204 Bailey Rd . , . DAVIE COUNTY HEALTH DEPARTMENT
' � • Environmental Health Section �. � �
�' . � � P.O.Boz 848/210 Hospital Street
� Mocksville,NC 27028 L�;�G,� /l�� �p
(33G)751-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B
Billed To: Jake Miller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27006
Proposed Facility: Residence Property Size: see map
ATC Number: 3581
**NOTE** This ImprovemendOperation 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 P�RMIT BEFORE INSTALLING SYSTENL
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Residential Specification: Building Type C ��'#Pe�e�_ #Bedrooms� #Baths�
Dishwasher� Garbage Disposal: 0 Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply�_ Design Wastewater Flow(GPD)_�� Site: Ne�Repair 0
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width����Rock Depth���Linear Ft.��
Other:
Required Site Modifications/Conditions:
IIFtPROVEI�1ENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6`�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. on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
. , , � 1 . ' `� /
' ' ' ' DAVIE COLJNTY HEALT'H DEPARTMENT
�Jv`
� ' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(336)751-87G0
Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B
Billed To: Jake Miller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27006
Proposed Facility: Residence Property Size: see map
ATC Number: 3581
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEWATER CON T UCTI N IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � Date: �%����
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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.
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Septic System Installed By: ��� �
Environmental Health SpecialisYs Signature: Date: �`"�����
DCHD OS/99(Revised)
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. . . . �no���o��ti�
��'�u������1� APP CATION FOR SITE @VALUATION/IMPROVEh1F1VT P[Rh11T&ATC
Davie County Heaith Department
��� Z Z d3S Environmenta/Hea/th Section
4 P.O. Box 848/210 Hospital Street
. � � ` � MocY.aville, NC 27028
" � R � (336)751-8760
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***IDSPORTANT*** THIS APPLICATION CANNOT BE PROC�SSED UNL�SS ALL TH� REQUIR�D
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instrucL-ion�.
l. Name to be Billed .Sa�,tL � y 1,\�C'�'' Contact Person ��,c,Y C�
Mailing Address L` 1 � Homo Phono s��6-' � I�i� '�%C�__
City/State/ZIP � Business Phone ��(�_; ���j `p�J_L�_
2. Nnne on Permit/ATC if Different than Above —
Mailing Address City/State/Zip
3. Application For: �Si • . Evaluation ❑ Improvement Permit/ATC Both
4. System to servico: L17 House b 'Mobile Home ❑ Business ❑ Induatry ❑ OLher
5. Type system requested: lrJ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People �_ # Bedrooms �_, t� nathrooms � 3
h(1Diahwasher LlaGarbaga Dispo�al LhWashing Machina ❑Dasement/Pliunbing ❑IIasement/No Plumbin�
7. If Huainess/Industry /Other: verify type �# �eople 4k Sinks
# Coamiode3 # Showers # Urinal3 A #{ Water Cooler:�
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay> __ __
8. Zype of water supp�y: �County/City ❑ Well ❑ Community
9. no You anticipata �dciition3 or cxpansions of tUc facility this systciii is i�itendcd to sc►•ve? ❑Ycs L�No
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. 3:
If ycs,���l�at typc? j �;�,
***IMPORTAIVT'`**CLICNTS AfUST CObIPLL•TB TII� RLQUIRED PItOYLIiTY INI�ORMATION RCQUGS7'GD
BGLOW. Eithcr a PLAT or SITE PLAN h1US'l BE SU6�YIITTED by tlic clicnt �vith TII IS APPLICA'1'ION.
Property Dinlcttsions: ,�1�t� (.�i��l WRI'CG DIRGCf10NS(from Modcsvillc)lo PKOPI;K'1'1':
`_._�`..
``Tax OfCcc PIN: > # ��S�SI�C�c������� ._.(�'�/(� �A"'o!,►.lrL� r,fJir���dl �' lt�C�✓�
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Property Address: Road Namc��jC-�;���I �� . ,.rX �� ��d - ��Ya�►�
Clty/Zip (�(1,Y1r � GC��� ,10.�� C>n ��/lCXri����.S .C.�Cr��
If in a Subdivision providc ii�forniation,as follows: � . ...� nn � i�C V ��,
Namc: '�(��� .����/ -%��-5SC>� � ,,� , - �
n�� �` �0;�5 u�-�-��c��•
Sectio�i: I31ock: Lot: Datc lionic cornci•s tlabecd: g'-�a-��
Tl�is is to certify tl�at tl�e inforination provided is correct to tlie bcst of my kiiowlcclgc. I uiidcrstaitd tlint any peru►il(s)
issucd hereafter are subject to suspension or revocatioti,if the site plans or iutended use change,or if the inforinaliou
suUmilted in tl�is applicatiou is falsi6ed or clianged. I,also, u�tderstaud tltnt I aut res��u��siGle for al!c/tr�rges irrcrrrrcc!fi•nnr
llcis applicalio�r. I,hereby,givc conscnt to thc Authorized Represcntativc of thc Davic County IIcalth Dcp.u-t�nenl
to ci�tcr upon abovc dcscribcd property located in Davie County aud owned by �p�Q.��_ G. �LiGLr-I t�,�'1
to conduct all testing procedures as necessai•y to determine the site suitability.
DATE I �`�,�'O�� SIGNATUItE O _4'(_' ,}'�-,,�('J� �(_�����/���
THIS AItEA MAY BE USLD rOR DRAWING YOUR SITE PLAN(Includc all of thc follotiti�ii�g: �xisting and proposcd
property lines and dimensions, structures, setbacks, and septic locatioiis).
��� ;� ��t � ��,i�---�:_�.��- � Sitc 12cvisit Cliai•bc
' )atc(s):
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. Clicut Notification Datc:
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Sign givcn S Accouut No. �;����„�--�
Revised DCHD(OS/03 (�'������C � s`s Iuvoicc No. d ✓
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� z . _ N. 5.548 Acres+/=
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. by o Stone 414.71'
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fn L
Tax Lot 8
Tax Map G-9
. n/f�Jcy H.�Mintz,
Trustee of the
_ Jay H. Mlntz
- Revocable Trust �
DB 195 O PG 87 ,;
, • ' .
' - •,� , � DAVIE COUNTY HEALTH DEPARTMENT
� �� ' . ' ' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B
Billed To: Jake Miller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27006
Proposed Facility: Residence Property Size: see map 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 L
Slo e%
HORIZON I DEPTH �< ci
Texture rou L.
Consistence
Structure
Mineralo
HORIZON II DEPTH `� %
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
LONG-TERM ACCEPTANCE RATE s �
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-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
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firtn
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-gal/day/ft2
DCHD OS/99(Revised)
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