173 Dance Hall Rd (2)DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
', P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001698 Tax PIN/EH #: 5833-93-2568sc
Biiled To: Sherry Campbell Subdivision Info:
Reference Name:
Proposed Facility: Residence
�� s �l—�l
Location/Address: Dance Hall Road-27028
Property Size: see map
ATC Number: 2823
**NOTE** This ImprovemendOperation 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms � #Baths ��
Dishwasher: � Garbage Disposal: � Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �/�� Type Water Supply L� � Design Wastewater Flow (GPD) � Site: New � Repair �
System Specifications: Tank Size l�0 � GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Widtt� Rock Depth � Linear Ft.�
INIPROVEMENT/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: 0 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-87G0.****
�
r
Environmental Health Specialist's Signature: Date: ��� �l �
DCHD OS/99 (Revised)
�A
�, DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-8760
Account #: 990001698 Tax PIN/EH #: 5833-93-2568sc
Billed To: Sherry Campbeli
Reference Name:
rivNvacu f dl.11ll�/. RGSIUGIII:G
ATC Number: 2823
Subdivision Info:
Location/Address: Dance Hall Road-27028
�
r1UjJGllj/ JILC. �CC
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
I**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
�'i Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
I the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
, G.S. Chapter 130A, Wastewater Systems, S ion .1900 Sewage Treatment and Disposal Systems). TI-IIS
� AUTHORIZATION FOR WASTEWATE�2 C�1STRUCTION IS VALID OR A PERIOD OF FIVE YEARS.
' �/� / °
Environmental Health Specialist s Signature: � , / Date: �
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall in ' ate the system described on ImprovemendOperation Permit
has been installed in compliance with Articl G.S. hapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO W tak a guar�ntee that the system will function satisfactorily for any
given period of time. �
�
Septic System Installed By:
—���,� yo� x�x1�U
��
Environmental Health Specialist's Signature :�/ r/�(.% Date: ��[� !/l �
DCHD OS/99 (Revised)
�+ � � � � � � 1
I�•••. ' � � APP
r , ., !
:� • � -
�. ._...�J
� ENVIRONMENT^.L HEALTH
UAVIE C� . . aTY
I�I FOi� SITE EVALUA7tON/IP�1PROVEMG'�!T �'�(t1�91T & A�'C
Davie County Health Department
Environmenta/ Hea/th Se+ction
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
I�C�g���
a r U'
�
APR 1 '� 20�1
_--•,..r.rrtt t".wtll�il
***IMPORTANT*** THIS APPLICATION CANNOT SE PROGESSED UNiESS ALI. THE REQUIRED
INFOR2�TION IS PROVIDED. ReEer to the INFORMATION BULLETIN for instructions.
Name to be SilledShc_�r� L..(X�. ll.i.�(Y1'��-',`1 Contact Peraon � I /L('�� � l��.l�_��. �
Mailinq Addreas � �—� ����1C � . M� A� � 2 C7� Home Phone �� � �i 7f ` ���1,�,
city/state/z=r (i1��C'.��71�1� � RJ. C. `��C��i�`� ausinea$ Phone � �C.s `(��;7C� '�C y 1 � � �k ��
r, � ,_, �K Z���J
Name on Permit/ATC i£ Different than Above �l���L
Msiling Address `��1�[' - CitY/Stats/Zip �i�'�1i .
Application For: 1�Site Evaluation 0 Improvement Pexmit/ATC Both
`� �/
syec� to se���a: �19CHouse ❑ Mobile Home ❑ Business D Industry ❑ Oth r
l `
s. =f Residence: # People ��-�_ �k Bedrooms ►J � # Bathrooms ylf�(�-�-.
Dishxasher ❑ Garbage Disposal � Wash.ing Muchine ❑ Basement/Plumbing ❑ Baaament/No Plumbing
6. f Buainess/Industxy/Other: Specify type �k People # Sinka
� Commodes # Shoxers � Urinals # Wator Coolers
IF FOODSERVICE : # Seats Estimated Water Usage (gallona ��r �y)
�. Type of water supply: 0 County/City Lv1�We11 C] Community
e. Do you anticipate additions or ezpansious of the facility tt�is system is intended to servc?
If ycs, what type?
❑ Ycs 1s�'�10
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATIUN EtEQUGSTLD
BELOW. Either a PLAT or SITE PLAN h1UST BESUBMI7TED by the clicnt with THIS APPLICATION.
Property Dimensions: � �� �.�1� ����( T��-�
Tax Oftice P1N: # �(; � �q � �J�� �
Property Address: Road Name r�?..r�C�, Tt �� ��
c�tyr�;P rt�.-����,,11 e I �'�o�
lf ia a Subdivision providc information, as follows:
Name: � I �
Section: Block: Loh
�VRiTE DIRECI'IONS (from Motluvillc) to PROPLR"Tl':
I�� � o.._'s� �,c) c��:�, � T��n ��-� G c�
�m � � �� M �r� ) � � �c7 �-C�J,.i.,c.-�' ; t1�A. �.- � G�t� }
�����T
�l_�.r, LP:� can-�� `�`�� � ���Z m; �e�
�-r=�..�- r�,, .�� ��� �� -��, c���c� 2 � ��
�J �
L !�� M ',1 e .> �xrr� 1 e�-� cx� -�c� ��r��_ �� �;' ��"
� � Gn 2,; �v.� A� �c�s� �'��0
Date Property Flagg d: �1 - � q_ o�
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 iutended use change, or if the information
submitted in this application is falsificd or changed I, also, undersland lhal I am responsible for all charges incr�rred fronl
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above descri6ed property located in Davie County and owned by7n-b�� CY:�_�, (�z_f.nrinQT,� ��. �Sy��c'�"�\ �=�-�'�'�(��`-��
to conduct all testing procedures as necessary to determiue the site suitability. � - �J
DATE G�R?cJ� �`� h,��C��� S[GNATURE � �/`/� � �
��
TiiIS AREA MAY BE US�D FOR DRAWIl�IG YOUR SITE PLAN (Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Revised DCHD (07/99)
Aczount No. W / �
. Ji/
Invoice No. � � � /
J ��,,�
- _(1643�_ __--�--- _-
�
I 287 -------
�
Oo
� -p �
� � �
� �
I
� -- �5Z
�
-_
� - -_ - _ 7� 0
--- - _- ---
m
DAVIE COUNTY HEALTH DEPAR'I'MENT
� -, � � Environmental Health Section
� Soil/Site Evaluation
� APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001698 Tax PIN/EH #: 5833-93-2568
Billed To: Sherry Campbell Subdivision Info:
Reference Name: Location/Address: Dance Hall Road-27028
Proposed Facility: �t�Ce Property Size: see map Date Evaluated: �/��fl �/
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut_
HORIZON I DEPTH
Texture group
Consistence
Stn�cture
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:
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 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 M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralo�v
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fll - 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
DC�ID OS/99 (Revised)
■■
■■
■
■�■
■�■
■�■
■�■
���
■��■��■■�■■■■
■��■��■■�■■�■
■��■��■■■�■�■
■��������■■�■
■��■������■�■
■�■■���■��■�■
■�■�����■�■�■
■�■��■�■����■
■���■■���■�■■
■■��■■��■■��■
■■■���■■�■�■■
■■■������■�■■
■
■�����������■
■■■■■■■■�■■■■
■�������■■■■■
■■■�■����■��■
■■�■��■�■��■■■■
■■■��■■■���■��■
■■■���■■�����■■
■■■������■��■■■
■�■�■�■��■�■��■
■�■�■�■■�■■��■■
■�■■■�■��■��■■■
■�■■■■■■��■��■■
■�■■■��■��■���■
■■���■�■■�■���■
■��■�■��■�■���■
■■�■��an■��■��■
■■�■■�■��■�■■�■
■■■■■■■����■■■■
■■����■�■■�■�■■
■■��■�■�■��■�■■
■■■�■�■�■■�■■■■
■�■������■�■■■■
■���■�■■�■���■■
■■��■■�■��■�■■■
■�■�■■�■�■■�■�■
■■�■■■�■■�■���■
■■�■■■����■�■�■
■■�■�■��■�■■■�■
■■�■���■■�■�■�■
■■■■�■�e===::::
■■�■��■�i■�■■■�■
■■�■��■�i■��■��■
��aiiiii�iiiiiii
■r�����■�i■■�■�■■
■■u��■■��■■�■■■■
i
i
ii
■■
ii
■■
■
■�■■���■
■���■��■
■���■��■
■��■■�■■
■��■■0�■
■�■■��■■
■�■��■■■
■��■���■
■��■�■■■
■■��■■■■
■���■�■■
■■�■��■■
■■���■■■
■������■
■■��■��■
■■�■■�e■
■■�■■��■
■■■��■■■
■���■■■■
■■■��■■■
■■■�■�■■
■■■�■�■■
■�■����■
■����■�■
■����■�■
■��■���■
■�■■�■�■
■��■�■�■
■�■��■�■
■������■
■��■■■■■
■��■■�■
■��■��■
■�����■
■�\�■�■
■��■��■
■�\�■�■
■�■�■�■
■��■■�■
■■����■
■■��■�■
■�����■
■�����■
■■����■
■■���■■
■■■��■■
■■����■
■����■■
■�■��■■
■�■�■■■
■��■■�■
■����■■
■■■���■
■■■���■
■�����■
■■■��■■
■■■���■
.■�■�■■■■��■��■�■■�■���■■��■■��■■�■
■�■■�■�■■��■����■�■■��■�■��■■��■■■
■��■���■���■■■■�����■■��■■■����■�■
'�iiiiiii��iiiiiii�iiiiiii�iiiiiii�
■■��■�������■■■■�■■�■■�■����■■■��■■
■■�■�����i■��■■■■■���■■■��■■■■■■��■
■■■■����u■��■��������■�����■�■�■�s
::::ii��r■��■■■■�■■��■■■������■■■■
■�■�■■■■�■■�■■�■�����■�■�■��■�■■■■
■�■����������■�■■�■����■■��■■�t■■■
�■�■�■■�������■■�■■����■■■■����■■
■�■�■■�■■��■■■■�■��■�■��■����■�■
■�����■■�■���■��■�■��������������■
■������■�����■��■�■■��■■■��■■■��■■
■�■■�■■■■�■��■�����■�����■■�■����■
■��■���■■��■■■■�■■�■■■�■������■■�■
■��■����������■■����■■■■��������■■
■■���������■�����������������■■■■■
����������■��■��■■�■■■■���������■
■■����■��■■�������■■■■������■��■
■��■�■�■■��■�■■��■�■■■��������■■�■
■�������■��■■�■■�■■■���■��■��■■■�■
■■��■��■■��■��■■�■�■�■�■���■��■��■
■���■���■���■�■■�■■��������t�■■��■
■■■�■����■�����■■■■■���■■����■■�■■
■■��■■■■�■■■�■■■■�■���■�■■�■��■�■■
�i■���■■�■■��■�■■�■■����■■��■���■■
i��■��■�■■�����■�■���■�■■■■■���■■
■�■��■�■�■■■■■■■■■�■■�■��■■■■���■■
■�■■■■�■■■■■■���■■�■■■■��■■�■■���■
■�■��■������■■■■■■�����■�■■■■■��■■
■�■■�■�■�����■��■��■�■���■■�■■■�■■
■��■�■�■■■■■■■��■��■■�■�■■■■■■■�■■
■��■�■■■■■■■�■��■��■■■■�■■■�■���■■
��■�■�■��■�■■��■��■■�■��■��■■��■■
■����■����■■■■■��■��������■■��■■
■t���■■■■■■�■■�■■�����������■■���■
■�■����■■����■■■�����t������■■��■■
■■■■�■�■■■■■■������■�������■�■���■
■■���■■■��■�■■����■��������■■■��■■
■����■■�■■■������■�������■■■■■�e�■
■��■�■��■�����■■■■���������■■����■