620 Deadmon Rd0
- DAVIE COUNTY HEALTH DEPARTMENT
� , Environmental Health Section
l P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900063
Billed To: Larry McDaniel
Reference Name:
Proposed Facility: Residence
ATC Number: 2604
Tax PIN/EH #: 5747-72-5649
Subdivision Info:
Location/Address: Deadmon Road-27028
Property Size: see map
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
��
I**NOTE** This Authorization for Wastewater System Construction MUST 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �. . �� Date: r� ��� '��
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. f,Sv ,�
�e�s��n,
� .� , � � f,� y�Yt�C �r�(
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Septic System Installed By:
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Environmental Health Specialist's Signature : �:�'' rG�� Date: �`�/�/— �1�
b
DCHD OS/99 (Revised)
0
DAVIE COUNTY HEALTH DEPARTMENT �?.�,Ll l— �--?— �'
Environmental Health Section �
P. O. Boz 848/210 Hospital Street C� ��' ��
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900063 Tax PIN/EH #: 5747-72-5649
Billed To: Larry McDaniel Subdivision Info:
Reference Name: �li�,q�,-� -� f���;�.T Location/Address: Deadmon Road-27028
Proposed Facility: Residence Property Size: see map
�TC N�.�p b�r: 2604
**N TE* *"l his mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION 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
Dishwasher: V� Garbage Disposal: �
#People s� #Bedrooms c� #Baths r�
Washing Machine: }� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
) �/
Lot Size ..�� 7� Type Water Supply �?s Design Wastewater Flow (GPD) � Site: New y� Repair ❑
System Specifications: Tank Size�'l�T�� GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width �� Rock Depth �� Linear Ftc;��f�
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 130 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** �-
Environmental Health Specialist's Signature: �, Y�`�' � Date: %� "/� -��} �
DCHD OS/99 (Revised)
�u-ru���uN tu�t bl lt EVAWAl1UN/IMPIiOVEMENT PEflMIT dc ATC
• Davie County Health Departrnent
. Environmenta/HeaKfi Sectton
, • P.O. Box 8�B/210 Hospital Streeti
Moaksville, NC 27028
� � �336)751-8760
D ��� M
�j 1 0 2000
•**IIKPO.RTAI�T**• TilIB APBLICl1TId1Q CAl�1' 8S PItOC�BSaD tINLE88 ALL TiiB ItEQOIRED'
INFORMAT20N I3 PROVIDED. Itefer to the INFORMATION SOLLBTIN for iastrnations.
i. llaas to be BtiYea � jy2�1�`�`�i�e�u!?`�,���s,l��l�o..aat nar�oa Larry McDaniel
1�aslitW �+3drw pn unx S 7 7 ' � p� 7 51 - 9 0 2 2
ctty/staee/zzr _ Mocksville, NC 2%OZH �i�a p� 940-81 64
s. Ilaa� oa i�tsit/J11'C 1= bi!lares�t thati 11bws g h�,,-,-� �,-a n t t� u i c k Je f f r i e s
x�sii� �aa��. PO Box 577 a��8t,���pMocksville, NC 27028
�. J►ppliaatioa sor: U Site Evalnation 0 Impsoviemeat Bermit/ATC ,�Both
s. sy.tiem to eesvsos: �i Honse 0 Mpbile 8o�ae U Bnsiness 0 Induatry 0 Other
e. ti Resideace: / people 3 ! Hadrooms 3 • Bathsooma 2
�Distnrasher 0 Oasbaqe Disposal �Nashinq ttaahins 0 8asesa�t/Pimbiaq [I 8asement/No pinabin�
6. i! 8nsiness/lnQnstry/Othes: SpeailY tYPe _%U� � i peaple
f Ccamodes * Shcwers f Urinals
/ Sitsl�s
• Natar Coolers
IP 1'OODSERVICB: � Seats ��- $stimsted Aatar Osage (4alloz�s p�r day)
7. �p� ot trater snpplp: �Connty/City 0 Rell ❑ C�ity
e. Do yau aat�cip�te additiow or e:pandon� ot the t�cllitJ� t6b ry�tem b intandcd to arve! 0 Ya �No
U ya, wbat type'
"* *IMPbRTANT"" CLIENTS �llUST L��llPLETE THB REQUIRED PROPLRTY INFORMATION REQUESTED
BELOW. Eit6er a Pl.AT or SITE PI.AN MUST BESUBMIITED by the clieat with ?H1S Al'PI.ICATION.
Prope�ty Dimen�ions: ) I�. 0 I X�� 3•��
Tai Ottice PiN: # ��1 � � - �a - � c�y�
Prnperly Addra�: Rnad N�une l>���cwOC1t� c�
City/Zip Y��ClocrkSv�l�o. N�-
��oa�
1� in a Subdivi�ioa provide iaformatioo, �u folbw::
Name:
Scctioa: Blak: Lot:
WR1TB DQtLCt'IONS (fram Mock:v[Ile) to PROPERTY:
��O � �.,�.�ur� �O c� �2a� rnon
�c� . ( ,.,��r r� �-�--� �- �Jl� i S
�-�c�- � �� �Z�.� '
DstcPro Ft cd: C���! �
p��7 s8t
Thi� is tvi certify t6at tbe informatiou provided is corntct to t6e best of mr knonitdga I anderstand 16at any permil(s)
issued 6e�t'ter arr subject to aa�pension or nevocatioo, if t6e aite plana or lntended nae cbange, or if t6e intormatioa
aubmided in t6i� spplication i� �alaiBed or changed. I, olso, andersta�rd tArai I ani rrspox�ible jor o!! climga inc��d from
tlUis arppllamtion. I, ber+eby, give consent to the Aat6orb.ed RepraentaNve of l6e Davie County Healt6 Department
to enter apon above deacribed property Iceated in Davie Coanty and owoed b� ���.� .L ,(�-, r c, n-4-
to conduct ali teiting procedura as uaatary to determiae t6e dte witabilih-.
DAT� �� II � I� SIGNATURE �.� �S�.JL4. �,_�` I�.C.I��'�
THIS AREA MAY BE USLD F'OR DitAWQIC YOUR SITL PLAN (Inciade all otthe following: Eitatiog aod prnpoaed
p�operty liva and dimeasion�, strnctara, utback�, aad �ptic locattoaa).
Rtvised DCflD (07/9��
.
�I �5
Accon�rt Na � � -3
Invoice Na � � � 3 `�
Deddmor� Road S.R. 1801
60' Public R/W 20'+/- Povement
— _ NoA fwnE 1 ^vprox7moh _ _ - - AC-NoW Ss! � Appro.LraN - _ - _ _ - Mwl FwnO O Approiumah
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— —_ 10.88' FwrM In Llrr�
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Survey for:
Sherri Lynn Crant
Port W � Lot 59 � �
Toi Mop K-5 -
Oeed Book 210 O Poye J71
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- DAVIE COUNTY HEALTH DEPARTMENT
� �• ' Environmental Health Section
, , Soil/Site Evaluation
�APPLICANT iNFORMATION PROPERTY INFORMATION
Account #: 989900063 Tax PIN/EH #: 5747-�2-5649
Billed To: Larry McDaniel Subdivision Info:
Reference Name: Location/Address: Deadmon Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: ^/� 1���
Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit
Public
Cut
icx�uic �ivu�
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 HORIZOP
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTA
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- Tenace 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 day 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 - Angulaz blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralo�v
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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