448 Deadmon RdAccount #: 990001598
Billed To: Norman Carter
Reference Name:
Proposed Facility: Residence
ATC Number: 4434
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-87G0
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Tax PIN/EH #: 5747-52 �83
Subdivision Info:
Location/Address: Deadmon Road-27028
Proaertv Size: 12.49 acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 YEARS.
Environmental Health Specialist's Signature: �C,% Date: C.��(Ci/�
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CERTI�ICf1TE.O�COMPLETION
**NOTE** The issuance of this Certificate of Completio
has been installed in compliance with Article
Disposal Systems," but shall in NO WAY be
given period of time.
(�it:���I sr� c�w�..�tC ���
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Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
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;a�e the system described on Improvement/Operation Permit
.,hapter 130A, Section .1900 "Sewage Treatment and
uara�tee that the system will function satisfactorily for any
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, DAVIE COUNTY HEALTH DEPARTMENT
' E' e� Environmental Health Section
P. O. Boz 848/210 Hospital Street
' Mocksville, NC 27028
(336)75]-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001598
Billed To: Norman Carter
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5747-52-3483
Subdivision Info:
Location/Address: Deadmon Road-27028
Property Size: 12.49 acres
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ATC Number: 4434
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AiJTHOWZATION 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 � #Bath��.2
Dishwasher� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
�
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply � Design Wastewater Flow (GPD) ��� Site: New � Repair ❑
System Specifications: Tank Siz�G�d GAL. Pump Tank GAL. Trench Width�:���' Rock Depth ��Linear Ft�pa
Other:
As stated in 15A NCAC 1E3A.2969(5)
Required Site Modifications/Conditions: accepted Systems r�ay ��so b� used
I1�IPROVEMENT/OPERAT[ON PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW
FINISFIED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 830 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33C►)751-87G0.****
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Environmental Health S ecialisYs Si ature: �4� '/ 1
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DCHD OS/99 (Revised)
ll� D e/`t-� �
Date: � �2� /�r
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. , � -
• APPLICATIO R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
�,� � �j � Davie County Health Department
�,� [� � Environmental Health Section
�,� P.O. Box 848/210 Hospital Street
•' i,, J�N �� 2006 - Mocksville, NC 27028
�-'-' (336)751-8760/ Fax (336)751-8786
R
A�HEALIN
Permit L�7'Authorization To Construct(ATC) ❑ Both
"'�IMPORTAN7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed �' Q.V� l�L� ��� Contact Person
Billing Address ` ,s- / -�U�- Home Phone - 5pi
City/State/ZIP `')'� ���-5 /Ji l� il1 L- Q270a t� Business Phone <,lf,i `�j'%35
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
City/State/Zip
NOTE: A survey'plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Street Address City
Subdivision Name
Directions To Site
Tax PIN# ,� �% �% -S� - .3 `�c�'�
Lot Size
«.�ti,;.. '�f, �C anr.l ��
Date House/Facility Corners �Flagged G(�
If the answer to any of the following questions is "yes", supporting documer��fion must be attached.
Are there any existing wastewater systems on the site? f�'%es ONo
Does the site contain jurisdictional wetlands? ❑Yes �
Are there any easements or right-of-ways on the site? ❑Yes C�
Is the site subject to approval by another public agency? ❑Yes 1�10 '
Will wastewater other than domestic sewage be generated? ❑Yes G3�No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms � #� Bathrooms �
_ Basement: � es ❑No Basement Plumbing: Q'%s ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Garden Tub/Whirlpool I�1`Yes ❑No
Type of FacilityBasiness Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type systemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: Ca'County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes (�'rIo
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I understand that I arn responsible for all charges incurred
�fi�om tlzis application. F'hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to
conduct necessary inspections to eternune compliance. /with applicable laws and rules on the above described property located in
Davie County and owned by Q(' t1R ,T�(,1t�,rG'!�
- �LL-�'= -
Prop rty owner's or owner's legal representative signature
����-'_� �
Date
Site Revisit Charge
Date(s):
Client Notification Date: _
EHS:
Sign given CiYes ❑No Account # ��T � ��1�
Revised 2/06 Invoice # S.SZ 3
w ,
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� NOV I 3 � _ . , ;.
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IN FOR SITE EVALUA�ION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Envir,vnmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORN�,TION IS PROVIDED. Refer to the INFORI�ITION BULLETIN £or instructions.
l. Name to be Billed
Contact Person
Mailinq Address �� C% �/J i/ 1'�q ��' �� �,n ���/.Q Home Phone
City/State/ZIP � `�(,)C /C � L/t `I�Q � "( e��(���� Business Phone � � � � � �v /
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: E�''Site Evaluation ❑ Improvement Permi.t/ATC ❑ Both
4. system to service: [�ouse ❑ Mobile Home � Business ❑ Industry ❑ Other
�- �
5. If Residence: # People # Bedrooms .---� # Bathrooms _�
�Dishnasher ❑ Garbage Disposal L�lashing Machine ❑ Base�ent/Plumbing f] Basement/No Plumbing
6. If Business/Industry/Other: Specify type R People # Sinks
# Commodes # Shoxers # Urinals # Water Coolers
IF FOODSERVICE : # Seats Esti.mated Water Usage �galions per aay>
7, R�pe o£ water supply: O�County/City ❑ Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Yes L�]'No
***IMPORTANT*'�* CLIENTS MUS'7'COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS APPLICATION.
Property Dimensions: 1 d+ l� �
Tax Office PIN: #.� 7 L% ?' s o� �' � �� $�
Property Address: Road Name �ect w�- v�
City/Zip
lf in a Subdivision providc information, as follows:
WRITE DIREC'I'IONS (from Mocksvillc) to PROPGRTY:
(�0% J` f'o ,C��c1 Man ��
1'/� ,���1�5 6 �� ���;h�
C/o � C�� SPe �- � �
��.� � k 1� � 1,�.� �
Name:
-j �k �s-�- `
Section: Block: Lot: Date Property Flagged: � C�Yc S������'�o�'
6 -� �
This is to certify that the information provided is correct to the best of my knowledge. I anderstand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site �lans or intended use change, or if the information
submitted in this application is falsified or changed I, also, understand tkat I am responsib[e jor al! c/rurges incurred fronr
this application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth Departmcnt
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the sitc suitability.
DATE �� / � '� ,� SIGNATURE � ���
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existi�g and proposed
property lioes and dimensions, structures, setbacks, and septic locatioas).
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Revised DCHD (07/99)
.
Site Revisit Chargc
Datc(s):
Client Notification Datc:
EHS:
Account No.
Invoice No. �OJ
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
, Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990001598
Billed To: N�an Carter
Reference Name:
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5747-52-3483
Subdivision Info:
Location/Address: Deadmon Road-27028
Property Size: 12.49 acres Date Evaluated: j� - I 9-°/
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring Pit � Cut
HORIZON I DEPTH
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 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
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
Structure
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangulaz 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
DCHD OS/99 (Revised)
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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street -
Courier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
November 20 , 2001
Norman Carter
- 229 Springhill Drive
Mocksville, NC 27028
Re: Site Evalution/ Dedmon Road
Tax Office Pin : # 5747-52-3483
Dear Client(s):
As requested, a representative from this offce visited the aforementioned site on
November 19 , 2001. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off. �
If you ha.ve any questions, please feel free to contact this office.
Sincerely,
/�a���/��,.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
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