322 Blevins Rd (3) � . DAVIE COUNTY HEALTH DEPARTMENT �t��'�'a a
� Environmental Health Section
� - P.O.Boz 848/210 Haspital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001066 Tax PIN/EH#: 5823-09-9209
Billed To: Robin Boyer Subdivision Info:
Reference Name: Robin Boyer Location/Address: Blevihs Road-27028
Proposed Facility: Residence Property Size: 2.239 Acres
ATC Number: 2402
**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 ,�� #Bedrooms � #Baths�
Dishwasher: XJ Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size � Type Water Supply—�'�vr,/ Design Wastewater Flow(GPD)� Site: New�Repair❑
<< <i /
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.�
Other: "
Required Site Modifications/Conditions: 4.
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RIS R(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health epartment or 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 da ]lati n. Tele ne#is 3G)751-87G0.****
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Environmental Health S ecialist's Si ature: � � Date: � ..
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DCHD OS/99(Revised)
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' Y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
r.o.Bog sasnio x�p��i s��t
Mocksville,NC 27028
(33G)751-8760
Account #: 990001066 Tax PIN/EH#: 5823-09-9209
Billed To: Robin Boyer Subdivision Info:
Reference Name: Robin Boyer Location/Address: Blevins Road-27028
Proposed Facility: Residence Property Size: 2239 Acres
ATC Number: 2402
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED 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 Of�'ice 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 SpecialisYs Signature: Date: �—���
CERTIFICATE OF COMPLETION
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**NOTE** The issuance of this Certificate of Completion shall indicate t�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 sha ' s guaran e system will function satisfactorily for any
given period of time.
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Septic System Installed By:
Environmental Health Specialist's Signature: 1��/ Date:_�/'�� v
DCHD OS/99(Revised)
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/f' �seG�l� ��1�-��� � C� C� � DaC�
/"j� A,PPUCA710N fOR SfTE EVALUATION/IMPROVEMFM PERMIT&A �
/�' �o.�� Davie County Health Department � 2 7 200Q
�-�'i7U�`� � Environmenta/Hea/th Se�ction
P.O. Bou 848/210 Hospital Street
��� y ����r e' Mocksnille, NC 27028 ENVIRONI�9ENTAL HE�LTH
� (336)751-8760 DAVIE COUNTY
***I1�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED L)NLESS ALL TIiE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Nsme to be Billed �['�b f rl 1' � • I�L�C.+��� Contact Peraon � Q LQ Li)(e/�(�
Mailinq Addreaa /� � ►7�r'1 't ���C� '�. Home Phone �� a' ����
City/State/2IP �,V- S r�� a �,�3 Susiness Phone (Y�?yj, �� 3 � �'� 7S/ �
2. :�a� cr. :erait/'n:C i� Di�Perent than Above n� ��2'� �
c"""��"T��7—
Mailing �1dd=eas City/State/Zip
3. Application For: C+]�Site Evaluation ❑ Iraprovement Permit/ATC � Both
a. syratem to sesvice: [�'House 0 Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People � � Bedrooms 3 � Bathrooms �
tYsishMasher CI Garbage Disposal l�ashing Machine fi Basement/Plumbing LI Basement/No Plumbing
6. If Bueiaeaa/Induetry/Other: Specify type Y People � 3inka
� Commodea � Shoxera � Urinals �1 Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (gaiiona per aay�
�. Type of water supply: ❑ County/City f{h�ell ❑ Community
e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes C�To
If yes,w6at type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIIZED PROPERTY INFORMATION REQUESTED
�E�i.�::'. E:t6e:«;:..r.;u�•�f:���i,�i:�::ii�T�s::S�t/�3iKii�cD'oy tne ciient with`1'Hi5 APPLICATION.
Property Dimeasions: o� ���l i/C��'-r WRITE DIRECf10NS(from Mocksville)to PROPERTY:
Taz Office PIN: # J'��.?�-- C��� %�U� �l�J o� 1 ( L� nn �t
Property Address: Road Name�/eUi�f�G� d LC�-�-�- tJrl -�{\u(' � c\��("`��(�'S
City/Zip,i�ac`��cl/� ��.�� �P -�-� C�r� ��C U i r1S � _ .
If in a Su6division provide information,as follows: �Ot k� `�-}- i n�d, �Q t.�.lc�,_�,
Name: m�-rlul�� c�n IP-�- 1 anc( on�
Section: Block: L,ot: Date Property Flagged: ��o�`i" c��C�
This is to certify that the information provided is correct to the best of my knowledge. I understand t6at any permit(s)
issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in t6is application is falsified or changed I,a/so,understand thal I am responsible jor a/[charges incurred Jrom
thls applJcation. I,6ereby,give consent to t6e Authorized Representative of the Davie County Health Department
to enter upon above described property located io Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE J�`o�7��CT�O SIGNATURE ,� �. �j�r�,r�
THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of t6e following: Ezisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notificatioa Date:
EHS:
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,' . '�' DAVIE COUNTY HEALTfI DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001066 Tax PIN/EH#: 5823-09-9209
Billed To: Robin Boyer Subdivision Info:
Reference Name: Robin Boyer Location/Address: Blevins Road-27028
Proposed Facility: Residence Property Size: 2.239 Acres Date Evaluated: ��;%���j
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L� L. L�
Slo e% �—
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH O '' '' �' "' g��
Texture rou Ci
Consistence /
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 ,
SITE CLASSIFICATION: 7 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 .
Mineraloav
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
DCFID OS/99(Revised)
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