173 Burton Rd . , , �c�-
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section � �
P.O.Boz 848/210 Hospital Street �(
Mocksville,NC 27028 � (o'��
(336)751-8760
Account #: 990001568 Tax PIN/EH#: 5789-80-4103
Billed To: Larry Decker Subdivision Info:
Reference Name: Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 0.767 acres
ATC Number: 2704
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 S wage Trea t and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON TIO I OR A PERIOD OF F VE YEARS.
:
Environmental Health Specialist's Signature: Date: ��Z
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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 guazantee that the system will function satisfactorily for any
given period of time. �?p (�t�
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Environmental Health SpecialisYs Signature• ' Date:
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DCHD OS/99(Revised)
. DAVIE COUNTY HEALTH DEPARTMENT �d 5- 3 °��
' ., , Environmental Health Section
• • ' • P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)75]-8760
\ IMPROVEMENT/OPERATION PERMIT
Account #: 990001568 Tax PIN/EH#: 5789-80-�103
Billed To: Larry Decker Subdivision info:
Reference Name: Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 0.767 acres
ATC Number: 2704
**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). THLS
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 �• t1���' #People 2 #Bedrooms 2 #Baths �
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size �� � ��41'�pe Water Supplyl,F,V�� Design Wastewater Flow(GPD) �1l/ Site: New�Repair�
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�,, Rock Depth �2�� Linear Ft. �G��
ocn�: � �75�+ �Jr�.� F'o X��.Tc�S'R�U— ►���S Q"�,a. r�,�rJ .
Required Site Modifications/Conditions: I �T�'�"� G��TDc�Q � {Q`� � � ,� ���� 1'ti/(.�n�``�
11�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER, RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.�0 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installati . Telephone#is(33G)751-87G0.****
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Environmental Health Specialist s Signa ure: cSTj,� Date: 0�
� 'NFLE
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DCHD OS/99(Revised) �-�
����N �ta,
� � ' ' . aPPLIC�ATION FOR SITE NALUATION/Ifl1P(tOVER�9E\IT i'�L�fii�9i3��&R►�'C D LK �G �Q�� r
Davie County Health Department � :�!�
Environmenta/Hea/[fi Section �
P.O. Box 848/210 Hospital Street F�8 - 7 2��)
MocksvilTe, NC 27028 � � o-
(336)751-8760 �
EfV'JiR���1��L��J�f;,l HEALTH
DAVIE CfIUNTY
***IMPORTANT*** THIS 'APPLICATION CANNOT BE PROGESSED UNLESS � THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be IIilled ��/�/�� (� , ��C�C�/`�--' Contact Peraon ��E ��yl���
Mailing Addresa ��� �y�T�/V /Y!L ' Home Phone �Jr�" �9O ��7�0
�^
City/State/ZIP ,��/�2/�L� ���� d��OL Buai.nesa Phono '
2. Name on Permit/ATC if DiP£erent than Above
24ailing Addresa City/State/Zip �
3. Application For: Site Evaluation Improvement Permit/ATC 0 Both
' a. syatem to service: ❑ House j� Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: � People _;�_ � Bedrooms �_ A Bathrooms Z-
�Diahxasher lFf'Garbage Diapoasl L! Washing Machine ❑ Hasement/Plumbing U IIasamant/No Plumbing
6. If Bueinesa/Industry/Other: Specify typo �k Paople �! Sinka
� Commodes 9 Shoxers # Urinals # Wate= Coolers
IF FOODSERVICE: # Seats Estimated Water U98J@ (gallona per a�y)
�. Type of water supply: �County/City � Well ❑ Community
8. Do you anticipate additions or eapansions of the facility this system is intended to scrve? ❑Yes �'No
If yes,what type?
***IMPORTANT***CLIENTS h1UST COMPLETETII E REQUIRGD PROPI:RTY INrOI2MATION IiEQULS7'GU
BELOVV. Either a PLAT or SITE PLAN MUST BESUI3MITTED by the client �vitli THIS APPLICATION.
Property Dimensions: � • �� / ��-'�:%t�.r/ VVRIT�DIRECt10NS(froro Mocksvilie)to PROI'I'sR'I'Y:
TaxOncePIN: # ��� / `�� ``7''��,3 ,�Y� G'�IS� ���Svv�� /�G6it/��
Property Address: Road Name ,�.,1�/�fj �� v�.O��CS/�!�°�-"��� ��1� �,G`�
,
c�ty,z�p ��,�✓c� ,,�111=�� �,t/.��� �� % .�•/� o�
If iu a Subdivision providc information,as follows: �C'�t
Namc:
Section: Block: Lot: Date Property Flagged: � �
This is to certify that the information provided is correct to the best of my knowledge. r understand that Any nermit(s)
issucd hcrcafter are subject to suspension or revocation,if the site plans or intended usc changc,or if tLc information
submitted in this application is falsified or changed I,also,understand tha[I am responsible jor all charges incr�rred frum
lhis application. I,hereby,give consent to the Authorized Representative of the Davie County Healtl�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 suitability.
DATE � """ �'—U � SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all f thc following: �aisting and proposed
property lines and dimensions, structares, setbacks, and septic locations).
Sitc Revisit Chargc
. Date(s):
Client Notification Date:
EHS•
Account No. ����
Revised DCHD(07/99) Invoice.No. � 3 �v
1�� �y,;ST',NG -� ... . . .
�a:.�. , � CLIFT UIV L. r�v�-��,�.� .--
, : �'a :�(i.�3� D 318, PG. 431 •
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IACED
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� � HO yYELL �Y �'OLTZ
i. YERNICE C. WOLTZ •
`'�` D.B. 157, PG. 481
� . .
- PLAT �F SURVEY
REYISI�NS SCALE� 1�� = 50�
oATE, JAN–12–2 .
BE«tG : TRAC?S T^
' . 50 25 0 50 . � 100 150 ,;n �; ,� .. F:,; �,;�
DA.viE C�>�_;�:Tr, NOi.
SCALE IN ��FEET �
- Tax M�
. � � DAVIE COUNTY HEALTH DEPARTMENT
•� ' ' ,'' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 99n001568 Tax PIN/EH#: 5789-80-4103
Billed To: Larry Decker Subdivision Info:
Reference Name: Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 0.767 acres Date Evaluated: � �
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �l Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo %
HORIZON I DEPTH C9 " - 2 ' 1
Texture rou L' C� c �-
Consistence r` �t' SS
Swcture S� �- C�
Mineralo � ' � ' 1
HORIZON II DEPTH — tD Z + � 3p
Texture rou k S
Consistence S r.� �=S
Structure 2L 2 1
Mineralo 1 - = I
HORIZON III DEPTH '� —�-(0
Texture rou S
Consistence
Structure Sg
Mineralo 1 � '
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE 'O. �
SITE CLASSIFICATION:
� EVALUATION BY: �F`'t'F' �"}�-�
LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT:
�'���Q � L t� Ss Q£.��-'�`1 �4��J L��.1� � .J
REMARKS: 1�0�� � � � C�?TS ��-a I � �•'�-- H��� _�
A�Z - l�t.�JJ i A�? LEGEN ��`��-*Y
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
l:l,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
I Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD OS/99(Revised)
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Z�avie Gvunty,,7fealth Z�e�artment
Errvirvnmerrtal,�fealth Section
' PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
February 22, 2001
Mr. Larry Decker
189 Burton Road
Advance,NC 27006
Re: Site Evaluation-
0.767 Acre TractBurton Road
Tax PIN#: 5789-80-4103
Dear Mr. Decker:
As requested, a representative from this office visited the above site on February
19, 2001. Based on the information provided on the Application for Site Evaluation and
a$er the evaluation was completed, the site was found to be provisionally suitable for the
installation of an on-site sewage disposal system. Please find enclosed a copy of the
Improvement Permit.
Please note that the septic system for the e�cisting dwelling at 189 Burton Road
encroaches on the 0.767 acres that is proposed to be cut out of the parent parcel. A
deeded easement for this septic system should be included in any real estate transaction if
there are no plans to move the system.
If you have any questions, feel free to contact this office at (336)751-8760.
Sincerely,
��_
� —`\
JeffG. Beauchamp, R.S.
Environmental Health Section
enc(s)