322 Boozie Ln � - ' . , � DAVIE COiTNTY HEALTH DEPARTMENT
, Environmental Health Section
� P.O.Boz 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760
Account #: 99QOOQ683 Tax PIN/EH#: 5821-31-0$33
Billed To: George Keith Bracken Subdivision Info:
Reference Name: George Bracken Location/Address: Boozie Lane-27028
Proposed Facility: Residence Property Size: 0.941 Acre
ATC Number: 2121
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). 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � cLL� � - Date: �!���
� QQ�rr�d 11'�S
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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. t,
D
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' � _ ��.� -�'��T�'��' ,�%�1
Septic System Installed By: ~
Environmental Health SpecialisYs Signature:�'��,,(�� Date:_�
?�'o�S'—o
DCHD OS/99(Revised) '/
. . �,m DAVIE COiTNTY HEALTH DEPARTMENT n� �'s'�J/�
,, _ .. , , D
� Environmental Health Section �
� ' � ' ' � , P.O.Boa 848/210 Hospital Street
, ' • Mocksville,NC 27028
(33G)751-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000683 Tax PIN/EH#: 5821-31-0833
Billed To: George Keith Bracken Subdivision Info:
Reference Name: George Bracken Location/Address: Boozie Lane-27028
Proposed Facility: Residence Property Size: 0.941 Acre
ATC Number. 2121
**NOTE** T`his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AtTTHORIZATION 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 uf 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 PERMTT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type /�7 � #People � #Bedrooms � #Baths�_
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo P(umbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��/�C� Type Water Supply� Design Wastewater Flow(GPD) c�lo� Site: New�Repair❑
System Specifications: Tank Size��jL GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.�D
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 ��BELOW
FINISHED GRADE. ****KOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system betweer� 8:30 a.m.t :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: s' Y Date: ��/��
DCHD OS/99(Revised)
, . _..�_
A.PPLICATION FOR SITE EVALUATION/IMPROVEMEM PEAMIT&ATC
. • � Davle County Health Oepartrnent � � � � � � �
r � ��rj, - Environmenta/Hea/Gh Se+ction
� � „`;� P.o. Box 8�8/210 Nospital streat � � 6 ��
�1 n�►�►" Moakaville, NC 27026
U t' (336)751-8760
EtlYI�ONP.iFIlTAI H�/`+d.Tt�
�'�V F .n[r�
***.Z1�ORT�1NTt** THI3 APPLIGATION CANNOT HE PROCESSED UNLE33 ALL TEiE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFOtiMATION BOLLETIN for instructfons.
1. tiame ta be Hilled C,'1�Q12c{1= ��-, ����i?i�C.K�-"'i� Contact Fnrson ��� CcC�C 6L�
►�ailing Addreas f�. n. , , �'i!� sc�a �or►e „�33 6� `7 9�— �6�/o
city/8tate/Zip �n��<��� ��r� /`�'•C• ��t�c�.� Suslness Bhone 9n�— �9�'1
Z. Name on Aermlt/11TC i! OiilerenE than Abave
Mailing ]lddresa City/8tate/Zip
�. ]lppliaati.oa sor: �Site Evaluation }�Im�ravemeat Pezmit/ATC 0 Both
4. sy.tem to service: �House O �tobile Nome 0 Busineas 0 Iadustry 0 Other
a. if Itesideace: / Peopie � � Sedrooms �� / Bathrooms �
�Dishxasher 0 ciarbaqe Disposal � ttaahing ltachine y� Haaement/plumbinQ 0. Baaeme�at/No plumbl�ng
��
6. I! Bnainess/industry/Other: Specify type � Feaple �k SiN�a
• Co�odea # 8hoxers f Urinals � Rater Cooiera
IF FOOD3ERVICE: � Seats Estiaiated Water Vsaqe (Qalions per aay)
7. Tppe of xater supplp: ❑ Conaty/City � iiell ❑ Co�nunity
e. Do you anticipAte Addition�or e:panaiona of t6e facility thls syatem ia intended to serve! U Yea `�No
U yea,what type'
'*'IMPnRTANT'**CLIENTS�lli1ST C0�1lPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eit6er a PLAT or SITE PI.AN�lUST 13ESUBbl11TED by the client with TEIIS APPI1CATlON.
i
Property Dimenaione: J :: � �-��` �.= % WRIT'E DIREGTIONS(trnm Maksville)to PROPERTY:
Ta:Otiice PIN: # ) S`� I ' � I � 0 2, � ;� �r) I :��h����-1, �1-�ac a�I �i r-s.,�Y� �._ ,
� 1
PrnpeNy Addre�a: Road Name �b a��� �c �an� �;J l.�- n „ ���t �� �o�r� , �
�
l � 2
Clt}'��p '�n C�<�� ��< (1).f r��lT'L�i }41 � w i?� �,t�`i rc r �J OS?r Y �.�!�'1`�--
�— til
If in a Subdivision provide informAtlon,a�foilow': tQ �� 1��� LJ{l i/ �;� ���{' „$�'
e
Name: 13o b�;Y r�_�.,�, ;,
Section: Biock: Lot: Date Property Flagged: � g
Thi�is to certify t6at t6e information prnvided f�correct to the best of my knowlMga I underatxnd 16at any permit(a)
issued bereafte�are subject to auspension or revocation,if the aite plans or intended use cbange,or if tbe information
submitted jn thia Appifcatioa ta talsified or c6anged I,atso,anderstand that I ani nes,porrsiblejor al!cbarges fircurred from
tbis application. I,hereby,give conaent to the Aut6oriud Repreaeeutative of t6e Davie County Hexlth Departmeot
to eoter upon above described property located in Davie County and owned b�- (-'r�:,rn Y h�'�:-1!, � T�•��,� S i������-�,,,
to couduct sll testing procedures su neceuary to determine t6e dte aitabilih. '
�
DATE �� :��v l tn I `� `I �� SIGNATURE �1�;-tL c ��_��_` ''� _.c.,_./
v
7'f�IS AREA MAY BE USED F'OR DRAWU�IG YOUR S9'TL PLAN(Include all of t6e following: E��ting and propo�ed
property linea and dfinenaions, �ructurcs, aetbacka, and aeptic locatlons). .. , �
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Revised DCHD(07/98) Invoice No. �y�
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�� �` �� � ' NORMAN C. DILLINGHAM ����m - . _� • � -
ENCROACMENT OF l.0'AS PER SURVEY RECORDED D.B. 192 PG. 513 �-�`� � �
' 1N PL.BK. 6, PG. I92 \w0 \�`��_
existing o 0.8.192, PG. 5/3 t\ o new �ron ` - - - -- --. 4`,`� i o. \ 0 q��
iron �— — — — — — � .— __ S 85 39 29 E --�- -- — —. ---- -- --- -- — -- -- — — — — — — — — — -- — — — —�� \�� y�c,� �r+cEu r�.
existing 205.18 existing \ �__ \�;� u —
iron iron \\ `� < r�,�
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� � LONNIE P. BRACKEN � � �
c� � � o p,6. I19, PG, 170 0 \
� existing \1� ��� NOT TO SCALE
Z iron
� c+a,u � '��"� � V1CINITY MAP
o y1�°�� �
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� A� � N�
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Q new ir n •� W n existing �
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O RE/''�� 0.�7'r't� ACr S 800�2� 20„E —i ;ONN iron �� _, _
� I18.gp � o new /--S 13°52� 19' W � .�
� � � iron � 28.25
� N � + N� \
,- -. _ � .�_ �_ 63g9 0 � existing
new iron
�"' � N �3�iq' 32,� 4641 iron
_.1 � w +_ 586' S1'23" w _ \ V
t
w
\S 81° 43� 07��W \ - S 13° 50� 54��W
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% iron \
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�a cn � � _
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p— �.�``N CAIq '�.,� �� KENNETH P. BRACKEN
� m �600 + � ��. Q,'(.............0�� ., ; �.8. 149 PG. 481
a . o . Essi -
_ . °� o�• 2 •' .
' =QQ � '
0 new • � �:� � I
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15 8 iron � S•�L
96 r
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r� s�85685TOTA� LONNIE P. BRACKEN ;�=:�9 L-2527 oe':�: /
�ew D.B. 114 PG. 337 %�-9'•�.�.',OSURv�,�Q�O`
��o� 119 170 '�,O •••......... .
"''�Y�;,,;;;,��''� SFOREY KEITH BRACKEN
M
h I,GRAUY L.TUTTROW,CERTIFY THAT UNDER
SCALE: I�� = 30� APPROVED BY DRAWN BY
'� MY DIRECTION ANO SUPERVISION,THIS MAP WAS GRADY L. TUTTEROW D. CHAFF(N
DRAWN FROM AN ACTUAL FIELD SURVEY MADE DATE: 5 / I 9/99
�w `�Q ��� BY TUTT ROW SU VEYIN COMPANY. BEING 0 941 ACRES TAKEN FP,OM THE LONNIE P. BRACKEN PROPERTY(D.B I 19 PG
exist�ng �] (,��� �H RQ�D r 170,D.8. 114 PG 337).LYING IN THE CLARKSVILLE TOWNSHIP, DAVIE COUNTY,
iron ��� �� 2�,� l} (, �fti NORTH CAROLINA
� PROFES51 NAL AND SURVEYOR L-2527
�3�8�4�� J�B76 DRAWING NUMBER
TAX MAP REF.= F-3, A PORTION OF PARCEL 57.0! 11499-Z
�
�j,��'{ NO.I�SA�It[17 ,
_L `•
, DAVIE COUNTY HEALTH DEPARTIVIENT
� ' '�''' �, • ' Environmental Health Section
, . , � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY IlVFORMATION
Account #: 990000683 Tax PIN/EH#: 5821-31-0833
Billed To: George Keith Bracken Subdivision Info:
Reference Name: George Bracken Location/Address: Boozie Lane-27028 �
Proposed Facility: Residence Property Size: 0.941 Acre Date Evaluated: �%
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 '
Slo e% -�
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH " � "
Texture rou (i
Consistence �
Structure i� h/�
Mineralo . 'l
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: � EVALUATION BY: � a G
LONG-TERM ACCEPTANCE RATE: � 7 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
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-gallday/ft2
DCHD OSl99(Revised)
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