767 Burton Rd �. �
DAVIE COUNTY HEALTH DEPARTMENT � u������
• ' Environmental Health Section
� � � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001064 Tax PIN/EH#: 5798-42-2755
Billed To: Michael Minor Subdivision Info:
Reference Name: Michael Minor Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 10 Acres
**NOT�*�'�iibginprovement/Operation Permit DOES NOT authorize the construction of a 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 �} #People� #Bedrooms�� #Baths�_
Dishwasher: �Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:�BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size_��/1'(� Type Water Supply ll� Design Wastewater Flow(GPD)S_�.�j1L Site: New,O'�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��Rock Depth 1�7 Linear Ft. ��
Other:
Required Site Modifications/Conditions:
IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROV LUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of �e County Health Department for final inspection ofthis
system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 130 p.m. y of installation. Telephone#is(336)751-8760.****
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Environmental Health Specia]isYs Signature: , Date: S '/����
DCHD OS/99(Revised)
. ,.. �oE .
• . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Bog 848/Z10 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990001064 Tax PIN/EH#: 5798-42-2755
Billed To: Michaei Minor Subdivision Info:
Reference Name: Michael Minor Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 10 Acres
ATC Number: 2403
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED 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 STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �� � Date:S^/-'�
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.
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Septic System Installed By: �TC� � � 1
Environmental Health SpecialisYs Signature: ��'F" - Date: �� /,3—�O�_
DCHD OS/99(Revised)
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� APPLICATION FOR SffE EVALUATION/IMPROVEMENT PER .�
� p/,e�'S Davie County Health Department � s ��
r /`� Environmenta/Hea/tfi SetYion �
�e � P.O. Box 848/210 Hospital Street �n� ^� -,I
�'1�iR �
���� Mocksville, NC 27028 � ����-�
` 6i�yG, (336)751-8760
/�� J
***I1�'aRTANT*** THIS APPLICATION GINNOT BE PROCESSED UNI,ESS ALL THE REQU ..
INFORMATION IS PROVIDED. Refer to the INFORMATION BLtLLETIN for instructions.
1. Name to be Billed C I � Contact Peraun �I G/1C/� ` �/G�i��1�
Mailinq Addresa ll� }� 8ome Phone �9g-?sa�
City/State/ZIP �vq�`e �� (� a��� t3usinesa Phone `�� �'"D.�� /
2. Name oa Permit/ATC if Differeat than Above
Mailing 1lddsesa City/State/Zip
3. Application For: C�Site Evaluation ❑ Improvement Permit/ATC �Both
a. sYetem to s6�-.ri�e: q/House ❑ Mobile Home O Business ❑ Industry ❑ Other
s. If Residence: M People NF- � Bedrooms �_ M Bathrooms
--�-
[�/biahnaaher �Gazbage Dispoaal [4�fdaehiag Machine C4�Sasement/Plumbinq fJ Saeemant/No Plumbinq
6. If Buainaea/Induetsy/Othar: SpeciEy type � People 11 33nka
Y Commndea i Shorera � Urinala � Water Coolera
IF FOODSERVICE: # Seats Estimated Wa�:er Usage (gallone per a8y�
7. Type of water supply: � CountyfCity lf�Well � Community
a. Do you anticipate additions or ezpansions of the facility this system is intended to sP:ve? ❑Yes C�1�to
If yes,what type? ,
***IMPORT�lN.7'***r!.:�:'�'.'*'�.'.:'.'S:"�:::..:�.,c:�.:ri� itc�ZltF�D P[�OPER'S'Y INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN wfUST BESUBMI7'TED by the client with THIS APPLICATION.
Property Dimensions: /v�L� WRITE DIRECI'IONS(from Mocksvilie)to PROPERTY:
Taz OtTice PIN: # � ���4� �� �.s �p � -{'p � (�� -� �
Property Address: Road Name Q U i` T (7 I'1 I� � 1-?�� p��e 'S C�'p e �'( � i� — (v✓' l'�
, �
c�tyiz�p d � � � � e n c (� -� ��' A a 1 � r,-��� �o - -
If in a Subdivision provide information,as follows: ��-�� h ��� • G o �'o ���
• Name: ('l �i fC c �.�e -��' � t �� I S a�'t ��y}�,cj`
SecNon: Block: Lot: Date Property Flagged: �"�����
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or iute►:ded use change,or if the information
submitted ia t6is applicallon is falsi£ed or c6anged. I,also,understand that I am responsib/e jor a/l charges incurred jrom
this appllcatlon. I,hereby,give consent to the Authorized Representative of the Davie Coun Heaith nDepartme t
to enter upon above described property located in Davie County and owned by 1�1��'�n�� U 1�/Yi,,,r�-ei ���%V�'�
to conduct all testing procedures as necessary to determiae tbe s'ste suet?1�E�E+•�. T � s�TP�
DATE �� YI'"Qd SIGNATURE � �
THIS AREA MAY BE USED FOR DRAWING YOUR S;TE PLAN(Include all of t6e following: Ezisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Accouat 1�10. �(l/
Revised DCHD(07/99) Invoice No. // �
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tab��5t�ed °�On9reet to eS�abGs . .. . , , .
r • ' .� • ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001064 Tax PIN/EH#: 5798-42-2755
Billed To: Michael Minor Subdivision Info:
Reference Name: Michael Minor Location/Address: Burton Road-27006
Proposed Facility: Residence Property Size: 10 Acres Date Evaluated: ����l`GU
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 .� `" ,�6•i
Texture rou
Consistence i �'
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: 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 firrr►
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
�CI-ID OS/99(Revised)
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