198 Cedar Creek RdAccount #: 990000877
Billed To: Candace Link
Reference Name: Candace Link
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
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Mocksville, NC 27028 ` C/ 3 � % �---
(336)7S]-8760 �/ ��g7�- U �' .
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IMPROVEMENT/OPERATION PERMIT � o - � —`' "
Tax PIN/EH #: 9� c�`�"`
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Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 5 Acres
ATC Number: 2268
**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). 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 �t9 c.25� #People �_ #Bedrooms �_ #Baths
Dishwasher: � Garbage Disposal: �' Washing Machine: �� Basement w/Plumbing: � Basement/No Plumbing: 0�
Commercial Specification: Facility Type #People #People/Shift #Seats
Lot Size (� �.�5 Type Water Supplyj.JE�-� Design Wastewater Flow (GPD) �- ".�-
Industrial Waste: ❑
Site: New ��Repair ❑
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width��� Rock Depth IZ�� Linear Ft.�;�p�
Other: 2'�D1STiZ-i gc)T�o•J �'lx��-i-'-� . I,J.SjL�L.L �i�..�S 710 . C.. ,
Required Site Modifications/Conditions: �r.1�',4L.� v� �►Jzo��(2, I�i--� 1� �� No��-. K�-�i� ��� �Q'^�—
�J�LI___
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G" BELOW
FINISHED GRADE. ****NOTtCE: 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 (336)751-8760,****
AP� ►4o'T�
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Environmental Health Specialist's Signature:
DCHD OS/99 (Revised)
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Date: /21314�
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Account #: 990000877
Billed To: Candace Link
Reference Name: Candace Link
Proposed Facility: Residence
ATC Number: 2268
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5841-09-2687
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 5 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 WASTEWATER CONSTRUCTION IS VA D FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: _ �._- Date: � 9
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. , , � �
�To � -�--D �JP��IL
1� ��S � �s�r qT-
1� — (�, x — ►�csr-
Cc�n,PL.�:T�` p,�,T
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Septic System Installed By:
Environmental Health Specialist's Signature :
(MM
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DCHD OS/99 (Revised) _
---�-----AP - TION FOR SITE EVAUlAT10N/IMPROVEMENT PEAMIT & ATC ��
. � (� � [� � �V] [� Davte County Health Department n � _ „ /f f
� Envfronnrwnta/ He�/th Secdon � . �J Ou,[ fI
NOV 2 2(999 ° p.o. �ock viiie Ncp 2� 8��� � ,�
� (336)?51-8T60 � ��� � L�1/Y� �1��'G
,
tv R nie�r � i � �
*** ** THI Ap�I+ICATION C�INNOT � PROG�88�D VNI,�88 ALL T� ItEQLTIR�D ,
� IN8'OR�ATION =S BRCVtDE15'. Refar to th� =NTORbAT=ON BnIS.�TiN for iastruatioas . �
1, liar to b� sill�d
Cosstaet P�r�oa
1t.sliaq 71aar•,. _/�ri.lJ� (� r�r,//"�'r ("/t�c° � ae�. rhoa�. �''`/ U�( H'i � Lo
cst�r/eat.�a:p � �C�.�cS L'I ��c° , tU �' ,� �/1.� R' swsa.., �. _ %�� R - ���iU X l05 � -� a��o P .�k
2. 11aa� on P�uit/�1TC i! Di!l�synt thaa ]lbow
lisiliuQ 7�ddr�i•
3. J►pplication ror: �it� avaluatioa
4. sy.t..: to s.�.o.: �' Hons• 0 Mobile Home
s. i! assidon�: � psopia �_
city/stat�/sip
❑ improv�at B�rmit/11TC Both
0 Husia�ss �=adustry 0 Oth�r
t Bedrooms �_ t Bstisrooms
� Di�hrul�r O Carbaq� Di�po�d 9�ashiaq Ifsahia� 0 sasu�a!/Dlvabiaq ��ud�atMo plisbi:►q
6. I! suai���/Industsy/Ot2►�r: Bp�ai=Y tYP� ��aPl� f Siaka
! Coamod�• f 8hox�r� i tlrinal� � Mai.�r Cooi�r�
Za II'OODSERVIC3: � S�ats 3stimat�d 1Pat�r tTaaq� �Qauon, r•= �r�
,. �. o# ,►:t.r .��Y: a co,�ty/rat� �ai o co�itp
e. Do yoa andclpAte nddlHons or eipanaione of the fa�ility this eystem ia iatended to eerveT 0 Yes 8�'�
If yes, what type?
***IMPORTANT*** CLIENTS MiIST C�UMPLETE THE REQUIRED PROPERTY INFORMATION REQUESfED
BELOW. Eit6er a PI.AT or SITE PI.AN MI/ST BE SIIBMIT?�D by t6e elient w�ith THI3 APPLICATION.
3oyX �8! X3o�1
Property Dimeaalons: � Ae X'7 ,5 O WRiTE DIRF.Cf[ON3 (irom Mxksville) to PROPERTY:
Tai OHice P1N: # ���� i - � 9 - oZ � � %
Property Address: Road Name �PdG1�' C�!P_ �K l�i
� �/ � .1 • L __ � .
If in n Sabdivision pravide informaHon, as follows:
Name:
Secdoat Biock: Lots
, / i �lr. �. r �. � � : t
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This b to certify that t6e inlormsNon pravided is con�eM to the beat of my knawlMge. I anderahnd t6�t sny permit(s)
iaaaed hereafter ere eabject to ewpeneton or revocaHon, if the s[te plans or intended as� chen�e, or if t6e informaHon
aabmitted in t61s applicaHon ie falsifted or changed. I, also, ttnd�rstand tArat I ar» nsponslb[e jor all cbaiges irtcumd frone
tbls app/lcatlon. I, hereby, give conseut to the Aut6orized RepreaentAtive of We Davie Coanty Hadth Dep�trtment
to eater npon above deacrtbed property locahd In Davie Coanty snd awned by
to condact �Il testing procedara As necesaary to determine the site =ultsbWty.
DATE o SIGNATURE /,i'�i%L/,/':/�',�.0 ���
THIS AREA MAY BE USED FOR DRAWQiG YOUR SITL PI.AN (Inclade All of t6e foUa�wing: Eztating and propoeecl
property Ilnea snd dimenst nq3 etractarea, eetbacka, aud aeptic locutions).
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Revised DCHD (07/99) �� � , Invoice Na �� �
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R/W INCLUDES S R 1434 R,%W
AREA = 4.��� QC� � DB. 35 PG. 33
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EATON, HEIRS
S 16° 42� 27�� W
202 86
PI P
..' � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990000877
Billed To: Candace Link
Reference Name: Candace Link
Proposed Facility: Residence
� PROPERTY INFORMATION
Tax PIN/EH #: 990000877
Subdivision info:
Location/Address: Cedar Creek Road-27028
Property Size: 5 Acres Date Evaluated: � Z�9�j
Water Supply: On-Site Well � Community
Evaluation By: Auger Boring � Pit
Public
Cut
SITE CLASSIFICATION: P s EVALUATION BY: ���C�t,-I-�-,,_�
LONG-TERM ACCEPTANCE RATE: D• Z OTHER(S) PRESENT: ��1 \�
REMARKS: __ �c�'`'�� �'-'l� . �1��t,1.1.0 v� �ao �►,. 1� �UM.�: PL4Gi;5 - QOSS ���-�i.,f Y ��c.�cX o�
LEGEND ��p�aG� �w.,� ,� t�,
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 frm 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
Mineraloav
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 - gal/day/ft2
DCHD OS/99 (Revised)
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