309 Cedar Creek RdAccount #: 990000890
Billed To: Jerry Banks
Reference Name: Jerry Banks
Proposed Facility: Residence
ATC Number: 2210
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r. o. Bog sasmo xo�p�tai s��t
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5832-81-8204
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 150 x 250
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). 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 VALID FOR A PERIOD OF FIVE YEARS.
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Environmental Health Specialist's Signature: Date: ___/(������/�
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.
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
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4.. DAVIE COLTNTY HEALTH DEPARTMENT
' Environmentai Heaith Section
P. O. Boz 848/210 I�ospital Street
� Mceksville, NC 27028
(336)751-87G0
Account #: 990t?00810
Billed To: Jerry Banks
Reference Name: Jerry Banks
Proposed Facility: ResidenCe
IMPROVEMENT/OPERATION PERMIT
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Tax PIN/EH #: 5832-81-8204
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 150 x 250
ATC Number: 2210
**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 � #People � #Bedrooms �� #Baths ''�
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size /,�"'� Xc3�('> Type Water Supply L�/Pl / Design Wastewater Flow (GPD) ��l� Site: New �" Repair ❑
System Specifications: Tank Size �� GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width ��Rock Depth�� Linear Ftc` �'
IMPROVEMENT/OPERATiON PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6`� BELOW
FINtSHED GRADE. ****NOTiCE: 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.****
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Environmental Health Specialist's Signature: � Date: �/.�2/��
DCHD OS/99 (Revised)
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� ' APPLlCAitON FOA SRE EVAWA710N/1MPROVEMENT PERMR &
Dav1e County Heatth Oapartment
� Envitvnmental Neu/th Se�abion
p.0. eax 818/210 �o�pitsl etrNt
. t�ook�vill�, ttC 27028 � •
(396)fisi-6760
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•*'�IMPORTANT"**CLiEKfSM[�LTUOMPIETSTHE REQUIREDPROPERTY[NFORMATtONREQUFSTED
� BEWW. Eit4ec � PLAT or SITE CI.AN MI�ST B� S[/BMITIED by t6a cUent rrit6 TNl3 APPWCATION.
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tuacd 6ereAttec �ce tabject to �wpewtou or revoeaHoa, l[ t4e ttte plaw oe tatended mta c6�nQe, or li tho In[ormallon
•abmitted to t6b appUcallon V tabltted or ehsnQed l, a/so, aaderataad �at I a�n rupansJ6k jor alI c�argu lncumed, j(ront
�is appitcadoa. I, henby, �lve wn�ent to the Aatborhed Aepcaentsthre ot the Dsvts Coanty Halt Depactmeat
to eater apoa �bave dacttbed property located In Dsvie Coanty �nd owaed by �1� �r�l"KS
to eaadact all tatis� proudara u naeaary to determine the dte inita .
DATL j�� R SIGNATURE
THIS AREA MAY 8E USED i�'OR DRAWQiti YOUR 81T� PLAN de �11 tha ioilowinas EiLt�na snd prnpaed
rnparty Una an8 dimewion�, �tractora, retbsctrr, �na �epNc loatiow�
f ._ - . - _ _ . . _ � ��� . _ _ _ _ _ � ( � Site Revbit Ch�r�e
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APPLICANT INFORMATION
Account #: 990000810
Billed To: Jerry Banks
Reference Name: Jerry Banks
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATTON
Tax PIN/EH #: 5832-81-8204
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 150 x 250 Date Evaluated: /0122�11�_
Water Supply: On-Site Well Community Public '
Evaluation By: Auger Boring v Pit Cut
HORIZON II DEPTH
SITE CLASSIFICATION:
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- 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
Strncture
SC - Single grain M- Massive CR - Crumb GR - Granulaz 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 OSl99 (Revised)
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