188 Cambridge LnDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
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IMPROVEMENT/OPERATION PERMIT
Account #: 990001137 Tax PIN/EH #: 5810-16-2979
Billed To: Buck &Melissa Hill Subdivision info:
Reference Name: Buck 8 Melissa Hilf Location/Address: Cambridge Lane-27028
Proposed Facility: Residence Property Size: 10 Acres
�,TC �I�ip� b�r. 2412 i
**N E* 'l his mprovement/Operation Permit DOES NOT authorize the construction of a septic tank syst�m 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 PERIV�IT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People � #Bedrooms � #Baths�
Dishwasher: Ja Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply �,�v !T/ Design Wastewater Flow (GPD) c31� � Site: New �Repair ❑
System Specifications: Tank Size%%7Qa GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width��� � Rock Depth �,Linear Ft��
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 130 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature: �C` — Date: � —� " � �
DCHD OS/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-8760
Account #: 990001137
Billed To: Buck 8�Melissa Hiil
Reference Name: Buck 8� Melissa Hill
Proposed Facility: Residence
ATC Number: 2412
Tax PIN/EH #: 5810-16-2979
Subdivision Info:
Location/Address: Cambridge Lane-27028
Property Size: 10 Acres
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 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: .- - Date: _,�' G�.� ��
CERTIFICATE OF COMPLETION
**NOTE** T'he 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:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
Date:
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1.
2.
APPUCATtON FOR SRE EYALUA710N/IMPROVEMEPIT PERMIT �
Davie County Health Department
Environmental Heaith Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
D
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� APR 2 5 �t��a
.
***Ii�ORTANT*** THIS APPLICATION CANNOT HE PROC,ESSED UNiI,ESS ALL THE REQUIRED
INFORMATiON IS PROV�DED. Refer to the INFORMATION BULLETIN for instructions.
0 �) �/'� 1t l
Name to be Billed �ll�Lp� � 1� ��/�AS��-�,�\ Contact Passon �c uU� �� , 1 FQ�1A�� �ll �'•
Mailinq Addreas _ 1 � p l._ CLm� `� �O� �--c^ �-�- Home Phoae 1 �3� � � � � � 1 �� �
City/State/ZIP �'� �t�.�7V� 5iL �� G b��� Z� Huainesa Phone �J�-P " iP�� - y-c�� (�
Nama on Permit/ATC iP Diffareat thara Above ��-i�-��
lfailinq Addreea ��-rnQ� City/State/zip � ���
3. Appiication For: G•Site Evaluation �Improvement Permi.t/ATC .�Hoth
a. sYst� to se=,.ice: [d" House ❑ Mobile Home 0 Business O Industry ❑ Other
s. If Residence: t People �_ � Bedrooms �� N Bathrooms �7
lyDist�Manher 11 Gasbaqe Disponal �ashinq !lachine hY�aaement/Plumbing II BasementJNo Plumbing
6. I! Huaineae/Induatry/Othor: Specify type � People � 3inke
/ Co�odee
M Showers
p Urinals
� Water Coolera
IE FOODSERVICE: # Sests Estimated WAter Usage (qnllone por dny)
�. Type of water supply: Q County/City �ell ❑ Community
e. Do you aoticipate additions or e=pansions of the facility this system is intended to serve? �i1'es D No
If yes, w6at type? �O<S5 �� 1`-i rY�v� �d�O rv�5 �'�--� `1--1vi'�tu�'1ur'-C_:
***/AtPORTANT*** CLiE1�iTS MUST COMPLETETf1E REQUIRED PRQPi�RTY INFORMATI4!� s?��!��c�rFn
n�.i.UW. �ither a�'LAT or Sli'E PLAN MUST BE SUBM/7TED by t6e clieat with THIS APPLICATION.
Property Dimensions: � �CtCk'�2S
Ta:Office PIN: # �� � � ` � l..P -' c� �� � �
PropertyAddress: RoadName Ig� Ct�mbr�d�- w`n'�-
c�Tyiz�p N�OC�SV� ��D , � C.
If ia a Subdivision provide information, as lollows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville� to PROPERTY:
I �- +-lu�� Cc �
�}c� ��-�ta�ci — r�r�n�,�t � � r�; an-t�
n�`� n,-na�roX', ma.t���� � m i l-P s
mc�k(Q � � Y�,�+ on� c�r��d�.
l�Cc. r�.e •�i r S-+ �f-ra �er Or `I-h� r i��,.`f-•
�
i c+C� ��s heh � � �tru� I�ec- .
Date Property Flagged: �-{-125�taC�
T6is is to certify that the information provided is correct to tLe best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, ii the site plans or intended use change, or if t6e information
submitted in this application is lalsified or changed I, also, understand that I am responsible jor a!! charges incurred from
this application. I, 6ereby, give consent to t6e Aut6orized Representative of the Davie Couqty H al Department
to enter upon above described property located in Davie Cauaty and owned by ��.i C,� c 1��� S� ')-�.1:�.�-
to conduct all testiag procedures as necessary to de rmine the site suit�bility. '
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DATE 7 I Z�J I(7� SIGNAT[JRE �D � I�'SG� �n/ '�I-��
THIS AREA MAY BE USED FOR DRA YOUR SITE PLAN (Include all oi the following: Ezisting and proposed
property liaes and dimensions, structures, s�backs, and septic locatious).
Revised DCHD (07/99)
Site Revisit Charge
� Date(s):
� Clieot Notification Date:
I EHS•
Account No. �
Invoice No. T ��
_ _ _ . __. .- _ _ . if _. ._ _ -.._ _. _
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� TRACT 7
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, . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• . , Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001137 Tax PIN/EH #: 5810-16-2979
Billed To: Buck 8�Melissa Hill Subdivision Info:
Reference Name: Buck & Melissa Hill Location/Address: Cambridge Lane-27028
Proposed Facility: Residence Property Size: 10 Acres Date Evaluated: �-� '�--�
Water Supply
Evaluation By:
SOIL WETNESS
On-Site Well 6� Community
Auger Boring Pit
SITE CLASSIFICATION: ��
LONG-TERM ACCEPTANCE RATE:
REMARKS:
Public
Cut
EVALUATION BY:
OTHER(S) PRESENT:
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 OS/99 (Revised)
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