300 Campground Rd (2), � DAVIE COUNTY HEALTH DEPARTMENT yy�/'��—�d
Environmental Health Section �
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001134 Tax PIN/EH #: 4797-41-4609
Billed To: Wolgang Brodauf Subdivision Info:
Reference Name: Herb Brodauf Location/Address: Campground Road-27028
Proposed Facility: Horse Bam Property Size: 8.941 Acres
**N()TE*'� Thi b�mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION 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 wlPlumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply �/ Design Wastewater Flow (GPD) ,/� D Site: New � Repair ❑
System Specifications: Tank Size � GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width ���Rock Depth ��Linear Ft. �OO �
IMPROVEMENT/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. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
S%�s�v d��BT
� �fI w ��' ��
Environmental Health SpecialisYs Signature: /�/� Date: �'�% ��
DCHD OS/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001134 Tax PIN/EH #: 4797-41-4609
Bilied To: Wolgang Brodauf
Reference Name: Herb Brodauf
Proposed Facility: Horse Barn
ATC Number: 2397
Subdivision Info:
Location/Address: Campground Road-27028
Property Size: 8.941 Acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � -�. � Date: �/��`'� .7 j Gr�'
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate of Completion shall indicate the system described on ImprovemenUOperation 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.
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
Date: ����.� ��
Please complete the highlighted area(s) and
return.
� � � l5 U U
TION FOR SiTE EVAWAT10Nf IMPROVEMEM PERMiT & ATC
Oavie County Hea{th Department �� z� 2�00
Environmenta/ Hea/th Se�ion
P.O. Box 848/210 Hospital Street
Mocksville, NC 2702B ENUIROPdi;1ENTAl NFAI
(336) ?51-8?60 DAVIE CQUN?Y
***II�ORTANT*** THIS APPLICAT20N CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
/. ,� Y�i i y d �, u,. � v� i
1. Na�mo to be Hillad
Mailinq Addrees 3B0
Citylstatolzzp
�i
Y.` e,/YG.Z�62.�
2. Namo on Pormit/ATC i! Diiferent than Above
Mailiny J►d�dresa
Contact Pareon
Home Phone /0 / — J T� ' ����
Huainesa Phone !�/ rp6 � �� / �� �
CitylState/2ip
3. Application For: �3ite Evaluation ❑ Improvement Permit/ATC ❑ Both
;. syst� to sez„i�a: ❑ House ❑ Mobile Home ❑ Business O Indus�ry � Other oY1' i'�'
� �
�- s. ' if Residence: II People � Bedrooms � t Bathrooms �o �
(l DishMaaher II Garbage Diepoaal ll Washinq Machine 11 Haaement/?lumbing 11 HaeementlNo Plumbing
6. It Businase/Induatry/Othor: 8pecily type
/ Commodee
� Showers � Urinala
� Peopls � 3inka
/ Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usaqe (qallone per day)
7. Z��e of water supply: � County/City �Rell � Community
8. Do you anticipate additions or ezpaosions of the facility this system is iatended to serve? Q Yes No
Iiyes, what type?
***/h��'�!�?'AN..T***�:.9�;�.':�..J�Ti:�ri►iri.�ic�i'iiE REQUIREDPROPERTYIN['ORMATtON�iF.n�IFSTFn
nGi.uN'. Eit6er a YLAT or SiTE PLAN htIIST BESU�MI7TED by the clieat with THIS APPLICATION.
PropertyDimeasions: 62�"i2'��L'--- ����-1 � �
�t rr# �} 7 i�d
Tax Ofiice P1N: ,_ _ _ _
Property Address: Road Name _�� k�r �
c�tyiz�����, e, �G�6��
If ia a Subdivision provide information, as fo{lows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from MocicSville) to PROPERTY:
� •�fl �r/�/✓� z�r-,e�, vL �/62 ��%f� � �� �
CO- (,tws B-Lr.uO ol � � B—�
GR��(d�-�y � � � D D
_�
Date Property Flagged: �f�o�6�00
This is to certify that the information provided is correct to the best of my knowledge. I understand that aay permit(s)
issued hereafter are subject to suspensioa or revocatioa, if the site plaas or intended use change, or if the information
submitted in this applicatioa is falsiGed ar changed l, also, rrnderstand that I am responsible jor al! charges incurred jrom
tbls applicatlon. I, hereby, give conseat to the Authorized Representative of the Davie County �iealth Department
to enter upon above described property located io Davie County and owned
to coaduct all testing procedures as aecessary to determiue t6e site suitab' �
i'if� i G � �%/ �� SIGNATURE
THIS AREA MAY BE USED FOR DRAWIl�iG YOUR SITE PI.AN (I de all of t6e following: E=isting and proposed
property tines aad dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
� Date(s):
I Client Notification Date:
I EH5:
Revised DCHD (07/99)
Ac¢ount No. �
Invoice No. 0
. . .
.� � � ' DAVIE COUNTY HEALTH DEPART'MENT
Environmental Health Section
Soi]/Site Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #: 990001134 Tax PIN/EH #: 4797-41-4609
Billed To: Wolgang Brodauf Subdivision Info:
Reference Name: Herb Brodauf Location/Address: Campground Road-27028
Proposed Facility: Horse Bam Property Size: 8.941 Acres Date Evaluated: ���6'lX�
Water Supply: On-Site Well �/ Community,
Evaluation By: Auger Boring l� Pit
i ex�ure
Texture gro�
�.__......_..,...
SITE CLASSIFICATION:
IIVHLUHl1V1V ISI:
Public
Cut
LONG-TERM ACCEPTANCE RATE: � OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscane 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
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
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 - gaUday/ft2
DCHD OS/99 (Revised)
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