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569 Cedar Creek Rdv
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002747
Billed To: Augdene Thomas
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5842-13-8730
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: see map
ATC Number: 3466
**NOTE** T'his 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 ��JS� #People Z #Bedrooms 3 #Baths Z
Dishwasher: d Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �- ���S Type Water Supply �i�=-rLJ�. Design Wastewater Flow (GPD) 3� Site: New � Repair ❑
System Specifications: Tank Size ��`�GAL. Pump Tank
Other: � I.71 S
Required Site Modifications/Conditions:
IM1IPROVEMENT/OPERATION PERMIT
FINISHED GRADE. ****NOTICE: Conta
system between 8:30 a.m. to 9:30 a.m. or 1:00
. �
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( Env' onmental Health
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���ST
ialisYs Signature:
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DCHD OS/99 (Revised)
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GAL. Trench Width 3� Rock Depth � Z�� Linear Ft�`
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C.�'����� . %� S � � �t� f��l��t.
�-JLZL
VED EFFLUENT FILTER. RISER(S) IF G" BELOW
"the Davie County Health Departrnent for final inspection of this
� the day of installation. Telephone # is (33G)751-8760.****
� .�-v1� �►^�S r'� �Q��-
%�`1�N� (5 ��I�� �-��;,,�. ► ;
�pv,�S��S �Pi� - ISS�
Date: I� I Z� O�I `��I��
'; s �� DAVIE COUNTY HEALTH DEPARTMENT
, , � ' Environmental Health Section
" P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-8760
�� pi(�i � -��
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�
IMPROVEMENT/OPERATION PERMIT
Account #: 990002747 Tax PIN/EH #: 5842-13-8730
Billed To: Augdene Thomas Subdivision Info:
Reference Name: , Location/Address: Cedar Creek Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3466
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 ��ljs�= #People � #Bedrooms 3 #Baths �-
Dishwasher: � Garbage Disposal: ❑ Washing Machine: �� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size L-. � 1�;'�,� Type Water Supply V`'t=U-- Design Wastewater Flow (GPD) �� Site: New � Repair ❑
System Specifications: Tank Size��� GAL. Pump Tank GAL. Trench Width�� � Rock Depth L Z� � Linear Ftl.p���
Other: `T �SI�,�JI����i "F�X�� r�LT�.Q/JtaTIr.1G� �LC�i Jp�-�
T
RequiredSiteModifications/Conditions: �����.1...- e9�i C.�hj`tO�Q, �-�� ��� E-�� ��Q C�`X�+ ��'
l.J �%l-l._
IN[PROVEI�1ENT/OPERATION PER1�11T LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6`� BELOW
FINISI�ED 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 130 p.m. on the day of installation. Telephone # is (33()751-8760.****
�,...___-___
___ ;;
Environmental Health Specialist's Signature:
DCHD OS/99 (Revised)
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1
. DAVIE COUNTY HEALTH DEPARTMENT �%��
Environmental Health Section �
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-87G0
Account #: 990002747 Tax PIN/EH #: 5842-13-8730
Billed To: Augdene Thomas Subdivision Info:
Reference Name: Location/Address: Cedar Creek Road-27028
Proposed Facility: Residence
ATC Number: 3466
Property Size: see map
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 WASTEWATER RUCT O LID F R A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: D �`� �
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the ystem described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter 130 , Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarant tha the $yst j will function satisfactorily for any
given period of time. �
�ja�11�D�� (j•2R
Septic System Installed By:
Environmental Health Specialist's Signahue :
DCHD OS/99 (Revised)
Date:
�. I
- , : � . , �NS�� , p�ih�� ��
` ' , 1l1"�NT�Ll� N
, • Af' '(� IQN �OR S9Ti� EVr1LUA7-if�4/IMPiiO�'[@'lEEVT �`yE(i11E�' y1c tiT�'i;
,� 2 2(�,p3 ;^1 Davie C�unty Health Dep��rtrrj�nt
. Mp`( � �-: �, �nvironinent`,�/he:�a/i`Jr 5'�c��`i�vn
'-1 .0. Box 848/210 Hospital SLreet
�1 � `� � ^ Mocksv�lle, NC 2702 ^u
�(\ � 5 (336) 751-876�
�\1
I�RT�iNT*** THIS APPLICATION CANNOT BE PROCF.SS.F.Zi U27L�;SS ALI� THE REQIISREU
ZNFORMATION IS PROVIDED. Refer to the INFOR�SATIOPd BULL�T]'N for insi:rv.ctions.
rr.une tr� l�e Billod y�����-s�-��_� /h n i��_S Contact E�er.son •-- .,.J��� -------
/ 1 -_' �• c/
�/ Mailing I�ddress _L% � ���R Fio:ne Phoiio � ��_��__�o � �
�City/State/ZIP� ��_ ��Fi'usiness shane ___ _ __
�2!Name on Permit/ATC if Different than �'lbove� ���_� �,�.������5 `��m'p'S
/� � �� � /-7
r343iling Addreas �///� G.: ��(�^ ��.__� City/State/Zi O� I ��_� ���r � �
�— 3. Application For: a.te Eval�}a.�ion Uvement Permit/AT . � oth
l �
���. sy3tem to service: House Mobile iioma IIusiness Tradustry Other __
v'
5. If Residence: k People � # Bedroom� �_ � Bathzooms�_�
�. Diahwaeher Garbage DittF�sa]. ashizg Machine BasemanL•/Plumbing Basement/No Plu:nbing
6. If Husinesa/Industry/Other: Specify type ___ 4'r Peu�.le _____ _ '# Sinks _ _
# Commodes � # Showers # Urir..al.: ____ # Water Co�lers _____
IF FOODSERVICE: # Sea�B �stimatecl Natc,x' Us��ye (gallons per dv.;�) __
�;/7. Type of water supp].y: County/Cit�* Well. Community
�/a. Do you anticipate additions or expansions of the facility this system is intend�d ta servc? �'es No
If yes, wl�at type?
***IMPt7RTAN7`"** CLIENTS D1US7'COh1PLCTETHE REQUII{Elf y'ROi'i:,K1'Y IiV1�Ul2MA'1'IOiti I�EQt1L'STGU
BELO�;'. Eitlier a PLA'P or SIT'E 1'I.,AN MUSTBE SU13;Y11TIED by Yhr. clicut ��;th TIIIS APPLICA'E'ION.
Pro tv lliu:�nsions:
Tax Ofitce PIN: # ������ D
Property Address: Road Name I.Y�Go4 Cr tGI�C, l�l
c►cyiz;�
If in a Sub�iivision provide inforr�iatimn, as foIlo�vs:
Namc:
Section: 131ock: Lot:
�1'[21TG DI�;LC�'I']O[�'S (#':'4t11 b'ioCksvllll') t0 i4'ROPLRTY:
�i�E L1 D Er� S t -�_.��in : n��
�� ��_�����_ a��i�_�d� �
P� � �..��__ �'��,� � � ? r��-� �d
/���eQ L�� �uRvc o��LL
-� � �
,.�-li55,_� p�C��� u�� a r1 � e �/1i�' �t
c/
Date home ccrucrs f7:ig�;ec1: ��
This is to certify that the informatioyi pro��i�led is cUrrect ta thc best of my knP.►vvle�i�;e. I undcrsland tinat auy permit(s)
issued t�ereafter are subject to suspensi�n or revocation, if tlie site plans or intended use change, or if tl�e inforcnation
submitted in this application is falsified ur cl�anged. I, also, iuic.'erstand t1�ut d au� respunsible for all cliar�es incrirrrerl fr•un:
t/iis applicatiar. I, hereby, give consent to thc Authorized Represe�itativc of tlre B�?%` 1�C CO Iltiy 1lealtl� artment
to enter upon abuve described property located iu Davie County and orcned byG!� -- —__1��_���� —
to couduct all testing procedures as necessary to determine the site suitabilitJ•. �
DATE � ' �' � ' � 3 GNATUItE __,�
THIS Al2EA MAY BE USED FOR DRAWING YOUR SI7['i, PL�' nctude all uf tiir following: �aisting and pruposed
property lines and dimensions, structGres, setbacks, aud septic Eocations).
Sign given
Revised DCF (07/99)
������;�. C '� � �� �
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Site I2evisit C'hargc
1}.att(s):
CIic.Tit Notiiicatiou i�atc:
EHS:
A�.couait rTo. ���_
Invo�ce No.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
. Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990002747
Billed To: Augdene Thomas
Reference Name:
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5842-13-8730
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: see map Date Evaluated: -� ?o�
Water Supply: On-Site Well Community,
Evaluation By: Auger Boring Pit
FACTORS
Slope %
HORIZON I DEPTH
Texture group �
Consistence
Structure
II DEPTH
Texture group
Consistence � � •
Structure '
Mineralogy `
HORIZON III DEPTH
Texture group
Consistence
Structure
HORIZON IV DEPTH
Texture erouv
Structure
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
�����
i
��i'���
�iA�'�r�,TJ
; Z;
LONG-TERM ACCEPTANCE RATE: � �
REMARKS: Y�1'�i "-�L�C Y�' j�TL�r•i[� 3���'h
9
4
�
F�
EVALUATION BY:
OTHER(S) PRESENT: _
�5r J� �.xA�c h- �v b -
,+
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 - Subangulaz 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 - gal/day/ft2
DCHD OS/99 (Revised)
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