1901 Cornatzer Rd DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street Z 3
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003073 Tax PIN/EH#: 5769-59-8367
Billed To: Graham Hendrix Subdivision Info:
Reference Name: Location/Address: 1901 Cornatzer Rd-27028
Proposed Facility: Residence Property Size: 1 +acres
ATC Number. 3696
**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 I 1 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 e W #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 C Type Water Supply t"46 Design Wastewater Flow(GPD) Site: New-Er"Repair❑
System Specifications: Tank Size GAL. Pump Tank GAL.'Trench Width--7,v'- Rock Depth�10 - Linear Ft..12
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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 . Telephone#is(336)751-8760.****
,,
SlI� o
Environmental Health Specialist's Signature: Date: �
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003073 Tax PIN/EH#: 5769-59-8367
Billed To: Graham Hendrix Subdivision Info:
Reference Name: Location/Address: 1901 Cornatzer Rd-27028
Proposed Facility: Residence Property Size: +acres
ATC Number. 3696
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.
Environmental Health Specialist's Signature: Date:
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 t shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
d
�S
A �
-o�
Septic System Installed By: ` l
Environmental Health Specialist's Signature: Date: d/L Ow
DCHD 05/99(Revised)
V AP TION F0I1 SITE EVALUATION/JAIPI1OVliAl • 1'L•II'1-Irr S�A1"C U /�
4
Davie County Health Departm t e�
EnVirOnmenta/Hea/t/i Sec
+ P.O. Dox 848/210 Hospital Str t �a� ��OQ
1 Uy�;Fphtl,UyTALhE�;!�N Mocksville, NC 27028
C'O""! Y (336)751-8760 D9�6-Ve y
***IMPORTANT*** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TIIL EQUIItE i
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instru s.
Name to be Billed 6 t-4:z 0-M P&-it r;_X Contact Person __ _.•. ,
Mailing Address jZ I Cort)a IZGY RA. llome Plionc + / F-93
•S 3
City/state/ZIP mo ks V; Ile- C, a909:8 Duuiness Phone
2. Name on Permit/ATC if Different than Above _ __,.. _......_
Mailing Address City/State/Zip
3. Application For: Site Evaluation 69flImprovemenL' Peimit/ATC CI Both
4. system to Service: ❑ House 9-11obile Home ❑ DusineSs ❑ Industry ❑ 0L-hc3
5. type system requested: Conventio
n
al 11conventional modified ❑ innovative —]
6. If Residence: tl People Bedrooms �_ 11 Bathrounlu o`er
ly"Dishwasher ❑Garbage Disposal Eiliashing Machine ❑Basement/Plumbing ❑DasemenL•/llo plumbing
7. If Dusineas/Industry /Other: verify type 8 People I1 sinks
II Commodes 0 Showers t1 Urinals 11 Water Coolero
IF FOODSERVICE: #iSeats Estimated Water Usage (gallons per day)
8. Typo of water supply: R, County/City ❑ Well ❑ ,Community
9. Do you anticipate additions or expansions of the facility this system is iu(cudetl to serve?❑ Yes FerNu
If yes,what type?
***IMPORTANT'CLIENTS AMST COAIPL1sTETHE REQUIRED I'ROI-EI IT 1NFORAIM ION REQ1JES-1.1.
BELOIV. Eithera PPLAI'orSITE PLAN BIUSTBESURK17TED by the client n•ith THIS AI'1'L1CAT10N.
Property Dimensions: _J_ + Q C�sx-� 1YIt1TE DIRECT-IONS(Crum 11•luckn ille) to 1,401,1.1,RTY:
Tax e PIN: _6-7 0 q5� 8 3 rl G a to S T Coe,-na f C
v z Cr�,
Property Address: Road Nalne Cot- n a Tx.C5 r ed 1 3 rn it e 5 D n )!f, 1 iJ e to t-
city/Zip E o &AP 0 t-)a t-
If in a Subdivision provide information,as follows: To Lon h
Nantc: _I /) t r b n a r C
Section: Block: Lot: Date halne corners!lagged:
This is to certify that the information provided is correct to the best of illy knowledge. I understand that:uly pernlit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. 1,also,«nderstand that 1 cull responsible fur all chargas blcurred fl•uu:
this application. I,hereby,give consent to (Ile Authorized Representative of the Davie County I latch Dcp:u•tuiell l
to enter upon above described property located in Davie County and owucd by Cr< t,4 ti-.
to conduct all testing procedures as necessary to determine the site suitability.
DXI _ b. SIGNATURh
TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge .
Client Notification Date:
/I EHS•
1 04
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003073 Tax PIN/EH#: 5769-59-8367
Billed To: Graham Hendrix Subdivision Info:
Reference Name: Location/Address: 1901 Cornatzer Rd-27 28
Proposed Facility: Residence Property Size: 1 +acres Date Evaluated: _ � 0
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH I
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH '`
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � EVALUATION BY:
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-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-Subangular blocky PL-Platy ' PR-Prismatic
Mineralogy
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 05/99(Revised)
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