220 Daisy Ridge Ln DAVIE COUNTY HEALTH DEPARTMENT 'Z'�
Environmental Health Section �� ,,Z � � -��
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, ,>--'�' � Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001493 Tax PIN/EH#: 5779-84-1600
Billed To: David Harp Subdivision Info:
Reference Name: Location/Address: /�'1 AR�t<�-�.� � •
Proposed Facility: Residence Property Size: 1.673 acres
**NO'I�.'*'�"Ttii b�mprb��ent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION FOR WASTEWAT'ER SYSTEM CONSTRUCTION must be obtaineti from this
Department prior to the constcuction/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 THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
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Residential Specification: Building Type �• �OME l �J�j eople #Bedrooms 3 #Baths
Dishwasher: � Garbage Disposal: ❑ Washing Machine: �" Basement w/Plumbing: ❑ Basement/No Plumbing:� -
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size . N�X.�-�ype Water Supply t�t�l%l..t_Design Wastewater Flow(GPD) ? � Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt��r Rock Depth��Linear Ft.3��
otn�: 2 �D�sT�►F�v-`��.J �}4�.�,� I*�sra.� ��,��� c.'I�o.G, w�i►S•
Required Site Modifications/Conditions: �,�� '�QI.►, � C.��17�Q, {cLCt' S' �� � I�t=�-"'" �'��`
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IMPROVEMENT/OPERATION PERMtT 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 Specialist's Signature: ate: �� 17 Zha v
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DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
. ' r � Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 9900Q1493 Tax PIN/EH#: 5779-84-1600
Billed To: David Harp Subdivision Info:
Reference Name: Location/Address:
Proposed Facility: Residence Property Size: 1.673 acres
ATC Number: 2643
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Autharization 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 Tre tment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT N C ON I ALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � Date: l/ll7/Oa
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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 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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Septic System Installed By:
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Environmental Health Specialist's Signature: � te: �Z
DCHD OS/99(Revised)
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APPIJCATION FOR SITE EVALUATION IMPROVEMEAfT FERMIT&ATC D ��
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~ Davie County Health Department ND
' Environmen[a/Hea/th Sec[ion - V � 3 2n.op
P.O. Box 848/210 Hospital Street
, Mocksville, NC 27028
(336)751-8760
***ZI�ORTANT*** THIS APPLICATION C�INNOT BE PROCESSED UNLESS ALI, THE REQUIRED
INFORI�TION IS PROVIDED. Refer to the INFORMATION SULLETIN for instructions.
1. Name to be Billed ��i/'Q ��G /�/.7 r'/7 Contact Person �J,r i � /�01 t�'
�a
Mailing Addreas ��n /� n v eL l�ome Phone -I -/� '� 7�� �
City/State/2IP �!/�yvJ�-C 1(�_Lr �./t�d b Business Phone �0��
2. Name on Pezmit/ATC if Ditferent than Above �dj''7 C
Mailing Addresa Sqs�'+� � City/State/Zip —- �q�'"� �
3. Appiication For: � Site Evaluation, �provement Permit/ATC ❑ Both
a. syet� to se��e: ❑ House �'Mobile Home ❑ Business ❑ Industry ❑ Other
s. xf ltesidence: � People � � Bedrooms 3 i Bathrooms �-
1�Diahxasher ❑ Garbage Disposal I�TWaahing Machine � Sasemeat/Plumbiag ❑ Basemant/No Plumbinq
6. If Buaineas/Induatry/Other: Specify type $ People # 3inka
� Co�odea � Shoxers # Vrinala N Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona �= a$y�
�. Type of water suppiy: ❑ County/City �'iWell ❑ Community
a. Do you anticipate additions or eapansions of the facility this system is intended to serve? �Yes E�'�10
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITI'ED by the client with THIS APPLICATION.
Property Dimeasions: �' � 1 � � WRITE DIRECI'IONS(trom M ksville)to PROPERTY:
Tax ORce PIN: # S 7�9�GI-1 I�OD „ _ � �°`T �o �� I �- .f-a w�..F-
l�—t?—o o ��h4�'��v�� �� ,�/ �
Property Address: Road Nam �,��,�<< �-�- ' '�d ll c�.nc� �L-/ d n �A"��`�'�a�
%� �� �
City/Zip 4,b u.�' � � �'1"4 S`�J � �r�/�
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lf in a Subdivision provide information,as follows: �'�' `-( L..O �.S ��( ��--
_ �
Name: �-w-�- S� F-c�'L��" Cc1 �i.c_rv�.r.S
Sectione Block: Lot: Date Property Flagged: �_��� �"b�
This is to certify that.the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the informatioa
submitted in this application is falsified or changed I,also,understand that I ani resporrsible jo�a/1 charges incurred from .
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie Couaty and owned by
to conduct all testing procedures as necessary to determine the site suitability.
, �
DATE �l'�( ?,�l�� SIGNATURE_ .1-��..s�t� �-� ��/�i
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed '
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
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Client Notification Date:
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' ' ' � DAVIE COiTNTY HEALTH DEPART'MENT
, �. � � ' Environmental Health Section
� ' � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001493 � Tax PIN/EH#: 5779-84-1600
Billed To: David Harp Subdivision Info:
Reference Name: Location/Address: . �� �� �
Proposed Facility: Residence Property Size: 1.673 acres Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L
Slo e%
`HORIZON I DEPTH �. to — 4�
Texture rou L SG `
Consistence +=�' � '
Structure
Mineralo ��l
HORIZON II DEPTH O� - - • O
Texture rou S �
Consistence S
Structure
Mineralo Y,
�
HORIZON III DEPTH - 2- �'
''.�Texture rou G t C
�f
� Consistence N .�
S Wcture
Mineralo :1 ( =1 : 1 .
HORIZON IV DEPTH r
Texture rou „ 4
Consistence
� Strucfure '
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON •
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE Q�j. �
SITE CLASSIFICATION: EVALUATION BY: �
LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT: 1 Yl,�►�1J
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 1V1-Massive CR-Crumb ` GR-Granulaz ABI�-Angulaz 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-gallday/ft2
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