1688 County Line Rd�
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DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990000865
Billed To: Sonya Spry
Reference Name: Sonya Spry
Proposed Facility: Residence
IMPROVEMENT/OPERATION PERMIT
P�/�,�2�i
Tax PIN/EH #: 5800-07'-7621
Subdivision Info:
Location/Address: Courrty Line Road-28634
Property Size: 2.558 Acres
ATC Number: 2258
**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 %J'% }� #People � #Bedrooms � #Baths -2
Dishwasher: � Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine: L1 Basement w/Plumbing: ❑ Basement/No Plumbing: 0
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size _ fi�� Type Water Supply �� Design Wastewater Flow (GPD) � Site: New � Repair ❑
System Specifications: Tank Size��}6D GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
!i
GAL. Trench Width'?�� Rock Depth � Linear Ft�
_ ___
iMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) 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 installation. Telephone # is 336)751-8760.****
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Environmental Health Specialist's Signature: �� G+' ` . Date: �/ —� ��(t
DCHD OS/99 (Revised)
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Account #: 990000865
Billed To: Sonya Spry
Reference Name: Sonya Spry
Proposed Facility: Residence
ATC Number: 2258
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5800-07-7621
Subdivision Info:
Location/Address: Courrty Line Road-28634
Property Size: 2.558 Acres
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). 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 WASTEW R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � � Date: �� �� ���
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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
eiven neriod of time. .�
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
Date: �j � — �� - (�C7
, � .
1.
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APPLlCAT10N FOR SRE kIIAWATION/IMPROVEMEM PERMR &
Davte County Health Department
EnwironmentaJ Hea/tfi Sectfon
P.O. 8ox 8�8/210 �ospital 8txa�t
Mock�vill�, NC 27028 �•
1336)751-9760
r �C�G�M�
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NOV I 51999
*** I3�OATAHT� *� THZS ]IppI+iC1►'rIO2t GHtfOZ A� PROCC88�D VNLa88 ALL TH� REQOSRED
=NrOR�ATtON =8 pROVIDED. A�lor to th� IN�'ORMIITION SULLBTIN for instruatioas.
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=t TOODStRVICs: � S�atia i�timu�d Kat�r O�aq� l�oA• ��yt
�. Typ� o! Kawr �uppiy: Coun City 0 R�11 0 Co�muaity
e. Do yoo aaHcipate addiHow or ezp�ndon� of the tncWty t6b ty�tem b intended to iervc?
V yes, wb�t typeT
❑ Ya � No
***IMPORTANT"** CLIENTB MUSTCY?MPLF.TETNE REQUlRED PROPERTY 11VFORMATION REQUESTED
BEWW. �ither � PLAT or SITE 1'LAN MLZST'BESUBM1TlED by the clleat �viW 1'N[3 APPLICATION.
���: ; :;:��:.;:�� a . � � � Q.CX e S
T�:081ce PINt � 5�DD - D'7 -� t� a i
Property Addras: Rad Name
City2lp RYYnOn ��, i�iC 7�(Q�-
U in �t Subdlvillon pravlde Intormadon, �u folimve:
N�mes
Secdout Biockt Lroh
WRCt� DIRECflONB (tcom Ma{�svtlle) to PROPERTY:
�e�t h�, (Qy- -fn �e�w�d �oad,
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T6is b to cerHf'y t6at the InformaHon pravided b corrcet to t6e be�t of my IcnmvledQa I anderrtsnd tbst aay permit(�)
iuoed 6enARer are �ablc�t to �wpewlon or revocAdon, i[ t6e dte pl�nt or tntead�d aae eh�n�e, or 1[ the inform�Non
�abmitted tn t6b sppltcaHou b t�lsilied or chw�ed. l, also, understand fJiat I am ruponsl6le jo� aU cbarges lncamd froni
tlils applk4do». I, hereby, �ive eouseot to the Aatho� RepseunhtEve of the vle Cawty Hailt6 Departmeat
to enter apon sbove dacNbed property Iocatal in Davie Coanty snd owaed bY
to condnet aq taHn� procednra u neeeaary to determiue t6e dte taitabWty.
DA'TB �Bv'. {J. Iq'q� $IGNATURE
7i�13 AREA MAY HE USED FOR DRAWING YOUR S1TL PI.AN (Inclade sll of t6e follm�ringi EiistinQ and prnpa�ed
property Una and dimen�low, �tructnra, �etbac{u, �nd tepNc locstion�). '
8ite Ravbit CLar�e
Cltent NotiAcaHon Date:
Efl3:
Reviaed DCBD (07/99)
Accoant Na ���
Invotce Na �� /
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NOTE : TMIS PLAT IS SUBJECT TO ANY EASELENTS. AGNEEI�EN75. OR
RIGHTS OF WAY OF RECORD YRIOR TO THE DATE OF TNIS PL�T.
TNIB SUIIK7 IS EWJ[CT TO ANT //1CT3 TNAT IMY SC D16CL06ED BT �/ULL
AND /1CQIR�TE TITIE SEMICM. NOT FURNISIIED TO 6E �5 OF 7MI5 D�TE.
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Porcei 48
B.T. Beck
D.B. 42 - 572
Sheffied Rd. S.R. 1306
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V Location Map n.�s.
LEGEND
R/W-RlgMrof-Wq - C�ni�r Lln•
EW - E�d�thg kon flW ,,�t�o,.
�Ed.w�° r°" "'°' = �.�«�oN °'"""M.
CY PoMt
NIP �N wyro�n�Plae�d �� ��
Pil - Prep�rtr L1�• R- Rodlu�
C A- ContrWbd A�ew CM - Cherd Dlatano�
� _ R�hdore�d M�P • �pip� �� -�� °�
CCP- Com�+9abd Pkstk Rw -�� B°�1`
-F- 100 ywr Flood Boundory �_�� F�at
X F� �d W� Sw�r
.• � .� � :•
I�����������--
7������\��---
Parcel 3g
Randy G. Vaughn
D.B. 158 - 885
Plat tor
Sonya Diane Spry
/ Portion oi Deed Book 42 - 512
�
Port of Porcel 48, Davie County Tax Mop F-1
,�g� r� � Ta�wr+s�xv �unn suh a��
Q°��a��o`i91�� �" � 60' Caiohan pavla Ncrth CoroMa 08-14-t
p.an �� C. Roy Catea
p8' ��` 119 Depot Street '� N0.
yppp� Mockaville. NC i7028 Zµ p��
� Phone (704) 63s-3735 2825L-g
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APPLICANT INFORMATION
Account #: 990000865
Billed To: Sonya Spry
Reference Name: Sonya Spry
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5800-07-7621
Subdivision Info:
Location/Address: County Line Road-28634
Property Size: 2.558 Acres Date Evaluated: //^/8�
Water Supply: On-Site Well Community
Evaluation By: Auger Boring C/ Pit
HORIZON I DEPTH
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: f1 l
LONG-TERM ACCEPTANCE RA'
REMARKS:
Public t/
Cut
EVALUATION BY:
OTHER(S) PRESENT:
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
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
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 - Subangular 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 - gaUday/ft2
DCHD OS/99 (Revised)
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