128 Countess Ln� . . DAVIE COUNTY ENVIRONMENTAL HEALTH �
�- -� . , P.O. Box 848/210 Hospital Street �C � `�
• . �' � . Mocksville, NC 27028 �`�\
(336)753-6780/Fax #(336)753-1680
�ccou�t #: 990005802
Biil�:i� io: Cynthia Kalish
f��fer�E�ce P�l�nie:
E�ro�c�s�c9 Fr��;iiity: Residence
OPERATION PERMIT
�'�x �'iN.��N #: G20000002808
Su�at�i�ri:.,ioti in��:
Loc�tionrAdr�r�ss: Countess Lane-27028
�'����r�y �iz�;: 1.143 Acres
�����I�� T1��3�uance of this Operation Permit shall indicate the system described on the ATC 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. 5� GI� G mi3e `CS
� Ng� j31 �'�.�,�52 Y' (� �/�
System Type: f-rpuS �BS.T. Manufacturer�� Tank Date - I" 3 Tank Size�vVb
Pump Tank Size
�j'j(�d :tS��
System Installed By: A � ��hOQ, E.H. Specialist: "- Date:�— Z���
GPS Coordinate:
7_2L �
DCHD 11/06 (Revised)
��
• ! '. .
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680 �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
�ccou�t #: 990005802 'i�x Pl�€.�EH #: G20000002808
�ille:� To: Cynthia Kalish 5���i�ivi:iort Ir�fc�:
}��fer�E�ce �fan�e�: Loc�iioniAd�r���: Countess Lane-27028
F�ro�c�sQi� F�t;i€ity: Residence � i�ro��rly S�iz�: 1.143 Acres
Site Type: �NNew ❑Repair ❑Expansion
f,T� �Iu�tb��-: 5866 . . . . . :
**NOTE** This Authorization to Construct (ATC) MiJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change. '
Residential Specifications: # Bedrooms � # Bathrooms Z# People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size LI (RC Type of Water Supply: ❑County/City jdlWell ❑Community Well
System Specifications: Design Wastewater Flow (GPD) �Tank SizeL� GAL. Pump Tank �GAL.
Trench Width � Max. Trench Depth !� Rock Depth� Linear Ft.�o?s°�
r t: F,tc;iiG� IIl i��"� r'�`�tf` ��
SiteModifications/Conditions/Other: t+��-�3=d u� t=��r�r ,r `".1 ' '��`���i �,P��p{�
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-8760.
Environmental Health �
DCHD 11/06 (Revised)
, �.
' Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005802
Billed To: Cynthia Kalish
Address: 5939 West Friendly Ave. Apt. 47E
City: Greensboro
Tax PIN/EH #:
Subdivision Info:
Location/Address:
Property Size:
G20000002808
Countess Lane-27028
1.143 Acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change. •
Permit Type: C�Iew ❑Repair ❑Expansion Permit Valid for: �5 Years ONo Expiration
Residential Specifications: # Bedrooms� # Bathrooms 2- # People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):_��
Site Modifications/Permit Conditions:
Type of Water Supply: ❑County/City �Well OCommunity Well
�.N. � , -,,,,
Taac Map :
Address: ___
� _ _ -
' ._.:�: �_- _ .
� Date:
Operation Permit Inspection Checklist
Location and Separation Distances
1. Distance from septic tank/pump tank to foundation/basement �J feet
2. Distance from system to well if applicable �(� feet
3. Any other setback (.1950) requirements_T�}
Supply linc 2
1. Material supply line is constructed of V G _ diameter J inches
2. Length of supply line (2' min.) 2,$
3. Amount of fall in supply line (1/8" per foot min)
4. Distance from STIPT to the nitrification field/dist. device) 2, , 5� feet
Septic Tank/Pump Tank
1. Visually inspect top of tanks(s), interior & exterior walls, baffle wall and bottom
2. Any honeycombing or exposed rebar present? Circle : YES or NO
3. Visually inspect sanitary tee, lids, and air vent for proper installation and sealant
4. Tank Serial Numbers: STB ']�p(7 PT
5. ST w/in 6" finished grade? Circle: YES or NO
6. Date of manufacture: ST G]- � PT
7. Liquid capacity of tanks ST � ��� PT
8. Ef�luent filter type
9. Pipe penetration seal present? Circle: )� or NO
10. Riser(s) present? Gircle: YES or� Riser Type
11. Pump Tank riser 6" above finished grade? Circle: �'ES or NO N j t�-
12. Riser approved? Circle: YES or NO N�F�
Nitrification Field
1. Septic Tank outlet elevation
2. Trench Depth Readings (inches) 2�-7j6" "
3. Number of Trenches �f Distance between trenches�' _
4. Trench Width 3
5, Aggregate material type �/l�' and size 3 4 5 6 57 (Circle)
6. Aggregate Depth (inches) l�l�t
7. Nitrification lines installed on contour? Circle: �or NO
,8� Innovative system type Installer certified for installation? Circle: YES or NO
9. 2' earthen dam between ST (or d-box) and beginning of nitrification line? Circle: YES or NO
10. Stepdowns
a. 2' undisturbed earthen dam(s) Circle: YES or NO
b. Proper rise over stepdowns? Circle: YES or NO
c. Solid pipe used? Solid, Corrugated or other?
d. Elevation of each stepdown
e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO
Distribution Devices
1. Type Is the device watertight? Is it level?
2. Distance from Dist. device to trenches feet
3. Record elevations: Inlets Outlets
� � �, �d
�� � . . ,
�,
• � ' ' �g � ICATION FOR S1TE �VALUATION/IMPROV�MENT PERMIT & ATC , � � /�Z
� � � :9�� Dirvie Couuty Euvironmt�it�l He:►ltti �
P.O. Box 848/21011ospitHl Strect
'; 0{� 20�� Mocksvillc, NC 27028
��r'<<'+ (33G)753-G780/ P'ax (33G)751-878G
�'� ��L Site L"valualion/Improvement Permit C Authorizalion To Construct(A7'C) �I3oUi
��`,�.�-�-�-�" ypc of Application: CNew System CRepa�r to hxistmg System C�xpansion/Modi[ication of Exislmg System or Pacility
"**lMPORTANT*•* Tf-IIS APPLICATlON CANNOT BEPROCLSSED UNLGSS ALL OP TIIG RGQUIRED
INI'O[tMAT10N IS PROVIDED. Refer to the INFOItMATION BULLGTIN for inslructions.
APPLICANT INFORMATION
Name to be Billcd � i Contact Person ��i'lili iQ� fSr�
13illing A�Idress `I Home 1'l�onc 33b- Ip(a�'Z2�15
City/State/Z1P 4'\� �+f 10 Business Yhone 33b ��"1� " � � I y eiC�'.�'�j,(
c�ns�� ee ►� �� att ca�a�rt3�-�19z�5yy�
Name on PermiUATC i Different ihan Above
Mliling Address Cily/Slate/Zip
PROP�RTY INFOKMATION *llate House/Facility Corners Plag ed �" �" �Z
NOTG: A survcy pint or site plan must accompany tliis application. Included: Site Plan CI'lat(to scale)
(I'ermit is valid for 60 monU�s with site plan, no expiration with complete plat.)
Owner's Name CcJ4?f �11 jj. �.. Ka I►sti Phonc Numbcr � �- 22��
Owner's Addres�— COLIY'1teSS �.-Qi'1 C City/State/Zin� ' ]�$
Property Address ; City
Lot Size (.�3 4,C(�E',S Tax PIN# C 'Z• C�P'J�Uz9 '
Subdivision Name(if applicable) Sectioq/Lot#
Diroctions To Site: "�Qi�(e �/ (pl}_ eS�' 1"p `�%1P.�IQ.�(�. ���i(,P. Q, �]q h�', _
If the ans�ver to an�bf the following qucslions is "yes",'supporting docdtficntation must be attached. C�,u��� j�,hg,
Arc thcre any existing waslewafer systems on Uie site7 CYcs No
Does the site contain jurisdictional wetlands7 LYes�No
Are lhcrc any easements or right-of-ways on the sitc9 CYes No
Is the sitc subject lo approval by another pubiic agency7 C Yes�No
Will wastewater othcr than dotnestic sewage be generated? CYes No
IP RGSIDGNC� PILL OUT THE BOX G W
!t Pcople # IIedrooms # Bathromns Garden Tub/Whiripool L1Ycs C7No
[3asemenC ❑Ycs l`1No Basement PlumbinQ: ❑Yes �No �
If NON-RCSIDI'sNCL PILL OU'C THE BOX BELOW
Typc of Pacility/Busincss Total Square Pootage of F3uildinR # Yeople
# Sinks # Commodcs # Showers !! Urinals
Gstimated Watcr Usage (gallons per day) (Attach documentation of similar facility waler consumption)
POODSGRVICE ONLY: # Seats
Type system requcsled: XConventional CAccepted Clnnovalive CAlternative L"OOicr,
Watcr Supply Typa C County/City Water C New Well CExisting Well L" Community Well
Do you anticipatc additions or cxpansions ofthe facility lhis system is intendcd lo scrve7 C Yes �No
If ycs, what type7
This is lo certify that lhe information provided on this application is true and corrcct lo thc best of my knowledge. I undersland that
any permit(s) or ATC(s) issued herealter are subject to suspension or revocalion if lhe site is altercd, lhc inlendcd usc changes, or il'
the infonnation submitted in this application is falsified or changed. I hereby grant right of enlry to the Aidhorized Rcprescnlativc
of thc Davie County Hcallh Departmcnt to conducl nccessary inspeclions lo delermine compliance wilh applicable laws and rules.
I undcrstand that ] am responsible for the proper identification and labeling of property lincs and corners and locating and Ilagging
�or aking the house/facilily loc� n, proposed well location and thc location of any other amcnitics.
���-` C��' 9� Site Revisit Charge �"
1 rop y owner's or owner's legal represcntative signature '
Date(s):
2 % Client Notification Date:
Date GI15:
Signgiven CYcs�No
Iteviscd I1/06
c��� jZol��
Account # V �O`�"
Invoice # �
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�'Xc 5 I��. �0 R. EYi�I.uA-�o►•1 P� �J+�t 1T -'
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, ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
Account #: 990005802
Billed To: Cynthia Kalish
Reference Name:
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: G20000002808
Subdivision Info:
Location/Address: Countess Lane-27028
Property Size: 1.143 Acres Date Evaluated: ��/ al
Water Supply: On-Site Well X Community
Evaluation By: Auger Boring � Pit
FACTORS 1 2 3
Texture
Structure
0
HORIZON II DEPTH
Texture group
Consistence
Structure
Texture groi
Consistence
Structure
HORIZON IV DEPTH
Texture group
Consistence
Structure
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
�
LONG-TERM ACCEPTANCE RATE: - b�
.
REMARKS:
0
4
EVALUATION BY:
OTHER(S) PRESENT:
Public
Cut
5 6 7
LEGEND
L�ndscaoe 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
T�ctuTg
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
�Qis�
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
S�T]I��IITg
SC - Single grain M- Massive CR - Crumb GR - Granulaz ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogv "
1:1, 2:1, Mixed ,
lY�� • �'
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 inch �s from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsiitable)
LTAR - I.rong-term acceptance rate - gaUday/ft2 � DCHD OS/OS (Revise
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