1227 Bear Creek Church Rd . � �i�
�. DAVIE COUNTY HEALTH DEPARTMENT
' . .
Environmental Health Section � l - �..C.../ ,.,U J
P.O.Bog 848n10 Hospital Street �
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001269 Tax PIN/EH#: 5802-13-9385
Billed To: Jerry Ander'son Subdivision Info:
Reference Name: Jerry Anderson LocationiAddress: Bear Creek Church Roaci-27028
Proposed Facility: Residence Property Size: 10 ACres
**NOT�*��liib�Impro4e$inent/Operation Permit DOES NOT authorize the construction ofa 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 �Dl�h.� #People Z. #Bedrooms � #Baths�
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size�� A��=� Type Water Supply �G�-L-- Design Wastewater Flow(GPD) 3t�-.�p Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�` Rock Depth 1Z Linear Ft.�t
Other: � �15TFi1 g��o� �4'r�c� , I,3ST�Lt� t.�.J�:.S ��o.C.w�i►.�,
�
RequiredSiteModifications/Conditions: �JS`�IaLL._ g,�l C��1`TCUc)Q �� lep` �Q�_�)� ,�Q j p�F
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6��BELOW
FINISNED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: Date: � i9
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DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmentai Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990001269 Tax PIN/EH#: 5802-13-9385
Billed To: Jerry AnderSon Subdivision Info:
Reference Name: Jerry Anderson Location/Address: Bear Creek Church Road-27028
Proposed Facility: Residence Property Size: 10 Acres
ATC Number: 2488
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLJST BE ISSLJED 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 CONS CT N IS V ID FOR A PERIOD OF FIVE YEARS.
i
Environmental Health SpecialisYs Signatu • � � Date: �f� C7C�
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion 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: �_ ���� IM Nw�s
Environmental Health SpecialisYs Signature: Date:� 1J �
DCHD OS/99(Revised)
. , . �Y �
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a APPUC�ATION FOR SRE EVALUATION/IMPROVEMENT PERM17&A � � � Q �YJ �
Davie County Heaith Department
Environmental Hea/tfi Se�ction
P.O. Box 848/210 Hospital Street � 2 9 20��
Mocksville, NC 27028
(336)751-8760 ENVIRCNP,1ENTAL HEALTN
DAVIE COUNTY
***II�ORTANT*** THIS APPLICATION C�INNOT BE PROCESSED UNLESS 11LL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i. N� to � siiiea __Uc R R V {�nale�so n Contact Pereon��a n►�e �der.5o„!
Mailinq 1►ddreas ���g t��„� �,eeek C�hUf cyn /Cd Home Phone 3�(„ t�9Z- �j5 7
city/state/zxp _�OG��S��� 1 I e N C Z 70 Z 8 Huaineae rhone 3 3(o /5 d t'
2. Na� on Parmit/ATC if Dilfarent than nbo,►e 33(� SI-21' i
Mailinq I►.ddreee City/State/Zip
� 3. Application For: �3ite Evaluation H'Improvement Permit/ATC Soth
�. syret� to Serv3ca: �9 FIouae ❑ Mobile Home ❑ Business Cl Industry ❑ Other
s. if Residence: f People Z � Bedrooms l.� t Sathrooms �
� Dishwaaher �Gerbaqe Dispoaal b(itashing Machine II SaaementlPlumbiag II Sasement/No plumbing
6. 2t Suainesa/Znduetry/Othor: 8pecify type Y People � Sisilce
� Commodee � Showern y U=inals � Piate= Coolers
IF FOODSERVICE: �F Sests Estimated Water Usage (qallone per day)
7. Type of water supply: ❑ County/City � Well L7 Community
e. Ao you anticipate additions or e=pansions of the facillty this system is inteaded to servc? ❑Yes �No
If yes,what type?
***(�4lPORTANT***CLIENTS MUST COMPLETETIIE REQU/RED PROPERTY 1NFORMATION REQUESTED
BEI.OW. Either a PLAT or SITE PLAN MUST BESUBMIT7'ED by the client with THIS APPLICATIOIV.
E:3�;�.:3r I1i�et�sioas: /�a�-�z� WRITE DIREGTIONS(irom Mocicsville)to PROPERTY:
Ta:OificePIN: # S80Z -' l3 � O�3 �6S� ,,fy0 / ��yfi -{� L� Beei'� ��. J��
Property Address: Road Name�ear �P..Lek �. l�� _�B'�'"� o�'1 �.+ ber'iV �► • ��c� "�
c�ryiz�p rYlo�cs��I 1e N C �ea.r p L�ti ,�Pd - �.e-4�'-� o„/�
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If in a Subdivision provide intormation,as follovvs: �et�.Y' (' p�A-pDI�D X �m i l�e s �
l.oca.�4-ec1 i,n Pl�S��f. �'t-wee�1
Name: �hpis fl-r�t�E(LSo/1_ �i-. L° 2 �Q.f'So�1
��-�s de o 2aa
Section: Block: Lot: Date Proper3�+Flagged: G 'a�-�2
This is to certify that the information provtded ts correct to the best of my knawledge. I understand that any permit(s)
issued hereafter are subject to suspension ar revocation,if the site plans or intended use change,or if the information
submitted ia t6is applicalloa is falsified or changed I,also,understand thal 1 am responsibte jor all charges incu�red from
1hTs appltcation. I,hereby,give consent to the Authorized Representative of the Davie County Iiealth Departmeat
to enter upon above described property located in Davie County and owned by Llhk15 �E�oi'1
to conduct all testing procedures as necessary to determine the site suitability.
DATE G�- �-�v SIGNATURE ,����
TIiIS AREA MAY BE USED FOR DRAWIlVG YOUR SITE PLA.N(Include al{of the following: Eiisting and proposed
property lines and dimensions, structures, setbacks, and se tic locations).
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. �w Site Revisit Charge
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2 Client Notification Date:
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• � . ,` � DAVIE COUNTY HEALTH DEPART"MENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001269 Tax PIN/EH#: 5802-13-9385
Billed To: Jerry Anderson Subdivision Info:
Reference Name: Jerry Anderson Location/Address: Bear Creek Church oa 27028
Proposed Facility: Residence Property Size: 90 Acres Date Evaluated: � _
Water Supply: On-Site Well ( Community Public
Evaluation By: Auger Boring Pit Cut �—
FACTORS 1 � Z 4 5 6 7
Landsca e osition � �
Slo e% Zo
HORIZON I DEPTH � -� � V D—
Texture rou Gt� :Ci� eL
Consistence Fi'S�� 5
Structure
Mineralo 1�` f �
HORIZON II DEPTH - lcJ - ZCv .- Z�
Texture rou C
Consistence :� F.`
SWcture
Mineralo � ` I`
HORIZON III DEPTH 20-�O —c.1t-j'
Texture rou C�- _ G�f C-�S
Consistence SyS�
Structure L� S
Mineralo l: 1 ;
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE C7 -
SITE CLASSIFICATION: � EVALUATION BY: ���� 'rol�('��`�P
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-Subangulaz blocky PL-Platy PR-Prismatic
Mineralo�v
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)
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