109 Emerald LnDAVIE COUNTY HEALTH DEPARTMENT �GC - �' 7– v 2—
Environmental
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002169
Billed To: Charlie Ridings
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5736-86-4330
Subdivision Info:
Location/Address: Emerald Lane -27028
Property Size: .0750 acres
ATC Number: 3080
**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 THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ` #People #Bedrooms—,S #Baths ��
Dishwasher: Garbage Disposal: ❑ Washing Machine: JQ 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) �<T- Site: NeW C?"' Repair ❑
System Specifications: Tank Size, GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width c�X� Rock Depth Linear Ft, --?,0—D
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " 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.****
,17
�n
Environmental Health Specialist's Signature: / $► • Dater �(J �/y
DCHD 05/99 (Revised)
Account #: 990002169
Billed To: Charlie Ridings
Reference Name:
t-acnay: Kesiaence
ATC Number: 3080
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5736-86-4330
Subdivision Info:
Location/Address: Emerald Lane -27028
rropeRy oize: viau acres
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 WASTEW ONSTRUCTI��ONNp IS VALID OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: G't✓ Date: �- G
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.
J�
S s
Septic System Installed By:
Environmental Health Specialist's Signature: Date: .
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
—�7 Davie County Health Department
Envifonmenta/Health Section
FEB 2 0 L
�,� P.O. Box 848/210 Hospital Street
r Mocksville, NC 27028
`t (336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed I Contact Person i�11 ��7H7`�^1�lo!/i' /
-kid c11�ir i
Mailing Address , Home Phon Cm ; a 7. Iii 9 7
City/State/ZIP / / /dckSt/,7/& /V Vn;2-7%Q��;__ Q' Business Phone
2. Name on Permit/ATC if Different than Above JK /—
Mailing Address City/State/Zip e-
3. Application For: U#49ite Evaluation ❑ Improvement Permit/ATC $ Both
4. System to Service:` 0 .House P"Mobile Home ❑ Business ❑ Industry 11 Other
5. If Residence: # People # Bedrooms -3_ # Bathrooms_
VDishwasher ❑ Garbage Disposal VWO`ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: (X County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 6-M
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: . o -75o
Tax Office PIN: #
Property Address: Road Name Erne &o 1 A Uqm
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
(,001 S CD % bPrd & owe_ I
b W Gl C-AS4.0tyc. to t21 ati-
16
city/zip n0"6 j . I Lv QoPA lr6wuA tact a, o -;b &ncAe q 1 d tie.
If in a Subdivision provide information, as follows:
Name:
��i-IGlir �- r�>d iJ Ei�ke�►o,lcF G' .12.ocnN�
CAP"t aaLq' Ldg!l
Section: Block: Lot: Date Property Flagged:
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 from
this application. I, hereby, give consent to the Authorized Representative of the D ' County He th Dgpartment
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE a I9,0 SIGNATUREe::&`
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. Z (�' 7
� !
Invoice No. O
S 75°39'55"E
24.74'
61, f/2" EIR Found
SFoundlR S'S:
N'
'RS Part' of Tax Lot 32.04
o, & 69'
0
Part of Tax Lot 32.07
1/2" EIR Fou
�u 0.750 Acres +/-
o S 10°4Ss
S 05°59'05"W
30.50' 146.13' N 83°5855"W 1/2" EIR'
1.10 1/2" EIR Found
Z Found
IRS 165.50' N 83°5855"W IRS S 10`
24.00' S 83.58'55"Ei
T -Bar w/cap 30.00
Found
Tax Lot 32.07 Tax Lot 32.08 1/211,
Tax Map L-4 Tax Map L-4 -
o n/f Choriie F. Ridings n/f Lucio Granodero
and wife I and wife
Rosalind 8. Ridings Flor Gronodero
10 DB 320 0 PG 239 ' DB 320 ®PG 242
o
Na 0.884 Acres'03'
HOMO
N
O^ fxisti j�` a' y
17.92' ng Mob/re Home I hl p
o z' a` N
N 83°56'55"W
40
i 42.90'
N 83039'45"W
127.87'
T -Bar w/cap +- - - - - - Point 1/2" OR T -Bar w/cap
Found Found Found `
N 83056'55"W
165.50'
j
Tax Lot 32.01 �+ `
+
Tax Map L-4 '+ +
n/f Chanes Ridings
and wife +
+
Rosalind B. Ridings +
DB 192 O PG 638 '
+ ,
Emerald Lane '
10-12' Gravel/Dirt Road
(Privn+n
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002169 Tax PIN/EH #: 5736-86-4330
Billed To: Charlie Ridings Subdivision Info:
Reference Name: Location/Address: Emerald Lane -27028
Proposed Facility: Residence Property Size: .0750 acres Date Evaluated: A, � �2
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
Texture group(;
L
�C
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
C�'
Consistence
/
7
Structure
r
jG
Mineralogy,
-
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
r/
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
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
Mineralogy
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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