183 Dakota Ln.
, , DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boa 848/Z10 Hospital Street
Mceksville, NC 27028
(33G)751-87G0
Account #: 990003634
Billed To: Derek Norman
Reference Name:
Proposed Facility Residence
ATC Number: 4096
Tax PIN/EH #: 5820-42-4976
Subdivision Info:
Location/Address: Dakota Lane-27028
Property Size: 5 acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE ARS.
�
Environmental Health SpecialisYs Signature: Date: � ,�
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.
Septic System Installed By:
Environmental Health SpecialisYs Signature :
DCHD OS/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
.� Environmental Health Section
�; P. O. Box 848/210 Hospital Street
Mocksville, NC 27028
(33fi)751-87G0
Account #: 990003634
Biiled To: Derek Norman
Reference Name:
Proposed Facility Residence
IMPROVEMENT/OPERATION PERMIT
/�� �%�°s
Tax PIN/EH #: 5820-42-4976
Subdivision Info:
Location/Address: Dakota Lane-27028
Property Size: 5 acres
ATC Number: 4096
**NOTE** This Improvement/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
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 %s #People � #Bedrooms �� #Baths �_
Dishwasher: y� Garbage Disposal: � Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: �
i
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply �a_ Design Wastewater Flow (GPD) ��i � Site: New �Repair ❑
System Specifications: Tank Size% GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
i� �
GAL. Trench Width �� Rock Depth � Linear FY.��
I I1�IPROVEI�1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW
FINISIIED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33()751-8760.****
�
Environmental Health Specialist's Signature: Date: .S
DCHD OS/99 (Revised)
. �
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D�����Q�C�
��Ay 2 4 2005
1
E!WlRONME�JTAL HEALJy
nAv�r�.., .._.
CATION FOIi SITE EVALUATION/Ih1PIi0VEh1CNT PERh117 & ATC
Davie County Health Department
Environmenta/Nea/th Section
P.O. Box 848/210 Hospital Stree�
Mocksville, NC 27028
(336) 751-8760
I ** R4�,�lN ** HI APPLICATION CANNOT BE PROCES5ED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION IIULLETIN for in�tructiona.
l. Name to be IIilled �Q/'Q ���� /Vu y^ ✓VI c� /� Contact Pernon _, Cf r
Mailing Addrona �yrj �I �, �, � �� L� Aome Phone 3 3G -y G 3 Jc� �CJ i
City/Stato/ZiP �,c�f �.� �1 �/;�( �� AJC I��O S S Businesa Phono Sr>•y� C
2. Nama on Pormit/ATC if Differont than Above S 9�, C?
Mailing Addresa 7�n., -� City/Statu/Zip 7t{iwt -1
3. Application F Site Evaluation �(Improvement Permit/ATC ❑ Both
��
a. Syatem to service: �iiouse � Diobila Aome ❑ Businesa O Industry ❑ Other
5. Typo ayutem requested: �'Conventional ❑ conventional modified ❑ innovativa
6. If Rasidence: # Paople _�_ # i3edrooms �_ N I3athrooms L
�Diahwaahar ❑Qarbage Disposal �Waahing Machino ❑Dasement/Plumbing
If Duainesa/Industsy /Othar: verify type /(/�;J�?'� N People �
# Commodos� Q # Showers � # Urinals �
ODaaemont/No Pliunbing
_ t! Sinka �
tk Water Coolera �
IF FOODSERVICE: # Seata O Estimated Water Usage (gallona por day) c�
Type of wator supplys �County/City
❑ Well
❑ Community
no You anticipata additiona or cxpansioi�s of tlic facility tliis systcni is ic�tcncled to scrvc? � Ycs �No
If ycs, ivhat typc? /�%6 h�
***I111PORTANT"`** CLIENTS1�tUSTCOAIPL�TETIiC REQUIRED PROPCRTY 1N1�ORA�IA'1'ION IiGQUCS'CCD
BELO�'V. Cithcr a PLAT or SITG PLAN hfUST IlES1113�11JT1'L•D by ll�c dicnt with TIIIS APPLICATION.
Property Dinuusions: �� � C h e�' s
� Tax Officc PIN: �f ��� o � Z�% 7 S`
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v
� Property Address: Road Namc �q y�c��" �
� r
� City/Zip �1Uc'. �7 U � � �
. �
If in a Sub�ivision providc informatioii, as follotivs:
Namc: _ 1�l 06�
Scction: Blocic: Lot:
1VRITL DIRLCTIONS (frum Modcsvillc) to PROI'L'sRTI':
� �t� L_ � 5 �-/,� � /'�.f
\ �J 'T� .;.K-, /�
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Datc l�omc corncrs 1]aggcd: � �� ��
This is to ccrtify tl�at il�c information providcd is corrcct to tl�c bcst of m}� l:no�vlcdgc. I uudcrstatid tliat any perci�it(s)
issucd I�crcaftcr are subjcct to suspcnsion or rcvocation, if thc sitc plans or inicudcd usc cl�augc, or if tl�c inlorwation
submitted in tltis application is falsiGed or cliangcd. I, also, rru�lersla�rd 1lcrrt I ani respousiGlc jor n!1 clra��es fiicrrrred jruur
tliis applicatiorr. I, l�crcby, givc consent to thc Authorized Represcutativc of thc Dayic Couiity IIcaIW Dcpartment
to cntcr upon lbovc Jcscribcd propert�� Iocatcd in Davic Count�� and o�rncd by
IO C0J1(IUCf 1II Il`SUIIs nI'OCCtIU7'CS 1S JICCCSSII'j� to dctcrniinc tlic sitc suitability.
DAT� : �'_� y - Q � SIGNATUIt� �-��n> h :� c7c / ��i�
.
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TIIIS AIt�A MAY B� US�D rOR DRAWING YOUR SI'T� 1'LAN (Iucludc all of thc follo�vinb: Lsisliug and proposcd
propert}� lincs and dimcnsions,� structures, setbacics, and scptic locations).
- � � � Silc 12cvisit Cb:u•6c
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Cv /�� DAVIE CO. ENVIRONMENTA� HE4LTH
t
T �U �'�/
Sign givcn�
Reviscd DCHD (OS/03
! Datc(s):
Clicnt Notific�tiou Dutc:
�HS:
Account Na � � J
Lrvoicc No. ��
v,tL,�,u 11UN NO: U y 1/ DA`YIE COUNTY HEALTIi DEPARTMENT
� .,,i�•� Eavironmentsi Health Section
��� s ' P.O. Box 848
'"�O,ab
PROPERTY INFORMATION
Name: ��} s? t� Q� �.. , NO��A N Mocksvillo, NC 27028 Subdivision Name: '� �
Direcbions to property: �� 1 N. • 1,� cqt`� Phone #: 704634-8760 Sxtion• "" " Lot; .._...
,. � �� AZTIHORIZATiON FOR � � �
, L1 'ti _ l,ic, "�
�:� �- ��sw �.'�+r.-=� WA5TL�WAIER Tax Office PIN:#.:►��� -.v�_. .�.L_l'.�?
. SYSTF.M CONSTRUCITON
_ 51��. � � �'1..��� S`�.�aa.�M Road Name�`r � �-a. �a •Zip: ��
.�.�..
*+NOTE�' lius A�oa fae Wastewatex System G�swction MUST $E ISSUED by the Davie County Environmental Heahh Seation prior
w issuance of any Buildmg Fermits.11ris Fonn/Authaizaqon Number should 6e pr�sentai to the Davie County Bwlding Iaspxtions
Office when applying fnr Building Y�. � :
(In camPliance with Article 11 of GS. ChapOer 130A,.Wastewater Sysee�s. �ric�..Z90Q Sewage Tc�aeat aad Dispo�at Systeins)
. ��
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yJ �
FiEAL1ii SP�QALLST DA1E ISSUHD
fLS AiTTFIORTLATION FOR WASIEWATER CONSTRUCTiON
LS VALID FOR A PERIOD OF FNE YEARS. '
R�DQ�iQAL SPSCIFIGTION: BtJILDaJCi ..•4 �i BSDROOMS N HATHS . N �OL%TPANTS (3ARBAt3B DISPOSAL: Ya o A�
COI�QAL SP&�fiCATION: FACiLTTY TYPB � PSOPLB � PFAPiLlSYiII�T N SBATS INBUSIRIAL WAS"I8: Yes � No
,
LOrT SII8 S, •U 1YPB WA'tEtt Si)PPLY �' DESICiN WA318WAT�i PIAW (GPD) ��D NEW 571�_.L._� RSPAJR ST18
.
SYS11t�S S�1CJ�IIONS: TAI� SII�B �� CiAL. P'tIMP TANK GAL. TREf�i WID�ii� 3 ROCK pEPTfi � LINBAR FT ��I
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�PIEDMONT �ECK INSTALLA71QI�1� INC
TNC MAP C�. a pat af PA!lGq. 34
APPLICANT INFORMATIOIV
Water Supply: On-Site Well
Evaluation By: l��� Auger Boring
FACTORS
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 ACCEPTAN
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
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PROPERTY INFORMATION
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Cut
5 6
7
SITE CLASSIFICATION: DL ) EVALUATION BY: //�''! L
LONG-TERM ACCEPTANCE RATE: � OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscane 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�tur�
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
s'ONSIST .N . .
�Z41S�
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
a�itli�tIItg
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
MineraloQv
1:1, 2:1, Mixed
LYQtes
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 - gal/day/ft2 DCHD OS/OS (Revised)
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