1332 Baltimore Rd . : - . . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
Account #: 990003707 Tax PIN/EH#: 5860-82-2987
Biiled To: CKJ Builders& Developers Subdivision Info:
Reference Name: Melissa Johnson Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: 2.974 Acres
ATC Number: 4453
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 Tre ment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW �(. C N IS V LID FOR PERIOD OF IVE ARS.
Environmental Health SpecialisYs Signature: Date:
CERTIITCATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion 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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Environmental Health Specialist's Signature: '�� Da •
" DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section
' • � ' � P.O.Bog 848/210 Hospital Street ��
Mocksville,NC 27028 � �,
(33f>)751-8760 'tiI�
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, IMPROVEMENT/OPERATION PERMIT
Account #: 990003707 Tax PIN/EH#: 5860-82-2987
Billed To: CKJ Builders& Developers Subdivision Info:
Reference Name: Melissa Johnson Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: 2.974 Acres
ATC Number: 4453
**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 IN'I'ENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � � - #People � #Bedrooms� #Baths�_
Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size �J�G' 'S Type Water Supply 1�����Design Wastewater Flow(GPD)_��.�L Site: New��Repair 0
�,�yr� 3 „ -/ �s
System Specifications: Tank Size �/GAL. Pump Tank GAL. Trench Width � Rock DepthN A Linear Ft.
Other: i� � 1� � � ��� �� �� � s �.�v! ��n� G�
,�� � ( �
Required Site Modifications/Conditions: �� � ��(`��T��lr}� � � t-NI�C� �� ��
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Il�'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT 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 .m�to 1:30 p.m. on the day of installation. Tele�phone#is(33G)751-87G0.****
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DCHD OS/99(Revised) � �'�'"�"'��� ?�I '
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' �l�L�'C�'��T � SITE EVALUATION/IMPROVEMENT PERMIT & ATC
D Davie County Health Department
JUL 1 B 2006 Enviro�zmental Healtlz Section
. P.O. Box 848/210 �-Iospital Street
ENVIRON��ENTAL HEALTN` Mocksville,NC 27028
oavi�cou�n (336)751-8760/Fax (336)751-8786
Application For: ❑ Site Evaluation/Improvement Pernut Authorization To Construct(ATC) ❑ Both
***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED ,
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION �
Name to be Billed �� •<< �Y � - � c� fl L�� Contact Person /'�(�����SC��¢_ �5�,�i� ��.
Billing Address �3 '�`� ` CF , . , Home Phone �!�CO�-a ,
City/State/ZIP � d Business Phone �-(/Y— �( -rj'D �
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION
NOTE: A survey'plat or site plan must accompany this application.
(Pemut is valid for 60 months with site plan,no expiration with complete plat.)
Street Address /33�� (f;�,�,r��,�� City j�n(c'�'"� c� Tax PIN#
Subdivision Name Section/Lot# Lot Size �, ��
Directions To Site: � .c -- G� �
L�� � � — � ��.. � �
Date House/Facility Corners�Flagged
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �Io
Does the site contain jurisdictional wetlands? ❑Yes �2Qo
Are there any easements or right-of-ways on the site? ❑Yes f1�Io
Is the site subject to approval by another public agency? ❑Yes�No
Will wastewater�otlier than domestic sewage be generated? ❑Yes�No
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool _JYes ❑No
__ Basement: ❑Yes o Basement Plumbing: ❑Yes fi�3�o
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
# Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested: C11�onventional ❑Accepted �Innovative ❑Alternative ❑Other
Water Supply Type: �unty/City Water O New Well �Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes �
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
. the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred
from tllis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to t rmiq ompl'anf�with ap ,1'cable laws and rules on the above described property located in
Davie County and owned by ,���i,�"���`'"�C/(������c�fj/.i
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✓h—�—'�— Site Revisit Charge
� Prop rty owner's or o er's legal representative signature
r. Date(s):
�� �' � Client Notification Date:
ate EHS:
Sign given ❑Yes ONo Account# U�
Revised 2/06 Invoice# y�3�7.`
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IF FDODSEBVICE: 9 Soata � Iiatimatad Watcr IIeage (gallon�p.r dnp)
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issued ACrca(Icr aft mbjeM to suspcnsica or reveeation,if fLc sifo plaax ar infencld use ehaugc,ar i[WQ LdOrfmllioa
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SUBDIVISION Si/9DIYISlON
PL. BK. 8, PG. 15 PL• BK. 8. PG. 150
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t , � � ' DAVIE COUNTY HEALTH DEPARTMENT
.--.
- Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003707 Tax PIN/EH#: 5860-82-2987
Billed To: CKJ Builders & Developers Subdivision Info:
Reference Name: Location/Address: Baltimore Road-27006 �
Proposed Facility: Residence Property Size: see map Date Evaluated: lZ ��
a.9����s
Water Supply: On-Site Well Community Public ✓
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 3 4 5 6 7
Landsca e sition L.
Slope% �
HORIZON I DEPTH �— 2
Texture grou •�
Consistence r S
Structure
Mineralo � ,�
HORIZON II DEPTH
Texture rou ;
Consistence - S .
Swcture 3
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 v. 1 � .
' SITE CLASSIFICATION: EVALUATION BY:
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'�' LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT:
{..
�' REMARKS:
'Z LEGEND
� i.�ndscape 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
T�Ct�urg
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
�'IQ1S�
VFR-Very friable FR-Friable FI-Firm VFI-Very�rm EFI-Extremely firm
�.�t' - . ' ', •
� NS-Non sticky SS-Slightly sticky � S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightiy 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
Mineralo�v
1:1,2:1,Mixed
LIQts�
Horizon depth-In inches � .
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
il wetness-Inches from lan�l'surface to free water or inches from land surface to soil colors with chroma 2 or less `
sification-S(suitable);�AS(pipvisionally suitable),U(unsuitable)
-Long-term acceptatice rate-gaUday/ft2 DCHD OS/OS(Revise
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. �
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►
. � .,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
� Phone: (336)751-8760 / Fax: (336)751-8786
August 17, 2005 �
CKJ Building&Design, LLC
Attn: Chris Johnson �
233 Falling Creek Dr.
Advance,NC 27006
Re: Site Evaluation-
2.974 Acre TractBaltimore Road
Tax PIN#: 5860822987
Dear Client(s):
As requested, a representative from this office visited the above site August 12,
2005 to perform a site evaluation. Based on the information provided on the Application
for Site Evaluation and after the evaluation was completed,the site was found to be
provisionally suitable for the installation of an on-site sewage disposal system.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct, the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
I
� .
�
Jeff G. Beauchamp, R.S.
Environmental Health Section
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