681 Becktown Rd , � � DAVIE COUNTY HEALTH DEPARTMENT �,�`�---�-Z-�3cf
Environmentai Health Section
P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028 �� �!�
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900422 Tax PIN/EH#: 5755-69-5373.00OE
Billed To: Erin Spry Subdivision Info:
Reference Name: Erin Spry Location/Address: Becktown Road-27028
Proposed Facility: Residence Property Size: 1 Acre
**NOTE'��Tfii b�mprovenient/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION 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 CONTI2ACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �� #People � #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 Type Water Supply� Design Wastewater Flow(GPD)�(Z Site: New� Repair❑
� �l �(
System Specifications: Tank Size��'iAL. Pump Tank GAL. Trench Width �� Rock Depth�� Linear Ft��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Deparirnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 .m. n the day of installation. Telephone#is(33G)751-8760.****
�
� � — -�
Environmental Health Spec�alist s S�gnature: i Date:_ � � �
DCHD OS/99(Revised)
, �
DAVIE COUNTY HEALTH DEPARTMENT
Environmentai Health Section
r.o.Bog sasnio x�p�ta�s��t
Mocksville,NC 27028
(33G)751-8760
Account #: 989900422 Tax PIN/EH#: 5755-69-5373.00OE
Billed To: Erin Spry Subdivision Info:
Reference Name: Erin Spry Location/Address: Becktown Road-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2361
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLJST 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 WASTEWATE CONSTRUCTION IS VALID OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: ..� Date:��:�.�-�
CERTIFICATE OF COMPLETION
**NOTE** The 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.
�,�1
��
�
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Septic System Installed By:
Environmental Health Specialist's Signature: Date: 7 �'���
DCHD OS/99(Revised)
' ` i ' � APPIICAiION FOR SITE EV1W1Al1UN/IMPItOVEMENT PFRMI 1b � � � � 15
• •� � Davie County Health Department
1 • �Q - - Envfronmental Nea/tfi SerHon F� � 0 (999
S � � P.O. Box 8�8/210 Hospital 3treet
� , Mockaville, NC 27028
� � (336)751-8760 �1VIRONP�1ENTAL�LTH
S DAVIE COU
***SF�ORTANT*** THI3 APPLICATION CANNOT BE PROCESSED UNLE33 ALL T'�iE REQUIRED
INFOP.MATION I3 PROVIDED. Refer to the INFORMATION BOLLETIN for iastructions.
i. Name !to be Billed L }T"'i� �, J 0 r� Contact Beraon
lisiling �ddreas � (�� �r.�e....��-�,� /_ � , $� rt►�,e �3 � G ��7�/ -�13 7�
City/8tate/2ip �6 C.1�S J�.``2 1V.l�� ��C] ��,� Bueineas Phone ��/ ^ � I I 2
�
Z. tiame or. Pe�it/ATC i! Different than Abave � T/�h �t'f'��
riailinq l�ddreas City/8tate/21p
3. licatioa For: fd 3ite Evaluation �� ✓22-U
App �Im¢�rov+ement Per�t/s'='C � Sotin
4. sy,t.em to servtce: C) House �l Mobile Homa ❑ Busineas I] Industty 0 Other
s. If Reaideac�: # People f ; Bedrooms �_ � Bathrooms �_
O Dishwa�her � (iarbaqe Diaposal I� ttaahinq !lachlna 0 Baaement/plumbinq 0 Basement/No Plumbinq
6. ii Bnsineaa/induat=y/other: Specity type # Beople f Sitil�a
• Coa�odea f shrnrera � Urinala • Nater Coolers •
IF FOOD3ERVICE: � 3eats Estimated iiater Usaqe (qalions per day)
7. Type of �+ater snpplp: el Connty/City 0 Nell ❑ Co�unity
e. Do you anticipate addition�or e:pansions of tde tacility thia eyatem is inteuded to serve! ❑Yes � No
It yes,what type'
**"IMP�ORTAN7'•'"CY.IENTS 1HUST CO�1tPLElE THE REQUtRED PROPERTY INFORMATION REQUESTED
r BEL(A4'V. E��ber a PLAT or SlTE PLAN hfUST BESUBhtITTED by the dtent with TEi1S APPI.ICATiON.
Property Dlmenaiona: 1 aerc. WRI'1�DIRECTIONS(tmm Mocl�ville�c�o A��P?R'II'Y:
ia:iiiiice�'YN: # � -�� � dDO��a I Socx{� �{-a �ec-l�%{�'a,c�r` Q,�,
rt
Property Addresa: Road Name ��ck��«,�.. ��. Sd �.��.c�s� ko end O�- 1}'b��, • -
�� City/Zip_,j`l�v�'il�v�lr�.�'LC. Zzvz�' �'o�e��tY l�e-��„cQ� �.��,�,.�e- c�.��,
� ' If in a Subdivision provide inSormation,a�followa: �f�r.e k�r y�S�p e �k� '�5 w��e�
Name: Q.C�c. , •
Section: Block: Lot: DAte Property Fiagged: Z � ID ---`��
This i�to cerlify that t6e ioformalion provided is correct to t6e best of my knowledga I underatand that any permit(s)
issued hereafter are subject tv su�pen�ion or nwocatioo,ii the aite plans or intended use c6ange,or if the information
submitted fn fB1�Applicatlon ia t�tlsitied or changed I,also,anderstand th�I an�responsib/e for all cbo,ga lircurred fronr
this application. I,6ereby,give consent to the Aut6or'rud Repreaentative of the Davie County Healt6 Departmeat
to enter upon above described property located in Davie County and owned b�� f�o•��, �ol E. 5 pr�
to couduct all testing procedurea as necessary to dMermine the�ite auitabilih-.
DATE � ��' f �'9 SIGNATURE � -
'*'�::ti ti;.��;.rrnn it i�L Y�SED Falt r�RA�+ING YOUR SI'I'E PLAN(Inciude xll of the toilowing: E�ning�nd proposed
property lines and dimensions, atructures, aetbacks, and aeptic locations): �L ,/
. C� (� C� � �IC� �� e��r
D /Q
� �
� �R I � 2oao �t�v� ��
� _ C^`'❑ r T I� 7l� �°���
O �J��yQ' �a�� T u�Ylf\�i\i�t�t.��11'1L�'�Lr\�7f1
� � pAVIE COUNTY
�, �, , �
---� ____� ,1 �
-s Account No. �
[3 e�kte,�•`�R.�. �'/,�,�Q� v
Revised DCHD(07/98) ���� Invoice No. ��v�-
�s
T
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t � �
' "� � DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section SECTION LOT
SoiUSite Evaluation
�
APPLICANT'S NAME �!�.`yt /I J'�/ DATE EVALUATED �If���
PROPOSED FACILITY �f�"+ PROPERTY SIZE 1 ��e
SUBDIVISION ROAD NAME ��CO✓/�� (i�
Water Supply: On-Site Well Community Public t�
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �L. ,L
Slo e%
HORIZON I DEPTH �' °�
Texture rou /
Consistence
Structure
Mineralo
HORIZON II DEPTH � '� '�
Texture rou G'
Consistence � i
Structure /c.
Mineralo � `/ /� "
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION i
LONG-TERM ACCEPTANCE RATE � , �
SITE CLASSIFICATION: �� EVALUATION BY: .0 /'Cb //
LONG-TERM ACCEPTANCE RATE: i OTHER(S)PRESENT:
REMARKS: ��rnC� �C�C �`l�(JLLyI��lG' �
LEGEND
Landsc�e Position
R-Ridge S-Shoulder L-Lineaz 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
et
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
l:l,2:1,Mixed
otes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-T'hickness 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(sui[able),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD(O1-90)
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♦ ' � �
Di�1lI� COUNTY�Ii�LT�I D���}iTh�I�1V'f
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
(336)75i-8760
March 5, 1999
" Erin E. Spry
169 Green Iron Lane
Mocksville, NC 27028
Re: Site Evaluation
Becktown Roadll Acre
Tax Office PIN: #5755-69-5373
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
March 1, 1999. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
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Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/wd
Enclosure(s)