machine: �" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �i s J� C Type Water Supply-�� Design Wastewater Flow(GPD) `S 6� Site: New�Repair❑
�� R
System Specifications: Tank Size�DD�GAL. Pump Tank GAL. Trench Width �lo Rock Depth /� Linear Ft. .:��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFF'LUENT FILTER RISER(S)IF 6"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 . p.m.on the day of installation. Telephone#is(336)751-8760.****
��
��SL I`�
� 3 � ,��
�� / �J
�
/'
Environmental Health Specialist's Signature: � . �- � Date: �J`'�o2 y��
DCHD OS/99(Revised)
,� . ��`er-�,���
.
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990000816 Tax PIN/EH#: 5861-66-6110.02
Billed To: volet Armsworthy Subdivision Info:
Reference Name: Wayne Frye Location/Address: Armsw�orthy Road-27006
Proposed Facility: Residence Property Size: 1.5 Acres
ATC Number: 2231
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of
G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: •�Date: /�—/��7�
CERTIFICATE OF COMPLETION
**NOTE** The 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.
�
�
�
Septic System Installed By:
Environmental Health Specialist's Signature: Date: �"��-Q� �
DCHD OS/99(Revised)
A �' �
1
t - �
� � '� � APPLICATION FOR SITE EYAI�lAT10N/IMPROVEMfM PERMR ����� l5
� Davle County Health Oepartment Q
�� � Env�itonme�tta!Hea/tfi Sec�fon
�� p.o. Box 8�8/210 �otpital BtrNt OC� l � �999
pj�' . Moak�vill�, NC 27028 �
�� (336)751-8760 ��VlROUh���T�1L HEALTH
bp.'•JIE COU_NTY
�+►+►IHPQRI'Al4T+►** TA28 71I+pI.ICl1TICN � � PROC�BBSD UNLa88 `�l'� ItaQUIRaD
IN�'01t�ATi02i i8 �AOVIDF�D. R�lor to th� tNa'ORM1lT=ON StII.I+�TiN !or instruatioaa.
�. uan. e�o�.—s��1.a � �/ns1l�� coac.ot �.r•oa 1 � ��
��� �... � L 1� .a.. �. �/ — F� 3� � '
cihr�■t�a�::a 14�U�l�C� �(.fG o� �� su.s�... �.
Z. xw on �sait/�TC 1! pitt�r�at tban �bo��
1lailiaq �dds��• City/Ytat.�/iip
a. 1►ppiiaatioa tor: ,�.8i.�t-�s�ua�tioa 0 Improvsm�t p�ssit/1LTC �Both
�. eY.c.. co �.�w� 1�8ons� 0 MAbil� Homs � Busin�sa 0 iadu�tsy � Oth�r
a. i! R��idu�o�s i p�opi� f B�drooma _ � Bsthrooms �_
0 oi.h,r..b�r o oarb.�o. ai.po..l o �a.ninQ wobsa. o s.,.arat/pl,absaq n s.,.�.nt/�to alu�bsaQ
�. st su.1s►.../I��S•esY/och.s� sp.nsl�r lyp. � p.o�rl. f �swax.
� Coa�od�� i Ybo�nr� ! Oriaal• f Nsbr Cool�ss
=t �'00�8=RVIQ: � S�ata =stimi�d Nat�r Oaaq� tvu�• � a•Y�
T. Typ� o! xat�r suppiys 0 Connty/City �lf�ll 0 Commuaity
a. Do yon andcipate addiHow or e��adon�oi t6e fncility t6V ryatem b intended to�erveT 0 Yea �No
Itya,w6�t type?
*"*JMPORTANT''**CWENf3 MUTT C10MPLETETHE REQUIRED PROPERTY INFORMATION REQUESfED
Elt6er�PL.AT or SITE PLAN MUST BBSUBMI7TED by the cUent �vlth TNI3 APPWCATION.
l i� , � r�1/:j- F AC/G. �
Prope men�ionu_'J/ � �l��.A� S✓DL'S: � � R+RITE D1�tECRONB(from Mak:vtlle)to PROPERTX:
Ta:081ce PINt #����' �D��� �2/nSll�D�hU �14�1 '1
Prop�rty Address: Rad Name �1.(7U r !t�%�G DJ�'� �lul� ^ �n �Y�i
� CitylZip�U��uc�. ��2�oob Yaca•-r� � DL{S��i
I[in�Sabdivbion provtde Informsdoa,ou foUaMs ,
N�mes �T t� �G '
SecHons Blockt � Lots D�te Property Fis�eds �G"�/-Y'�
T6te b to certi!'y t6at t6e InfbrmsHon pravlded b con�ect to t6e best oi my knuwledga I ander:tand t6�t�ny permit(�)
lasaed 6eceafter�re�object to�aspen�ton or revoaiHon,it the dte pltnt or Intended ua�c6an�e,or if the Iotorm�Hon
�abmitted io t6b appllcallon V falettial or c6anQed. J,aLso,anderatand tJiot I am ruponslble jor all cl�arges lncumd frorn
t1ils applJcadon. I,6enby,�ive cowent to the Ant6orized Rspnuubtive ot the Davie Coadty Health Department
to enter npon�bove dactibed property laated in Dsvie Coanty and a�vned bp
to condact aq tattn�procedara u neeeaary to detecmine t6e dte�attabWty.
DATE �D— Ir=GI � SIGNATURE , •O� .
THl3 AREA MAY BE USED FOR DRAWING YOUR S1TL PLAN(ln¢lu sli of t6e follo�vinQ: E�sHn�snd propaed
property Uaes sqd dimewioni, ttractwa, utba¢ki, �ud aptic loc�Hon�). •
8ih Revbtt Ch�r�e
/ Date(�):
` 1 Client NoHBcaH�n Dste:
'N
,�(�� EA3:
M1`�
7l,
Accoant Na �/tv
Revtaed DCHD(07/99) Invoice Na ��`��
� •• , ,
� . ^�
, + . ;� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section S ���
Soil/Site EvaluaHon
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000816 Tax PIN/EH#: 5861-66-6110
Bilied To: Violet Armsworthy Subdivision Info:
Reference Name: Ricky G.Armsworthy, POA Location/Address: Armsworthy Road-27006
Prpposed Facility: Residence Property Size: �!lAcres Date Evaluated: /�`/�l'�
/�.5'�c.
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 p'' 3p '
Texture rou
Consistence � �
Swcture ( /
Mineralo ; ,'
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION Q
LONG-TERM ACCEPTANCE RATE < <
SITE CLASSIFICATION: ��� EVALUATION BY: i
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-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
DCHD OS/99(Revised)
■������■■■■����������■■■�■■��■�■���■■�■�����■�■���■■����■��■■�■��■
■�■��■��■■■�■�������■�■■■����■��■�■�■�■���■��■����■������■��■��■�■
■�������■�■�■��■���■■�■■■■�����■�■■■�■■■�■��■��■�■�■■�■■���■��■■
■■�����■■�■�������■���■■�■���■■■ ■■■�■■■■■����■��■��■■�■�����■��■
■������■■■■■��0�■A■■��■■����■■�■■���■�■■��■�■�■■av■�\■■■■�■�■�■��■
■����■■����■�■■����■■���■�■■�����■��■�■■�����■■■��■��■������■�■��■
■��■�■■■���■�������■����■�■■����■■■��■■�■�■��0■������■■����■■�■�\■
■��■����■■■ss��■■ee��■���■����■��■■���■�■�■��■e�e■�s■e■■t■�����■�■
■�������■�■���■■■���■■���■■���■�■■■t��■��■■���r��■■■■�■���■�■■�■■■
■��������■■�■�■������■■��■��■�■■�■■���■■��■���■��■��■a������■����■
■■����������■��■■��■��■��■����������■■■��■■�■���■��■�����■�■■�■■■
■■■�■���■�■�■�■��■��■�■��■■■■�■■ ■�■■■■���■■�■��■■�■�������■■■■■■
■�■�■��■■�■�■�■■�■����■■�■���ee�■�■■���a■�■■��■��■��■�o■���■■■�■�■
■■��������■���■■�■■�■�■■��■��■■���■��■�■■��■��■■�■�■■■■■�■�■���■�■
■��������■�■■■■���■�■�������■��■■�■■■■�■����■�������■■�■�■��■■■■■■
■����■■�■��■�■��■��■■■��■��■�■�■■��■����■���■�����■���■��■��■■■��■
■�■��■����■■�■��■■�■�■��■��■■■�■■��■���■■���■�■■■�■■�����■■�■■■��■
■���■■■��■��■�■■�■��■■■�■�■■■���■�■■�����■���■e■��■���■�■■■�■■���■
■�■�■�■��■��■■■■����■■�����■■�����■■���■■��■��■��■■��■���■���■■�■
■����■■■��■�■��■���■�■��■■■�■�■■ ■■■■■��■■■■�■■��■��■■���■■■�■■�■
■����■■■■�■�■�■■���������■■�■�■��■��■■■��■■��■■■��■���■����■■�■■�■
■■���■■���■■�■�����������■��■�■��■�■■■■�����■■■■��■���■����■■�■�■■
■����■■��������■■�■���■■�■■�■�■��■��■■■■�����■�■��■���■■�����■��■■
■����■■�■■������■�■���■�����■■■�����■■■■�■■��■����■■■���������■■�■
■■��■�■�■■�■����■�■����■��■���■■��■��■■■��■��■��■�■■■�■���■��■■■�■
■■�■������■�■■■�■�■■■■��■��■���■■�■��■�■■�■��■��■��■■��■��■���■��■
■��■�����■■�■�■�■��■�������■■■�■�■����■■�■■�■��■■�■■■■��������■�■
■■�■������■���■�■��■■■��■��■■��■ ■����■��■�����■■�■■��■�����■■■�■
■���������■�■�■■�■������■��■�■�■��■■�■�■■�■■�s■�■■■�■■■■�����■■■�■
■�■��■■����■■�■■�■������■■�■�■����������■�����■■■■■��■■�������■■�■
■�■��■■����■■■�■�■�������■�■■■��■���■��■■�■■��■��■■■■■■■■■����■■e■
■�■��■■���■■�■�■�■■�■�■�t���■■■�■■�■■���■��■■�■��■■��■��■��■■■���■
■■■�■■■�■■�■�■�s�■��■�■��►•�j�a■■���■�■�■��■■�■■�■���■��■���������■�■
■■�■■��■■■������■���■■■e�W��.e���■����■�������■■■�����■�■■��■���■■
■■■�■■■■■■�■�■��■�■�■��■�■■�■�■��■�■�■��■�����■��■■�����■�����■■■
■■��■��■■��■�■■��������■�■■�■��■ ■�■■■■�■��■■�■■�■■��■�■��■■■■��■
■��■■■����■���■�■�■■���■�■■���■■�■■�■�■■�■■��■�■■�■■■�■��■■■■���■■
■�■��■■■■■■���■�■��■�■�■��■����■�■■����■��■��■�■■��■■�■�■�■■■�■�■■
■���■■�■�■���■■e■�■�■■�■�■���■�■��■���■■�����■�■■��■■���■■■■■■���■
■�■��■��■■���■��■�■■���■■�■��■■■��■��■�■��■■���■■��■■�����■�■■■�■■
■�■��■■■�■���■■�■��■�■��■�■��■�■��■����■■�■���������■■�����������■
■■■�■■�■���■■■■����■�■■�■�������■�■■�■�■■��■■���■�■■���������■■■�■
�iiiiii�iiiiiii�iiiiiii�i�ii:��.'�iiiiiii�iiiiiii�iiiiiii�iiiiiii�
■■■v■■�■�■■��■■�■����■��■��ii�a■��■�■■��u�■■�■■�■�■■■�■■■■�����■■■�■
■■■������■■��■■�■�■�i�■��■�■r�■��■■��■■�������■■■���■■��■�■■■■�����■■
■■■�■�■�■■■���■�■�����■��■�■■■■��■��■�����■■�■■�■����������■■■�■���s
■�■��■■��■■��■�o■��■��s����i■■■�����■���i�■■��■■■■������■■■■��■��■�■
■■��■■■■�■■���■�e■���■��■�u�■�■��■�■■��i■�■■�■■�■■��■��������■■■■�■
■■■��■■■��■�■�■�■■�■�■������■■����■��■■■i��■�■■■��■�■■■��������■■■�■
■■��■�■■■�■■■���■■����������■■■■��■�■��i■■■■■�■�■■■�■■�■■�����■■■■■
■���■���■��■�■�■�■�������vi����■■ ■�����■��■�����■■�■■■■��■�������■
■�■��■��■��■�■�■�■■�■t���■t��_:��::::::�������■��■■��■���������■■�■
■�■��■�■■�■■�■�■�■oe��■��■���■■�������■■■�■���■�■■�■■■■■�■������■■
■��■��■■■��■��N�■��■����■■�■■����:n��■■■■�■■■■■��■■��■■■■■■■■■��■■
■��■■�■■■■���■�■�■�����■�■■�■����li���■�■■�■■■�■��■■�■■��■■■■■■���■
■■�■�����■�■■■�■■���■��■��■����■�'I■■�■■�■��■��■■��■�������■■■■■■�■
■������■�■�■���■��■�■��■��■�■■■■��■■����■���������������l��■■■■��■
■��■■�■■■■�■������■�■�����■�■■■��������������■���������■■■■■■��■■
■�■�■■���■���■�■��■�■��■��■�■■■■ ■�������������������■■■■■■■■���■
■�■■�■�■�■�■�■�■��■����■��■���■■■�■■����■��■��■��������■■■■■■■����
■■■■■■■■�■�■�■�■0�■�■��■��■��■�■��■■■■■�■��■■����■■■■■■■■■■■�����■
■■���■�■■■���■��■�■■���■��■■■��������■���■�■■�■■��■�����■■�■■����■
■�■��■■■��■�����■�■■■■■������■■■■■■■�■�����■���■��■���■����������■
■�■��■��■�■��■■�■■■■�■�����■■■■�������������������■��■■�■■■�■■���■
■�■�����■�■�■■■�■�■■����■■■■�0�����������■■■����■■■■�■■■����■����■
■���■■■■��■���■�■��■�■■�■■■■�■����■■�■��■���■�����■�■■��■■■�■���■
■■�■■■■���■�■�■�■■■■■����■��■■■■ ■�■�■�■■■■�■��■�■■���■�■■■■■■■�■
■■�■■■�����■■■■■�■■■■■■��■��■■■■�■����■��■�����■■������■■■■■��■■■■
■����■�■■��■■��■�■����■��■■�■�■�■■■�■�■��■■��■��■��■■�■■��■■■■■■�■
■■���■�����■■■■■■■■�■■■�����■�■��■■�■�■■■■■■■■■■■■■�■■�■��■■�����■
■�������■��■■■■■�■■�■�■����■■�■■�■■■�■■■■■■■■■■�■■�■■�■■���■�����■
■�■■���■���■�■�■�■����■�����■�■■■■■���■■■�■�����■������■�■�����■�■
■�■��■�����■�■�■�■■��■�����■■■■■�■■■■■■■■�■■■���■��■�■■■■■■■■■�■�■
■�■��■■■■■���■���■■�■\■■��■■■�■■�■■�■■■■�■■■■���■�■■■■■■■■■�■■■�■
■��������■�■�����■■�■����■�����■ ■���������■■■■�■■■■��■■■■■�■■■�■
■■��■�������������■■�����■�■■�■■�■■��■�■■■■�■■�■����■■���������■■■
■���■���■��■■�����■�■��■���■■�■���s�■�����■��■■■����■��■�������■■■
■�■�■■��■�■■■■■���■�■■■■■■�■��■■�■■■■��■�����■■■■■���������■�����■
■■■■■■■■�■���■���■■�■������������■■�■■■■�■■■■■�■�■��■■■�■■��■�■�■■
■��■�������■■�������■■■■■■�■■■■■�■■■���������■■■■���■��■����■���■■
■■■�■■■��■�������■■■■���■��������■��t��■����■��■■■��■■■■■�■�■���■■
■�■��■�■■��■■���■���������■�e����■■�■��■��■���■���■■■■�■■����■■�■
■��t■■■��■■■��■�������■■■■■■■■�■ ■■■■■■■■■■�����■■■■����■■��■■■■■
■■■■■■■■�■■■�■■�■■■■��■��■��������■��■■�■■���������■����■�■�■■■��■
i .
I _
I �
� �'AUL �JeCULL01y �
D'B• 54, PG, 495 '�
( D�.B. 49, pG. 55 � �
B• >38
� D.B, �7 p' pG• 819 � p
� PG. Sz� �'!
� �` y
$iONE BUGG1 � M�
Ax�E � v
y 33.77��
S 86•20'26' E ' �
ITIf� � S 8S•35'03• E w
91 .83 \., b
� . ..��:��`✓ - —_ ..�c^ - �?.7' TO
.
.����.
� _,- "__
,»
, � � _-.- _ , - x .
,-,-°-
,, < .. �
� - - w , �
0
g N
Z , - _ `� . : 4. 50 A C. ;
�_,,., � -�
� `��' ( UBJECT lT0'S.R. 633 R/W) • �
�:_ � $(�,
� /' N�3
� ; H
2' E iP
' 90b.68
_ - N B4•30'pp• j
�
7 *'r 13' TO �ENT)
' CHARLES
P R � ., L• �ILLIA Mr �R;��--