696 Cedar Creek Rd (2)Account #: 990001470
Billed To: Don�ld Smith
Reference Name:
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #: 5842-45-2462
Subdivision Info:
Location/Address: Cedar Creek Road-27006
Property Size: 11.54 acres
**NOTE�* Ttiibgrripro em�er►t/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 /, j7%7� #People _� #Bedrooms ,s� #Baths .�
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size f�G' Type Water Supply J�C//� Design Wastewater Flow (GPD) �� Site: New� Repair ❑
System Specifications: Tank Size/,� GAL. Pump Tank GAL. Trench Width�6�� Rock Depth � Linear Ft.�l
Other: �y� ��s �i,�.,�/ .�-�, �%`��-c
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Coun ealth D ent for final inspection ofthis
system between 8:30 a.m. to 930 a.m. or : 0 p. . m. ' s allat� . elephone # is (336)751-87G0.****
. �� � ,
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❑
Environmental Health S ecialist's Si ature: � � Date: ��✓O �
P �
DCHD OS/99 (Revised)
Account #: 990001470
Billed To: Donald Smith
Reference Name:
Proposed Facility: Residence
ATC Number: 2634
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
r. o. Bog sasmo x�p�tai s��t
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5842-45-2462
Subdivision Info:
Location/Address: Cedar Creek Road-27006
Property Size: 11.54 acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction M[JST 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 NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �V "� Date: l� ���
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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:
Environmentai Health Specialist's Signature :
DCHD OS/99 (Revised)
Date:
APPLICATION FOR SITE EVALUATION/IMPROVEI44ENf P�ti�9oi & ATC
Davie County Health Department
Envinvnmenta/ Hea/tfi Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
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***IMPORTAIVT*** THZS APFLICATION G;:.�v'OT IIE P12ih�S�D Li7'�SS ALZ TFic. n�QUIRED
INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions.
1. Nama to be Billed � .C`� �(''� � � � �� Y \ � Contset Peraon � 6(.1 ��1)
Mailinq Addres����aa� Fiome Phone ��� ��"� (�— ����
t ,�1 + � ��� �y'7 /�
City/State/ZIP 1 (��j����Q�i \V��� { 2� Businesa Phone ��,p / / �� V30 �
2. Name on Permit/ATC if Different than Above
Mailing Address City/3tate/Zip
3. Application For: '�Site Evaluation �Improvement Permit/ATC ❑ Both �
�\ �iA�� 2 W i C� ¢,
a. sy8t� to se�i�e: � House � Mobile Home '❑ Business ❑ Industry 'Fa Other ��
� �� � � �
s. xf Residence: N People �_ p Bedrooms � # Bathrooms �� bt� ,
1� Diahwasher 11 Garbage Disposal � Washing Machine ❑ Basement/Plumbing U Basament/No Plumbingr3�
6. Sf Businesa/Industry/Other: Specify type
i Commodes # Shoxera
� Urinals
# People
# Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay)
�. Type of water supply: 0 County/City � Well ❑ Community
e. Do you anticipate additions ar eapansions of tl�e facility this system is intended to serve? ❑ lles �No
If yes, what type?
***IMPORTANT*** CLIEN'j'S MUST CObtPLETETHE REQUIRED PIiOPERTY INFORMATION R�QUI;ST�D
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the clicat with THIS APPLICATION.
Property Dimensions: 1� � �� Q�,.
Tax Office PIN: #��� a��a y(� a
Property Address: Road Name
� b �
c�tyiz;� �vc�,n,es�, Nc a7o01�
If in a Subdivision provide information, as follows:
Namc:
Section: Block: Lot:
WRITE DIRECI'IONS (from Mocksvillc) to PROP1;Fi7'Y:
� ��, �� • � �� � � . , � �i1 � • �
—� 1�
,��. �_J � ; � ...�:;,� �:; �
�
•� `•� ' -
Date Property Flagged: _ ��� �cj � OD
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued 6ereafter are subject to suspension or revceation, if the site plans or intended use change, or if the information
submitted in this application is Talsified or changed I, also, undersland that I am responsible jor all charges incurred jront
this application. I, hereby, give consent to the Authorized Representative of the I2avie County Health Department
to enter upon above described property located in Davie County and owned Uy ��nn�c� l� .S r"r;;�_
to conduct ail testing procedures as necessary to determine the site suitability.
DATE � O, 2� 1 O�O SIGNATUIiE __ • �. ���
THIS AREA MAY BE USED FOR DRAWING YOUIi SITE PLAN (Include all of tLe following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit CLargc
Date(s):
Clieat Notification Datc:
EHS:
Revised DCHD (07/99)
Account No. � / � �
Invoice No. � c� � � �
O�w
.588
]590
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i JE%E� ON 5812.1� I INDE%FD ON 5812.1♦ m
INDEXED ON SBe210
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IRIDIXED CN 5&215
�Davie County .7�ealtFr Depar�ment
and .�fome .�ealtFr .�yency
21O HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
5epten�:r : �. 1':�`=� =
i.�or",nld lv. 5�ith
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i='ir,-�acle. ��:�_ �i�v,�:3
�:E: sir�= EV%�1Cl�tlGfc
G_da�� Cr,_�ek Road
L�a;~ �1r. S.:,i�h:
R� ;�:�a�sas'r.=d, a t,�c:r•��ser��a;:ve �r�on t��i� af; ice vi�ited t�e c�fGt'2�1ei1�1Grie�
Sit� o;i Se�';��7Ler' ic•, ��yc. Tt.: 51:e �a�•: f.:;+_ii�G pY'��visicrraiiy Si_ti��`.�ble �07' �i':e
7.;1•;,t��il�tt3.uit Df � O;�G_.��d dbSG�';��:�T =e:rct�2 Sy5�eL1.
Ir yClt r��t'Ji %K?'�Y ���.te•3'GiO�i�, j�ie%�5� 1`eei �Y'=e 'Gu Ccfct3C� 'i.i�is of'FiCe.
Sir,4�r = y,
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DAVIE COUNTY HEALTH DEPARTMENT
, . .. ,� Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990001470
Billed To: Donald Smith
Reference Name:
Proposed Facility: Residence
Tax PINIEH #: 5842-45-2'�OPERTY INFORMA'T�O�....
-ysram�.��..
Subdivision Info:
LocationlAddress: Cedar Creek R�d?3 �JC�
Property Size: 11.54 aCGes Date Evaluated: ��_—�------
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring Pit Cut_
tcx�uic �i�uY
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Swcture
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE
REMARKS: �//'X �
✓C��� z � �
,
�¢�;� : � �
/ / OTHER(S) PRESENT:
�
�!�
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
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely �rm
SS - Slightly sticky S- Sticky VS - Very Sticky
SP - Slightly plastic P- Plastic VP - Very plastic
tructure
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 we[ness - 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
DCi-ID OS/99 (Revised)
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