Daisy Ridge Ln - Vacant DAVIE COUNTY HEALTH DEPARTMENT
. . . , Environmental Health Section ��'.3-''�' � �
P.O.Boa 848/210 Hospital Street
, , — Mocksville,NC 27028
(336)751-8760
� IMPROVEMENT/OPERATION PERMIT
Account #: 990001564 Tax PIN/EH#: 5779-84-3873 ,�y�A R�L�,L�
Billed To: Jerry&Shi�ley Drake Subdivision Info: R� r/� � �. �
Reference Name: Location/Address: No{�amed yet-27028
Proposed Facility: Residence Property Size: 1.86 acres
**NOTE�'�'TIilb�mproveirient/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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TAE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type t� #People � #Bedrooms � #Baths �
Dishwasher:� Garbage Disposal: 0 , Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �.. Type Water Supply /rflC// Design Wastewater Flow(GPD) c�6� Site: New� Repair❑
System Specifications: Tank Size/�GAL. Pump Tank GAL. Trench Width�'�� Rock Depth� Linear Ft.�
Other:
Required Site Modifications/Conditions:
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.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health SpecialisYs Signature: Date: �'"��`'p1✓
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
. Environmental�Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001564 Tax PIN/EH#: 5779-84-3873
Billed To: Jerry&Shirley Drake Subdivision Info:
Reference Name: Location/Address: Not named yet-27028
Proposed Facility: Residence Property Size: 1.86 acres
ATC Number: 2711
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 Fonn/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 Signahue: 461�� Date: �`T'�l7J
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation 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
given period of time.
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S tic S tem Installed By: �
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Environmental Health Specialist's Signature:�Q rLk%C/� Date: � y`������
DCHD OS/99(Revised)
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' , . . � QP('11CATION FUIi SIiE CVALUA�i10�/Ifl1I'(itlyEh9CM�I��1i�9t1"&�► ' S �
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Davie County Heafth Department F� "
Environmenia/Hea/!fi Section
P.O. Box 848/210 Hospital Street ��{RONMENTAL HEALjH
� . Mocksville, NC 27028 DAVIE COUNTY
(336)751-8760
***IMPORTANT*** THIS APPLIGATION CANNOT BE PROGESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
l. Name to be Billed � SI�1 1�I��/ �1�Q Y)� Contact Peraon �Jhl (�e C/ /1 rGLI'1 e
Mailing Address r� � � Home Phone 79�'�3"19
City/State/22P �I�v/A►7(�_(� . /Yi Lr. 27oa� Businosa Phone ��1—��Q l
2. Nama on Pesmit/ATC iE DifEerent than Above 1Q•�� / / � �" �� � Z
Mailinq Addreas City/State/Zip
s. 7�pplication For: Site Evaluation �1 Improvement Permit/ATC ❑ F3oth
/ �
a. syat� to se=,.��e: � House � Mobile Home 0 Business � Industry ❑ Other
s. If Residence: � People � � Bedrooms � � Ba�hrooms �
Q� Diahirasher Q Garbaqe Diaposal �(Washinq Machine U Basement/P1umUing U IIaaamant/No Plumbing
6. If Buainesa/Industry/Other: Specify typo � Paople 11 Sinkn
N Co�odes # Shoxers � Urinals # Wator Coolorn
IF FOODSERVICE: # Seats Estimated Water Usage (gallona por aay) '
7. Type of water supply: ❑ County/City �I Well � Community
e. Do you anticipate additions or eapansions of thc facility tl�is system is intended to servc? 0 Ycs I�No
If ycs,whut type?
***1MPORTANT***CLIENTS MUSTCOMPLETETlI E RL•QUIRCD PROPERTY 1NrORlYIATION ItGQUL:S'I'CD
� BELOW. Either a PLAT orSITE PI,,A.1�I MUSTBESU13MI7TED by tlic clicnt with THIS A['PLICATION.
Property Dimcnsions: �• �� � WRITG DIRGCTIONS(frum Mocksvillc)lo PILU!'l;lt't'1':
�Taxon��r�rr: # 5'�1 '7�-8� - .�B'l,� :�� ��/ fo�ard Lexi�vGt�oN._
j���c,/`�„t o�d (�oss.e/y�
Property Address: Road Name ne -i� n.��_ $b�� .�I�'._/Y�rzr�� G�t�ld road Cle f+� �
. ?s�- n. s►e.Ka..4.�..c,. 2+� .
,� � c� iz�P .� mile , �iba�1 bes�de c�ov�ble�c��-w�¢e.��h
I' f in a Subd���n provi c inCo mat�,�follows: b(� �-� �'b ��p(� 1-1 C'_ C`rbSS
,
Namc: C�c'E2�, `� t�r'bDer�cd �f� ��'.-�'.
1
Sectioa: Block: Lots Date Property Flaggcd: ,
This is to certify that the information provided is correct to the best of my knowledge. I understand that uny permit(s)
issucd hereafter are subject to suspension or revocation,if the site plans or intended use cLange,or if tLe inforination
submitted in this application is falsified or cLanged I,also,understand that I am resporrsible for all charges incr�rred f�oni
lhis applicalion. I,hereby,give consent to the Authorizcd Represcntative of the Davie County Hca1tL Dcp rtmcnt
to enter upon above dcscribed property locatcd in Davie County and owncd by.,�jr`e��. Mi�►o r��h i r�P U V. pralhe)
to conduct all tcsting procedures as nccc§sary to determinc the sitc suitabilit y.
,
DATE SIGNAT[JR�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: �aisting and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Rcvisit Chargc
. . Date(s):
�,/� Ciicnt Notircation Dates
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�'/�/o� ����� Account No.
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Revised DCHD(07/99) ��� ! �L �S� Invoice,No. �� 7 g
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• �. � . DAVIE COUNTY HEALTH DEPARTMENT
� ' : • � '- Environmental Health Section
• . � Soil/Site Evaluation
APPLICANT INFORMATION � PROPERTY INFORMATION
Account #: 990001564 Tax PIN/EH#: 5779-84-3873
Billed To: Jerry 8 Shirley Drake Subdivision Info:
Reference Name: Location/Address Not named yet-27028
Proposed Facility: Residence Property Size: 1.86 aCCes Date Evaluated: �-.7�—��
Water Supply: On-Site Well t/ Community Public
Evaluation By: Auger Boring_ l� Pit Cut 11
FACTORS 1 2 3 4 5 6 7
Landsca e osition .1- "
Slo %
HORIZON I DEPTH
• Texture rou
Consistence
Swcture
Mineralo
HORIZON II DEPTH L " �•
Texture rou
Consistence �
Structure 1C /
Mineralo
HORIZON III DEPTH
Texture rou •
Consistence
SWcture
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS �
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: /"" EVALUATION BY: �4
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 VFT-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
truct r .
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
. SBK-Subangular blocky PL-Platy PR-Prismatic .
Mineraloav
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
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