202 Dutchman Creek Rd (2)' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003505 Tax PIN/EH #: 5766-56-9254
Billed To: Avery Sealey Subdivision Info:
Reference Name: Location/Address: 2021 Dutchman Creek -27006
Proposed Facility Residence Property Size: 30 acres
ATC Number: 3999
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**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 WASTEWATER CONS RUCT ON IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health �
Specialist's Signature: Date:
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. N n�^'+�; C&'
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Septic System Installed By: N QwhA�-
Environmental Health Specialist's Signature :Date: & -o -O (0 w6t!4
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
.► Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003505 Tax PIN/EH #: 5766-56-9254
Billed To: Avery Sealey Subdivision Info:
Reference Name: Location/Address: 202 Dutchman Creek -27006
Proposed Facility Residence Property Size: 30 acres
ATC Number: 3999
**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 THISPERMITBEFORE INSTALLING SYSTEM.
Residenoal Specification: Building Type #People #Bedrooms #Baths �• 5
Dishwasher: Z� Garbage Disposal: ❑ Washing Machine;, Basement w/Plumbing: ❑ Basement/No Plumbing: El
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 30&, Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑
`mac
System Specifications: Tank Size,�GAL. Pump Tank GAL. Trench Width ;9'4 Rock Depth Linear Ft.�l%�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER.. RISER(S) IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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 (336)751-8760.****
Environmental Health Special:
DCHD 05/99 (Revised)
0
Date:
s�
ON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
20 • Environmental Health Section
.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
** *** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed _ 5` t/eLfn��! li p/ Contact Person
Mailing Address,? /�G/G `4 A"AN G0' n G/ Home Phone3W 7Vd �,9
City/State/ZIP/&1//)/VGE' "A)6 Z 2"!V I, Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit/ATC Both
4. System to Service: ,H
,�/o
,use El Mobile Home El Business 13 Industry ❑ Other
5. Type system requested:.ldl Conventional ❑ conventional modified P innovative
6. If Residence: # People # Bedrooms # Bathrooms 2 z
.TDishwasher ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commode #Shower"': #Urinal$ L # Water Coolers-'-
IF
oolers-' IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: ❑ County/City ,L�Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Al•1Q•o
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Pr imensions: 3e7 -A6. WRITE DIRECTIONS (from Mocksville) to PROPERTY:
% (per _
<Tax Office PIN: 0. .24-
% O D o O a Z 9 ('7 A h'o
Property Address: Road Name 2-0?- P -,%1i 4r AA1 0-? , To, 7 %y %3v/,
City/Zip 2 7diq/-�.�i/a�G o` Rel a A/ Rl p! 6> ; 2 d ?_
If in a Subdivision provide information, as follows:
Name: S'ep=2 6",
Section: Block: Lot: Date home corners flagged: Z _Z %' 0 S
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 intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I ant responsible for all charges incurred front
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by A 1, 4 1a
to conduct all testing procedures as necessary to determine the site suitability.
DATE Z - Z 1 'O rj SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
V
Sign given
\ Revised DCHD (05/03
Site Revisit Charge
Date(s):
Client Notification Date:
EHS: '
Account No.
Invoice No.
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F VDAVIE COUNTY HEALTII DEPARTMENT
E't I H 14 S t'
o nvironmen a ea ec ion
' Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990003505
Billed To:. Avery Sealey
Reference Name:
Proposed, Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #:. 5766-56-9254
,Subdivision Info:
Location/Address: 2020 Dutchman Creek -27006
Property Size: 30 acres Date Evaluated: 0I2
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
A 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture groupC
Consistence
j" -r -
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
�.
Mineralogy-
l
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
L
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:.,2�Z
OTHER(S) PRESENT:
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 VF. - Very yfirm 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
Structure
'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
MineraloEY
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 - gal/day/ft2
DCHD 05/99 (Revised)
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