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746-748 County Line RdDAVIE COUNTY HEALTH DEPARTMENT
r • Environmental Health Section
P. O. Boz 848/210 Hospital Street
, ' Mocksville, NC 27028
(336)751-87G0
� 3 - 2w- dl
IMPROVEMENT/OPERATION PERMIT 1� --� �
Account #: 889900631 Tax PIN/EH #: 4799-86-9137
Billed To: Robert BrBcken Subdivision Info:
Reference Name: John Bracken Location/Address: County Line Road-28834
Proposed Facility: Residence
Property Size: 54 Acres
ATC Number: 2123
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained'from this
Deparhnent 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
PERMTT LS SUBJECT TO REVOCATION IF SITE PLANS OR T�IE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM.
J
Residential Specification: Building Type � �� #People � #Bedrooms �� #Baths � 2
Dishwasher: � Garbage Disposal: ❑ Washing Machine: la' Basement w/Plumbing: 0 Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��� Type Water Supply `�/'tl� Design Wastewater Flow (GPD) �,e�',� Site: New �Repair ❑
System Specifications: Tank Size��GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width �' Rock Depth � Linear F��a �
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW
FINISHED GRADE. ****NOTICE: Contact a r resentative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m. to 9:30 a.m. or I:O�p.n%to 1:30 p.m. on the day of installation. Telephone # is (336)751-87G0.****
Environmental Health Specialist's Signature: / v� �(� Date: ��.��� �
DCHD OS/99 (Revised)
Account #: 989900631
Billed To: Robert Bracken
Reference Name: John Bracken
Proposed Facility: Residence
ATC Number: 2123
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-87G0
Tax PIN/EH #: 4799-86-9137
Subdivision Info:
��W' / . �t71 V
Cn1 � �/ _
.�/
Location/Address: County Line Road-28634
Property Size: 54 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 WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: , � ,, Date: �j�/��
.
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall in te the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. apter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken a gua ntee that the system will function satisfactorily for any
given period of time. � �� ��
Septic System Installed By:
Environmental Health Specialist's Signature r v �U Date: "�� �
DCHD OS/99 (Revised)
�
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APPL�CATION FOR SffE EVALUATION/IM�ROVfMEM PERMff & ATC D
i�avte i.c�nty liealth Department
S�� Fnvironmenk'a/Hea/thSe�ction
P.o. aox �as/Zio xo8pit� stxeet
O �/ � � Moc:ksnilie, xc 27028 � � / ` .q �
�i�� y��C (336) 751-8760 S' r%�
\ 11�
+�'x*2MPORTANZ"A'** '1�iiI3 l�P�,'.+ICi+TI0,4� C.Aii�'NOT BE PROCESSED UNLE33 ALL THE REQIIIRED
iNFOF�TION I3 ?ROVID�. Refer to �hhe INFORt�,TION BULLETIN for instructions.
1. xam. to b. 9ill.a p n e r�- I�.��n� l�r�1 C,� contaat r.rsoa ,'��/jn %r4r /�'en
Ma.a linQ Irddr�ss '/ c.I Qi � ['�u� �-U I �f� °L /l � . Ho� ?hona �/ � � - � u � (A
�— T
Ci�y/stat.o/Zip ��9fml�flC.l �v,�. 25�3�1 Husinesa Bhona
2. Na�s on 8ormit/ATC if Dilfarant than Abovo
Msillnq 11ddr�as City/Stato/Zip
- 3. Appiication For: 0 3ite Enaluatioa ❑ Impronemsnt Permit/ATC C� Both
a. , syst..m to s•�soo: ❑ i3ouse SYMobile Home ❑ Business ❑ Industry ❑ Other
s. �� �cc�iaence: � Peopla ___�__ # Bedrooms �_ � Bathrooms r jz,
❑ Dishraahor O GarbaQ� Disposal �ashiaq Machina 0 Sasomant/Plumbinq ❑ Has�at/No Plumbinq
6. S! Businoss/3ndustry/�thor: Spacify typ� �?ooplo � Siaks
i Co�odos � Shoxars � Urinals # Nater Coolors
IiT FOODSER�I�CE: #�eats Estimated Water Usage cQ�loas p.r dag)
7. '1`ype of pater supply: C+�County/City ❑ Well ❑ Commusiity
e. Do you anticipate add�tions or eapansions of the facility this system is intended to serve7 0 Yes �No
If yes, ��vhat type? - -- --
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROP�RTY INFORMATION REQUESTET�
BELOW. Either a PLAT or SITE PLAN MI/ST BE SUBMIY'TED by the clieLt witL THIS APPLICA'Y'ION.
Property Dimensicins: S��i /�� _,�
�Caa Office PIN: # L� 7 9�- �s� '�1 I 3'7
�'�•;aiperty �:4dress: Road Name i� oc..�' n%4 1; a� e%�
City/ZIp %��yrrnDn i/ ;.�-�l03�%
If in a�'abdivision provide information, as follows:
Name:
u�e :tion: Block: Lot:
WltITE DIREGTIONS (from Mocksville) tu P�30PER7i 1:
�O � +O W q r cl S-�a �u> l l e -�4/n
�■ �� ►. � L� .�.
. • . C
• . . .• �. �'.
Date Property Fiagged: (o �l4 � �7
�'his is to certify that the information provided is correct to the best of my knowledge. � anderstand that any permlt(s)
�ssued hereafter are subject to saspension or revocation, if the site plans or intended use change, or if the inf�rmation
sabrmitted in this app.ication is falsified or chn�gad I, also, understand that I am responsible for all cA;arges incurred jrom
thJs applicatdon. I, hereby, give consent to the Aathorized Representative of the Davie County HealtL Department
to enter apon above described property located in Davle Couuty and ovrned by 3r,1�,r-� %�,r c� ,�'�
to conddct all testing p;•ocednres as nece.ssary to determine the site snitability.
DATE Co - � $ - 9 �T SIGNATURE g��T.n .���, _._
THIS AREA MAY BE USETi FOR DRAWING YOUR SITE PLAN (Inclnde all of the fo�!�;•�ving: E�t�.i� and pr�?. ��nsed
property lines and dimensions, stractares, setbacks, and septi�, iocationsf.
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UAVIE COUNTY HEALTH DEPARTMENT
� �; .r , , Environmental Health Section
Soi�/Site Evaluation
A�'P'L1CA:�'�' INFORMATION PROPERTY INFORMATION
.�,
Account #: 989900631 Tax PIN/EH #: 4799-86-9137
Billed To: Robert Bracken Subdivision Info:
Reference Name: John Bracken Location/Address: County Line Road-28634
Proposed Facility: Residence Property Size: 54 Acres Date Evaluated: $"�.�� � _
Water Supply:
Evaluation By:
unor�nu t n�a�ru
r,,..�:�►a.,..a
Swcture
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
�tructure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
On-Site Well � Community
Auger Boting Pit
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RA
REMARKS:
Public
Cut
OTHER(S) PRESENT:
LEGEND �
Landscape Positton
R- Ridge S- Shoulder L- Linear siope 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
oist
VFR - Very friable
�
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
tr ture
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
MineraloQy
1:1, 2:1, Mixed
tes
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
►�.,• _ �
•�CE',.h ;Revised CS/99}
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