1141-1143 Deadmon Rd,, .
DAVIE COUNTY HEALTH DEPARTMENT J
Environmental Heaith Section � �'-�- �� �
,.,
. P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-8760
Account #: 990001763
Bilied To: Robert Thies
Reference Name:
Proposed Facility: Residence
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #: 5757-31-6363
Subdivision Info:
Location/Address: Deadmon Road-27028
Property Size: 2.14 acres
**NOT�*��iibginpro 8ement/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 #People � #Bedrooms � #Baths �
Dishwasher� Garbage Disposal: � Washing Machine;,�'� Basement w/Plumbing: � Basement/No Plumbing: �
<
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size _� 1� C Type Water Supply e/� Design Wastewater Flow (GPD) 3� D Site: Nevv� 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 (33G)751-8760.****
Environmental Health Specialist's Signature: � Date: ��l �/ �
DCHD OS/99 (Revised)
Account #: 990001763
Biiled To: Robert Thies
Reference Name:
Proposed Facility: ResidenCe
ATC Number: 2862
DAVIE COUNTY HEALTH DEPARTMENT
Environmentai Health Section
P. O. Boz 848/210 Hospital Street
Mceksville, NC 27028
(33G)751-8760
Tax PIN/EH #: 5757-31-6363
Subdivision Info:
Location/Address: Deadmon Road-27028
Property Size: 2.14 acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� /
**NOTE** This Authorization for Wastewater System Construction MLJST 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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT C NSTRUCTION IS VA ID� A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �ff � � - ' Date: .S —�l ��
CERTIFICATE OF COMPLETION
�**NOTE** The issuance of this Certificate of Completion 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:
�
� �/
X����L
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Environmental Health Specialist's Signature :�Q �'��� Date: t��/Z5� �� �
DCHD OS/99 (Revised)
APPUCATION FOR SITE EVALUATIOW/111�1Pii0VEh9�l+IC I'�fif�9iT & A7�� p
. Davie County Health Department
Environmenia/ Hea/th Sect�ion
P.O. Hox 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
U U
� � g 240E
***IMPORTANT*** THIS APPLICATION C�INNOT BE PROCESSED UNLESS ALI, THE REQUIRED
INFORMI�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be IIilled. J 1 RZ�� Contact Peraon �.
Mailing Addreae Home Phone �J.�� 10 `VL-t 1 __
City/State/ZIP �OVhUyllll. I V� �lV`� Busineas Phone �0�-{'' ������
2. Name on Permit/ATC iE Difierent than Above
Mailinq 1kldresa
3. Application For: � ite Evaluation
City/State/Zip
� Improvement Permit/ATC ❑ Both
a. syst� to service: � House O Mobile Home ❑ Business ❑ Industry ❑ Other
s. =f Residence: � People � # Bedrooms � � Bathrooms _�_
� Diahxasher (1 Garbaqe Diaposal (k Waehing Machine ❑ Dasement/Plumbing ❑ IIasement/No Plumbing
6. Zf Businesa/Induatry/Other: Specify type
� Commodes
� Shoxers
N Urinals
ij People # 3inka
# Water Coolers
IF FOODSERVICE : # Seats Es�imated Water Usage (gallona per a$y)
7. 2�pe of water supply: ❑ County/City � Well � Community
s. Do you antici�ate additions or eapansions of the facility this system is intended to scrve?
If ycs, what type?
❑ Ycs ,� No
***IMPORTANT*** CLIENTS MUSTCO�lPLETETHE ,REQUIRBD PROPERTY INFORMATION REQUES7'CD
BELOW. Either a PLAT or SITE PLAN �1USTI3ESUBMITTED by the clicnt with THIS API'LICATION.
Property Dimensions: � � ` �'
Tux Once PIN: # ���'�' `���"��
Property Address: Road Name �9C.IJ�4�lJ1 1 1 Vi l��
��ty,Z�p YY�C�Sv�'Il�- �-�D�
lf in a Subdivision provide information, as follows:
Namc:
Section: Block: Lot:
WRITE DIRGCTIONS (from Mocicsvillc) to PROPER'i'1':
(� d I � af.� �,l'� `fi� �
� %.�i� � � ,
�� , ,
r. � i.�, �., �
. ,
•11 . / /�. /. � .J.//�! ,� � ' �� '
� '� �
� '
This is to certify that the information provided is correct to the 6est of my knowledge. I understand that auy permit(s)
issued hereafter are subject to suspcnsion or revocation, if the site plans or intcnded usc cl�ange, or if the information
submitted in this application is falsified or changed I, also, understand that I am responsible for all charges i�rcr�rred front
this application. I, 6creby, give consent to the Authorized Representative of tLe Davie County �Iealtli Dep�rtmcnt
to cntcr upon abovc describcd property located in Davie County and owned by
to conduct all testing procedures as necessary to determine tl�e site suitability.
DATE � � `�' �' SIGNATURE ( +
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eaisting and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Cl�arge
Da tc(s):
Client Notification Date:
EHS•
Revised DCHD (07/99)
Account No. l 1 � �
Invoice No. �-�� 7 �
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APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soi]/Site Evaluation
PROPERTY INFORMATION
Account #: 990001763 Tax PIN/EH #: 5757-31-6363
Billed To: Robert Thies Subdivision Info:
Reference Name: Location/Address: Deadmon Road-27028
Proposed Facility: Residence Property Size: 2.14 aCres Date Evaluated: �-�� � ��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �% Pit Cut
i ex[ure grui
.�___:_.__..,.
1CXlUiC �1V1
�'(111 Cl StCi1Ce
leXLUIC �'IVI
n.._.....a....,.,.
HORIZON IV DEPTH
SOIL WETNESS
SITE CLASSIFICATION: %�_
LONG-TERM ACCEPTANCE RATE: �
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
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
Wet
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
tructure
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular 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 - T'hickness 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
Classiiication - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gaUday/ft2
DC�ID OS/99 (Revised)
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