325 Ben Anderson Rd DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
, , ' ' ' P.O.Bog 848/210 Hospital Street G� 3�7�D
Mocksville,NC 27028 �
. � ' /
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001579 Tax PIN/EH#: 5802-45-9392
Billed To: John Hohmann Subdivision Info:
Reference Name: Location/Address: Ben Anderson Road-27028
Proposed Facility: Residence Property Size: 3.974 acres
ATC Number: 2719
**NOTE** This ImprovemendOperation 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 M �t #People 3 #Bedrooms 3 #Baths Z
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) Site: New❑ Repair�
System Specifications: Tank Size /Op�GAL. Pump Tank GAL. Trench Width.3G�� Rock Depth /�t Linear Ft.ZO�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTTCE: Contact a r r o t e Davie Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:0 .to 1:30 . e ay of7tistallation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: Date: p���ZS�'Q�
DCHD OS/99(Revised)
' . �Q/ .3- 7�/
. ' ' ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' ' � r.o.Bog sasnio x�p�t��st,��t
Mceksville,NC 27028
(336)751-8760
Account #: 990001579 Tax PIN/EH#: 5802-45-9392
Billed To: John Hohmann Subdivision Info:
Reference Name: Location/Address: Ben Anderson Road-27028
Proposed Facility: Residence Property Size: 3.974 acres
ATC Number: 2719
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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Gx%(�f Date: c�.c ��� �1
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 I 1 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 oftime. i/
���X /�'
�
Septic System Installed By:
Environmental Health Specialist's Signature: Date:�— o� (O�v f
DCHD OS/99(Revised)
, . . - p � � � � M �
. , ` � � APPLJCATION FOR SITE EVALUATION/IMPROVEMENT PEI�MI��c ATC �
Davie County Health Department FE6 ! 4 ZOpI
• ' Environmenta/Hea/tfiSection �
P.O. Box 848/210 Hospital Street �_____��
Mocksville, NC 27028 EN''�'�'����"�,ici�17;;�
(336)751-8760 D�i'ulE���,v yEl�tTH
***I1�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Nama to be Billed rl Contact Peraon
Mailinq Addzesa �� p ��WCk..ti'`� ��'('k � Home Phone 7'7�—S.�/y�-
City/State/ZZP 1 1 �OC'��S1�`I�le �t/c � /(���7 Husinesa Phone 3�0�—O 7oT
2. Name on Pezmit/ATC i£ Different than Above
Mailinq Addreas City/State/Zip
3. Application For: �( Site Evaluation ❑ Improvement Permit/ATC ❑ Both
a. syHtem to se=vice: ❑ House J�' Mobile Home ❑ Business 0 Industry ❑ Other
5. Zf Residence: � People �_ R Bedrooms �_ A Bathrooms �_
f_1 Dishxasher ❑ Garbage Disposal ❑ Washing Machine O Basement/PlumY�inq ❑ Basement/No Plumbing
6. If Buainess/Induatry/Other: Specify type # People �k 3inka
� Commodes / Shoxers i Urinals �F Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per day)
�. Type oP water supply: ❑ County/City j� Well � Comaunity
s. Do you unticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY 1NFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: � ., 6 l � �--� WRITE DIREGTIONS(Srom Mocksville)to PROPERTY:
TaxOfficePIN: # 5`dDa-�45-Q�a C�01 Nar`1-� - /urn �c°f�
PropertyAddress: RoadName_ '1,Cr1 �Y1det'S�VL (�v� �i��v �YIuV'c{� �a ��
City/Zip �OC'_��S V►��c o�7��� ��-t-t' D`(�-}�� I�c�^ �v'e��< C� ,
If in a Su6division provide information,as follows: ��_ _ �i� ��` n� I)f.et t�y nC�^S�x _
' �/i D � ���,� w�//
Name:
G{ P r� h-� 4 ��s an�so� .-w,rl
Section: Block: Lot: DatePropertyFlagged:,..-- " � � n,�{--{a o/S
r 1 ; 8' �...' 6ccrfL
Th�s is to certify that the information provided is correct.to the best of my knowledge. I dcrstand t6at any pe�I A �cco
. • rmit(s) ��/ l��ll� w�i��e.
issued herea[ter are subject to suspension or revocation,if the site plans or intended use chunge,or if the mformation h�{
submitted in this applicatioa is falsified or changed I,also,understand that I am responsible for all charges incurred from
thts applicalion. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitabili .
DATE 2 13"' �� SIGNATURE _ � �/ ��...�--
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
�0 �{� 5��s �`�� Site Revisit Charge
• � ����,� Date(s):
-2� r«-ti�' �ubbo,•s �
Client Notification Date:
��� S�,ll,��- _ �,�r—�....� EHS: .
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t� Account Na �� !
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Revised DCHD(07/99) � , ) � ��,�,, Invoice No.
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� � ' ' DAVIE COUN'I'I'HEALTH DEPARTMENT
, .. '� � ' ` Environmental Health Section
.
Soil/Site Evaluation
" APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001579 Tax PIN/EH#: 5802-45-9392
Billed To: John Hohmann Subdivision Info:
Reference Name: Location/Address: Ben Anderson Road-27028
Proposed Facility: Residence Property Size: 3.974 acres Date Evaluated: �—�Z�,/
Water Supply: On-Site Well �� Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 .6 7
Landsca e osition ,[r
Slo e% o� .
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH " ''
Texture rou G
Consistence �
Structure 1C"
Mineralo �'
HORIZON III DEPTH
Texture rou
Consisfence
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
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 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-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
DCF�ID OS/99(Revised)
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