180 Buena Vista Ln DAVIE COUNTY HEALTH DEPARTMENT
, . �� � �" s_ .Z'
Environmental Health Section
� P.O.Boz 848/Z10 Hospital Street �
, Mocksville,NC 27028
► (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002085 Tax PIN/EH#: 5811-69-6370
Billed To: Sherman Dunn Subdivision Info:
Reference Name: Location/Address: Buena Vista Lane-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3036
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An ALJTHORIZATION 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 �J// #People� #Bedrooms�� #Baths�_
Dishwasher:� Garbage Disposal: ❑ Washing Machin� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size�(� Type Water Supply �G Design Wastewater Flow(GPD) Site: New❑ Repair❑�
System Specifications: Tank Size`d6D GAL. Pump Tank GAL. Trench Width�6� Rock Depth ✓���Linear Ftt��'B'
Other:
Required Site Modifications/Conditions:
I1�IPROVEl1'IENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF C"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health 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(33G)751-8760.****
�
Environmental Health Specialist's Signature: � Date: /�� "����
DCHD OS/99(Revised)
� . ���
• . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
, • P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990002085 Tax PIN/EH#: 5811-69-6370
Billed To: Sherman Dunn Subdivision info:
Reference Name: Location/Address: Buena Vista Lane-27p28
ATC Number: 3036
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWA NS RUCTION IS A D R 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 ImprovemendOperation 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.
I'
Septic System Installed By:
Environmental Health Specialist's Signature: ��fi'�.��- Date: �—2 /-!�Z �'
DCHD OS/99(Revised)
APPLICATION FOR SRE EVALUATION/IMPROVEMFM PEAMIT&ATC
. . Oavle County Health Depa�tment
� r -� � Env3ivnmenh�/Hea/th Se�Gion
p.0. Box 848/210 �oepital BtrNt
. . Moakevilie, NC 27028 � •
' (336)751-8760
***Zl�GRTANT�** '1'HI8 71ppI+IC71TI0N CJINNOT B� PROC688�D UNL�88 71LL T� REQOIRaD
IN�'ORM'ATION I$ PROVIDED. R�f�r to th� IN�"ORMATIO�i BULL�TIN !or iastxuatione.
1. mas� to b. siii.d �� C r M A N .f�, ,� 1 i✓V n� Coataot p+r�oa J�� �
�tasiiew 71aar•s• f�D /���w.� V �`S T60 •,�d1/', 1[0�. phoa. ���-S')/ �
cshr/asat../s=a /� �G.�S(�,` i�� ,N� . 2 7ti.�$ au.sa.,. �on. `7 �6 S-[fl ? �� ��
Z. Itaw on �uit/1►TC i! Di!l�synt thari 7lbosr
�tailinQ 71dds��• City/8l�t�/iin
�. 1►ppiication ror: 0 Sit� =valua�i.oa 0 Improv�meat II�rmit/11TC �"8oth
�. a�.s.. to e.rvio.� 0 Hons• p�obile Hom� 0 Husin�ss � tadustsy 0 Oth�r
c �
a. It ttesieiuia�: f peopl� � Hadrooms S � Bathzooms
�'Di�hruls�r O Qasbaq� Di�po�al '1t�'lrasbiaq 1faoLia� O Huwnt/Dlisbiaq 0 tai�n!/1to plusbiaQ
6. It suaia���/ZnQu�tsy/O!t►�e� sp�oilp Lyp� i P�opl� t 81aka
� Cosood�� i eho�r� i Uriaal• + Xat�r Cool�s�
It �'+OODSERVZC3: � S�ats Zatimat�d Kat�r Osaq� �Q.uon. p.r a.�r�
7. �p� o! xat�r supply: �ouaty/City 0 N�11 0 Costmuaity
e. Do yoa auHcipste AddiHow or e�anelon�of the fncility thV ry�tem la intendal to urve? 0 Yea �to
If yea,w6�t type?
***IMPORTANT�*�CLiENT3 M(hTT C1OMPtETETHE REQUIRBD PROPERTX INFORMATION REQUE3TED
BELAW. EltLer a PL.AT or S1TE PLAN M�1ST BESUBbIITTED by the tlient �vith THIS APPWCATION.
Ptop�rty Dimewions: �� ^ ! /� �- R+It1TE D1RECflON3(from Moek:ville)to PROPERTY:
Tai 081ce PIN: # �'��.�� � � 3 7 0
Property Addres�: RoAd Name ,��e_ti,� if�,�� -(.t�,
� City/Zip�'i�cX�S U;I)C � 7 c�-1S�
U IO A Sabdiviaion provide informallon,aa followe:
N�Iriti
SecNoat Hlocks Lot: Date Property Fla�als
This is ko certi�y thpt t6e Infa:�n�Hon prwtded is correct to the beat of my Icnmvledga I nndersbnd that�ny permit(�)
issaed 6ereafler�re snbject to taapeneton or rovotAHoa,it the eite plene or latended ase chan�e,or i!the Intormallon
aabmitted in t61s appl[caHon L�falsllied or chsn�ed I,also,undrrstand tiat 1 a�»rapons/ble jor al!che�ges lncurred jro�
tbls appllcattorr. I,hereby,�ive eonaent to t6e Aat6orized Repreaentative o!the Davie Coanty Heult6 Department
to enter npon above desctibed propecty located tn Davle�^oanty and owaed by ��-'��c�r-n-�.a�v 1���v r�
to condact all testinQ proc�dara Aa neceaa�rp to detesmine the�Ite tattabWty.
DATE SIGNATURE
THI3 AR.EA MAY BE USED FOR DRAWING YOUR SITE PI.AN(Inclade all oi t6e foilo�rings LziaHng and proposed
prnperty Una and dimenaiona, atructurea, aetbacka, aad eepHc IoaiHoas).
C.ero�-er� C oro�e r
Site Revbit Char�e
D�te(a):
�-;v C
-^- , CHent NotiBcsHon Date:
I Nc`�S-2 1
t ) EPS:
� ��
� �� � ���
� e Accoant Na
1
Revised DCHD(07 oJ�e 4 Invola Na -�-� �
I
� •
- �. , , � DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section SECTION LOT
• � ' �� Soil/Site Evaluation
APPLICANT'S NAME �(f[�ti ' DATE EVALUATED �'�l�/CI�_
PROPOSED FACILITY ��'I�/ PROPERTY SIZE � 1`�C/
SUBDNISION ROAD NAME �'���
.-�
Water Supply: On-Site Well Community Public ��
Evaluation By: Auger Boring j/ 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 r" i''
Texture rou �
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 c
SITE CLASSIFICATION: EVALUATION BY: l�'
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-gaUday/ft2
DCHD(O]-90)
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