287 Bailey's Chapel Rd + r :. '
" DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
P.O.Boa 848/210 Hospital Street
Moctcsville,NC 27028
(33G)751-8760
Account #: 990001626 Tax PIN/EH#: 5779-24-7532
Billed To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Baileys Ch. Rd.-27006
Proposed Facility Residence Property Size: 42 x 76
ATC Number: 4245
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). 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 11 of
G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /�' Date: ��' Z "jJ�
CERTIFICATE OF COM f`�E IO I�`
**NOTE** T'he issuance of this Certificate of Completion shall indicate the sys em d ibed on ImprovemendOperation Permit
has been installed in compliance with Article 11 of G.S. Chapter 13 A, ion.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee t at system will function satisfactorily for any
given period of time. ���
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Septic System Installed By: ��� / �
Environmental Health Specialist's Signature: Date: �//�f�i(�
DCHD OS/99(Revised)
� � DAVIE COUNTY HEALTH DEPARTMENT ����
, ` Environmental Health Section ,I�
- . • P.O.Boz 848/210 Hospital Street �C��
Mocksville,NC 27028 ��
(33G)751-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001626 Tax PIN/EH#: 5779-24-7532
Biiled To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Baileys Ch. Rd.-27006
Proposed Facility Residence Property Size: 42 x 76
ATC Number: 4245
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction ofa 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
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 #People � #Bedrooms_ �� #Baths�
Dishwasher� Garbage Disposal: ❑ Washing Machin� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply C v Design Wastewater Flow(GPD) �� Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt�� Rock Depth�� �Linear F - DU�
Other:
aCcepied Systems may �,Iso�be use5d
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLU .N ILTER. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Cou ty H alth 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 inst 11 ti n. Telephone#is(33C)751-87G0.****
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DCHD OS/99(Revised)
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DEDICATE AU.$7REEf5 (ROAD), ALLEYS, WAU(S, PMKS AND OTHER SRES AND PIPE 1 a \ _ � C.0 �
EASEMENT TO PUBLIC OR PRNATE USE AS NOTED. �O ' � �
OWNERS / oo �s 9� pq V, \ \ D
DATE SICNED �` r
/ IPS S �I�S3�2Sa E/P \R/W e �
GARY F. YARBROUGH � IS0°0' e �` E,P
DB 326 PG 281 � IPS
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I HEREBY CEKfIFY THAT THE OAVIE COUNTY HEALTH DEPARTMENT HAS /
EVALUATED THE SUBDMSION ENTITLEp CHRIStt ROELS WRH �
RESPECT TO CRITERIA AND CONOITIONS ESTABLISHED BY STATE U1W OR -
PROMULGATEO THEREUNDER AND THE SAME IS FOUNO TO COMPLY WITH SUCH /
CRITERIA AND CONDITIONS EXCEPT AS FOUND IN SUCH EVALUATION. FOR
FlLE AT THE SWD DEPARTMENT, .
IMPORTANT NOTICE: THIS CERTIFlCATE DOES NOT /
CONSTIME q PERMIT OR APPROVAL OF INDIVIDUAL lOTS IN /
SPJD�Z �118DMStON FOR IN LATION SEWACE FACIUTIES ,
Cj.'a—
�A� � COUNTI'HEALTH OFFICIAL / \
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NO APPROVAL REQUIRED BY THE DAVIE COUNIY PLANNINC DEPARTMENT � 3
� / Q �
PLANNING DIRECTOR OATE � `
� / �� � LOUIE S. BEAUCHAMP
/ � P/o
� � + �' DB 152 PG 471
� _ � . 001 Ac -
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DB 152 PG 471
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NOTES: /
1.) THE CURRENT ZONING IS R4
2.) THEIR IS NO NC GEODEf1C MONUMENT FOUND WITHIN 2000' /
3.) AREA BY CO-ORDINATE ME7HOD
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.�- - � • DAVIE COUNTY HEALTH DEPARTMENT
��' ' ' . Environmental Health Section
� Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001626 Tax PIN/EH#: 5779-24-7532
Billed To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Baileys Ch. Rd.-�7006
Proposed Facility: Residence Property Size: 42 x 76 Date Evaluated: �1'�3 �'G?S�
nit Public �
Water Supply: On-Site Well Commu y
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition L
Slo e % � L
HORIZON I DEPTH G' �. �.
Texture grou
Consistence �"
Structure � /
Mineralo
HORIZON II DEPTH �' �`'
Texture rou
Consistence �
Structure � /{
Mineralo � `
HORIZON III DEPTH T
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
T,andsca,�e 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
Textur�
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
.ON4IST�.N . .
�'IQ3SY
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky .
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S r, ,r
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralog,v
1:1,2:1,Mixed
1Y4�&
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/OS(Revised)
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