630 Childrens Home RdDAVIE COUNTY HEALTH DEPARTMENT
' � Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
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IMI'ROVEMENT/OPERATION PERMIT
Account #: 989900186 , Tax PIN/EH #: 5813-72-3673
Billed To: Boger Real Estat%S�� �'�`��/�� ��y� Subdivision Info:
Reference Name: -Gil� �'KSa� r`�avid �%ry�. Location/Address: Children's Home Road 27028
Proposed Facility: Residence Property Size: 3.5 Acres
ATC Number: 2244
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 ��o/si #People #Bedrooms _� #Baths ��
Dishwasher: �1 Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size J-� ��' Type Water Supply ��!/ Design Wastewater Flow (GPD) � Site: New �" Repair ❑
System Specifications: Tank Size ��6� GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
�
GAL. Trench Width �� `� Rock Depth �� Linear Ft,��Zi
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 9:30 a.m. or 1:00 p.m. t p. .�he day of install tion. Telephone # is (336)751-87G0.****
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Environmental Health Specialist's Signature:
DC�-ID OS/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTME �G �
Environmental Heaith Section ��
P. O. Boz 848/210 Hospital Street � M�-� C�
Mocksville, NC 27028 (f�� ��,,�( �
(336)751-8760 � U'
Account #: 989900186 . � ,� e_Tax PIN/EH #:
Billed To: Boger Real Estate��u'��� €�v � Subdivision Info:
Reference Name: �u�� � �uv�o� b�y � Location/Address:
Proposed Facility: Residence Property Size:
ATC Number. 2244
5813-72-3673
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Children's Home Road 27028
3.5 Acres
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 NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: „� l- � Date: l/'//�'��
CERTIFICATE OF
**NOTE** The issuance of this Certificate of Completion shall ind
has been installed in compliance with Article 11 of .S.
Disposal Systems," but shall in NO WAY be taken s a
given period of time.
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�P�'S �� � ``
Septic System Installed By: :� �
ETION
system described on ImprovemendOperation Permit
130A, Section .1900 "Sewage Treatment and
� that the system will function atisfactoril`for any
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Environmental Health Specialist's Signature : ����Yc�i E' � Date: �—�' -- D�
DCHD OS/99 (Revised)
� ���� q��� ���
C(�►V" ,�,,;c�' � APPLICATION FOR SITE EVALUATION/IMPROVEMENfT PERMIT &
y'`� Davie County Health Department
�� 5�,.� � Environmenta/Hea/tfi Se�ction
Q"` / P.O. Hox 848/210 Hospital 3treet
Mockaville, NC 27028 �
D'ECE
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�/ �J�i��336) 751-8760 �'
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***iI�ORTANT*** THI3 APPLICATION CANNOT BE PROCE3SED UNLE33 ALL THE REQUIRED
INFORI�ATION IS PROVIDF.D. Refes to the INFORMATION BtJT.LETIN for instructions.
Nam� to bo Hi12�d T p� �� l L�J 1 r4' I`� Contaat P�rsoa '� � �_
Mailinq )1ddr�ss ,� 2� iJ S f-� �1�1 � S�� som� �ona ,�9'�� 7% 3 8
City/Stato/ZIP /��d �.�iCl C' E� �jf • e • a,L, %��� Buainess Phono / / a � ��� �
Nama on 8armit/ATC if Diffarant than Abow �i4 A.{� O Ci'� /v�f:�� /✓ �1��
Mailinq 71dcLr�es City/Stato/Zip �
Application For: ,� 3ite Evaluatioa 0 Impronement Permit/ATC /�,tt,�q E'�Both
�
syet.� to so�i�o: �House ❑ Mobile Home ❑ Business � Industry ❑ Other
s. If Residenca: i People � Bedrooms � � Bathrooms � _
❑ Dishwasiur ❑ Garbaqo Disposal ❑ lvaahinq Machiao O Has�t/pivmbinq ❑ Hasam�nt/No Hlvmbiaq
6. If Susinass/Industry/Othor: Spocify typa # pooplo # Siaks
� Commodas A Shox�rs i Uriaals ��Pat�r Coolore
IF FOOD$ERVICE: # Seats Estimnted �ater Osnge (qalions par day)
�. Zjtpe of �ater supply: ❑ County/City
�' Well
e. Do you anticipate addiHons or eapans��ns of tLe facillty this system is intended to serve?
If yes, what type? /1� t�
❑ Community
❑ Yes 0 No
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. �ither a PLAT or SITE PLAN MUST BE SUBMITTED by the client w[th THIS APPLICATION.
Proper4y Dimensions: 3.� %�-C Y E'S'
Taa Office PIN: # _��/3 ""' 7-z _-
C
Propert,y Address: Road Name _
City/Zip ���- �.2� �
Sf ia a Snbdi-�ision provide information, as follows:
Name:
Section: Block: Lot:
WR1TE DIRE�CTIQ Y�f%m (.�i���lcGw..PEfi � i4P
Goi�✓ - L. C!� %�',
�-�v� o� G , a/
��.1 vl ' e o C�
r7'L� �' �S % � A/
LI��kJ !�v YY� ea.'t a�-
Date Property Flagged: S : -�
lfiis is to certify that the information provided is correct to the best of my knowledge. I nnderstand that any permit(s)
Issued hereafter are subject to saspension or revocation, if the $ite plans or intended ase change, or if the informaHon
submitted in this application is falsified or changed I, a/so, understand that I am responsIble jor all charges incurred from
thJs application. I, hereby, give consent to the Aathorized Representative of the Davie Connty Health Department
to enter upoa above described property located in Davie Connty and owned
to conduet aA testing procedares as necessary to determine the site snitab
DATE -- �Z � —' n/ 7 SIGNATURE
TffiS AREA MAY BE USED FOR DRAWING YOUR S1TE PLAN (Include all of the following: Eristing and proposed
�roperty lines and dimensions, stractares, setbacks, and septic loeat3c���,+.
Revised � =."1D (07/99)
Site Revisit Char�e
Date(s): _�
Client Notiiicstion Date:
EHS•
A cconnt Na ��
Invoice No. �Z_
, . . llAVIE CUUN'I'Y HEAL'fH DEPAIt"I'MEN'1'
' , , _ .' � ' ' � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #: 989900186 Tax PIN/EH #: 5813-72-3673
Billed To: Boger Real Estate Subdivision Info: ,
Reference Name: Gilbert Boger Location/Address: Children's Home Road-27028
Proposed Facility: Residence �roperty Size: 3.5 Acres Date Evaluated: �0 �7
Water Supply:
Evaluation By:
FACTORS
Landscape gosition
s�o� %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON lII DEP'I'H
Texture group
Consistence
Stnicture
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Swcture
Mineralogy
SOIL WETNESS
RESTRICTIVE HORI;
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEF
SITE CLASSIFICATII
On-Site Well L� Community
Auger Boring Pit
Public '
Cut
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0
0
EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: �`� OTHER(S) PRESENT:
REMARKS: S�VI� II� �.✓ �A—�i��
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
ois
VFR - Very friable
�
NS - Non sticky
NP - Non plastic
FR - Friable Fl - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
SP - Slightly plastic P- Plastic VP - l�e:�a plastic
tru re
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR -�rismat:c
Mineralo¢v
1: l, 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 ��ater or incnes from land sarface to soil colors with chroma 2 or less
Ciassification - S(suitable), PS(provisionally :,uitable), U(unsuitable)
LTAR - Long-term acceptance rate - gaVday/ft2
vCHb (Revised OS/99)
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ENVIRONMENTAI HFALTH SECTION
P. O. Box 84S/210 Hospital Street
Courier #09-40-OG
Mocksville, NC 27028
Phone #: (336)751-8760
November 2, 1999
Gilbert Boger
5248 US Hwy. 158
Advance, NC 27006
Re: Site Evaluation/Children's Home Road
Tax Office PIN: #5813-72-3673
Dear Mr. Boger:
As requested, a representative from this office visited the aforementioned site on
July 19, 1999. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system for a four bedroom
house.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
/�a�� ��,/��,.
Robert B. Hall, Jr., RS.
Environmental Health Specialist
RH/mp
Enclosure(s)
,� ' . , ', . ', . �
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... .... _._ _ ........ ..... .. ...... ._ _ _ _.... _ .. . .. ,. .
D��li� C4U�1TY �LT�i DE�'��T1�I�I'
. . _
ENVIRONMENTAL HEAITN SECTION
P. 0. Box 848/210 Hospital Street
" Courier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
July 20, 1999
Boger Real Estate
Attn: Gilbert Boger
5248 U.S. Hwy. 158
Advance, NC 27006
Re: Site Evaluation/Children's Home Road, 3.5 Acres
Tax Office PIN: #5813-72-3673
Dear Mr. Gilbert:
As requested, a representative from this office visited the aforementioned site on
July 19, 1999. Based upon the information provided on the Application for Site
Evaluation and after an evalua.tion was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house✓mobile home location staked off.
If you have any questions, please feel free to coirtact this offce.
Sincerely,
,I�i2!�t�B, ����,.
Robert B. Hall, Jr., RS.
Environmental Health Specialist
��i1 •
Enclosure(s)
'9