349 Big Oak Ln DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �,� �".� s-� v��
� � P.O.Boz 848/210 Hospital Street
• ' Mocksville,NC 27028
� (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001612 Tax PIN/EH#: 5850-99-7644.01
Billed To: Sean Sprinkle Subdivision Info:
Reference Name: Location/Address: Big Oak Lane-27028
Proposed Facility: Residence Property Size: 2-3 acres
ATC Number: 2772
**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 INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People Z #Bedrooms � #Baths�
Dishwasher:� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �.�L Type Water Supply G�1P// Design Wastewater Flow(GPD) Site: New� Repair❑
System Specifications: Tank Size�t10 GAL. Pump Tank GAL. Trench Width�6 �� Rock Depth� Linear Ft.�
Other:��� -.f''�7 �.�y� U�
Required Site Modifications/Conditions:
IN[PROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G `�BELOW
FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie CountyHealth 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 installation. Telephone#is(336)751-87G0.****
�
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Environmental Health Specialist's Signature: � ,. � Date: �S h c
DCHD OS/99(Revised)
. , ��
DAVIE COUNTY HEALTH DEPARTMENT
. ' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990001612 Tax PIN/EH#: 5850-99-7644.01
Billed To: Sean Sprinkle Subdivision Info: -
Reference Name: Location/Address: Big Oak Lane-27028
Proposed Facility: Residence Property Size: 2-3 acres
ATC Number: 2772
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEWAT � CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � - � Date: '�'S — �}l
CERTIFICA,,TE F COMPLETION
C�
**NOTE** T'he issuance ofthis Ce 'ficate Co plet n sh 11 i icate the system described on ImprovemendOperation Permit
has been installed in comp �ance 'th icle 1 o G. .Chapter 130A,Section .1900"Sewage Treatment and
Disposal Systems,"but shal 'n NO A be t en s a uarantee that the system will function satisfactorily for any
given period of time. �I� �b�
�
Septic System Installed By: �,L/�-FyL (���,<-%.��
Environmental Health Specialist's Signature: Date:�` 2?�2 ��
DCHD OS/99(Revised)
. o�. �j�- i � � i
' " ' APPLICATION FOR SITE EVALUATION/If�1PROVE1titCNT P�[tAti�. CL5 � �I
� �'' ;' � Davie County Health Department �'�+
Please complete the highlighted area(s) d � Environmenta/Hea/th Section ' � �'
e����� .o. s o x 8 4 8/2 1 0 H o s p i t a l S�r e e t , �1 A R F ?��� ;
return. � � Mocksville, NC 27028
(336)751-8760
� �O ��� � �'�VIROI�MEPJTAL NEALTH
***IMYORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL T � � UFR�
INFOR2�ITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Nama to be Billed ��-� 5��� N 1'�LE Contact Peraon ��p�� s r R�N���_
Mailinq Addroea 3�y1 /�I�-j- �t'T Y� i�T��. flome Phono�_i—�3�� �"'� b - � 25q�
_�
City/State/ZZP tv{Q('�V( L� E �C � (Q�15 Hu ' Phono �3 �lQ ) -( � J`S 7 9
.
2. Name on Permit/ATC if Different than Above
� �
Mailing Addresa City/State/Zip
/ ���-S � ' '�� �
3. Application For: C'ISite Evaluation ❑ Improve t Pe t/ATC F3o
4. Syatem to se�„ica: � House 0 Mobile Home ❑ Bu ness Industry ❑ Othe
5. =f Residenco: � People �_ �k Be ooms � # Bathrooms ��
f.�7 Dishwasher (7 Garbaqe Disposal Wsahing Machine C Basement/Plumbing ❑ Ssaement/No Plumbing
6. Zf Huaineea/Induatry/Other: Specify typa � Paoplo A Sinke
� Commode� � Shoxera � Urinals �! Water Coolors
IF FOODSERVICE: # Seats Estimated Water Usage (gallons por day)
�. Type�of water supply: ❑ County/City Q Well ❑ Community
e. Do you anticipate additions or capansions ot tt�e facility tl�is system is intended to servc? 0 Ycs L'f No
lf ycs,what typc?
***IMPORTANT***CLIENTS MUSTC06tPLETETIi� RL'QUIKED PROP�RTY 1NrORMATION RGQUCSTGD
BELOW. Either a PLAT or SITE PGAN h1UST BESUBMITTCD by tlie clicnt with TIIIS APPLICATION.
Pro��crty Dimcnsions: �'�pf, 02 "' 3 Qe.fC WRIT�DIItCCI'IONS(from blocluvillc)to f'IiOPLIi'1'1':
Tax Oftice P1N: # , S�-S 6— �� �����` ��g � � ��o� � mi�r�s PQSs �1e..
Property Address: Road Name �{G Ge41� l�-NE �Q!mi r10"I on �� '�JC[ � — ►`7�`p
d"
C;tyiZip {�(OC,KSv��F �p�8 C Qa k La�n t s Gn �e ����-�
lf in a Subdivision providc information,as follows: n�('� .�l�S �h� 1'1of S2 harrZ ,
Namc:
Section: Block: Lot: Date Property Fla�gecf: l�
Tt�is is to certify t6at the information provided is correct to tl�e best of my knotivlcdge. I ttndcrstand tLat any permit(s)
issucd hcreatter are suUject to suspension or revocation,if the site plans or intcndcd use cLange,or if the infurmalion
submitted in this upplication is falsificd or changcd. I,also,uaderstand thal!am responsible jor a11 charges incurrc�!jrom
this applicalion. I,I�ereby,give consent to the Authorized Representative of the Dnvie County I�calth Department
to enter upon abovc described property located iu I)avie County pnd owned by
to concluct alt testing procedures as necessary to deterinine the site sui bility. �
DATE 63�6 S�O I SIGNATURG �
TIiIS AREA MAY B�USED FOR DRAWING YOUR SITE PLAN(Include nll of the following: �aisting and proposed
property lines and dimensions, structures, setbacks, and septic locations). .
�r �� ' Sitc Rcvisit Cl�argc
3 � va���s�:
1 ��- ���� Client Notification Datc:
�`� � �`�� � EHS:
S.a.._ ,.�—
(� .:., �� _ (�,
��-`�'"� Accouat No. `E� � Z_
V � �
Revised DCHD(07/99) �' p�� � ' Invoice No. �� �t-`�
� �
� -L S' � �.••Z..
�` /!'Z ` L�-�-�"-�� . � .
�1 �� _ J / fNr� � ! �
7
DAVIE COUNTY HEALTH DEPART'MENT
, • • . Environmental Health Section
� � � � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001612 Tax PIN/EH#: 5850-99-7644.01
Billed To: Sean Sprinkle Subdivision Info:
Reference Name: Location/Address: Big Oak Lane-27028
Proposed Facility: Residence Property Size: 2-3 acres Date Evaluated: �-- /-s ��
Water Supply: On-Site Well �- Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH `� �``
Texture rou
Consistence r— 1'
Structure /�
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 .2�
SITE CLASSIFICATION: � EVALUATION BY:
�
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS: l��►���� ���J C 'p �` �'
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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
otes
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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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-4�06
Mocksville, NC 27028
Phone #: (336)751-87G0
March 15, 2001
Sean Sprinkle
349 Big Oak Lane
Mocksville,N.C. 27028
Re: Site Evaluation/Big Oak Lane
Tax Office PIN: #5850-99-7644.01
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
March 15, 2001. 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 a modified, oversized 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
RH/di
Enclosure(s)