131 Fish Face Ln . DAVIE COUNTY HEALTH DEPARTMENT � � ��l �' () U
Environmental Health Section � �
• - �p" P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001506 Tax PIN/EH#: 5759-13-1077
Biiled To: Talia Carter Subdivision Info:
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: RESIDENCE Property Size: 1/2 ACRE
**NOT�**'Thib�mprove ment/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
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �Mr #People � #Bedrooms 2— #Baths 2
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size r'L A�� Type Water Supply�t�� Design Wastewater Flow(GPD)��_ Site: New�Repair❑
�� �r �
System Specifications: Tank Size'�AL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.�
o�h�: � �STQ-�B�r�o...� T�yo. ��.S�e�u.,U.�,-s Q��,G. ,�.,a.
Required SiteModifications/Conditions: Itvs"�L�ll. O-� ��T��, �' �� � Y��, �—���.'G� ��F
•1 OMn�.
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 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)751-5760.****
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Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
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. • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001506 Tax PIN/EH#: 5759-13-1077
Bilied To: Talia Carter Subdivision Info:
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: RESIDENCE Property Size: 1/2 ACRE
ATC Number: 2656
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction M[JST 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 buildin permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Secti .1900 Sewage Tr ent and Disposal Systems). THIS
AUTHORIZATION FOR WAS O C IS PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa e: Date: C�
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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.
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Septic System Installed By: - �-J +�/
Environmental Health Specialist's Signature: Date: .� '�
DCHD OS/99(Revised)
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, : . ' ... � �.� ��:5
• =� + APPUCATION FOR SITE EVALUATION/IMPROVEhlEflfT PfRMIT&ATC D �
Davie County Heaith Department �
Environmenta/Hea/tfiSecrion N�� 2 $ ���n
P.O. Box 848/210 Hospital Street .
. Mocksville, NC 27028 �
(336)751-8760 ; '
,
***I1�ORTANT*** THIS APPI�ICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED ,
INFORt�TION IS PROVIDED. Refer to .the INFORMATION BULLETIN for instructions. . .
..�'
1. Name to be Silled �G�/f �G✓tFft' Contact Peraon
Mailing ]lddresa p� e ��/�N KL7 ' Home Phone �S �� '774�
City/State/ZZP ��O 1i� �Y'0�lL�G���� Husineas Phona ��0 `(rT S o�-�
2. Name on Pezmit/ATC iP Different than Above
Mailing lyddreea �'' " • City/State/Zip
. �` f " ....
s. 1�ppiication �or , .Site Evaluation L�fImprovement Permit/ATC ❑ Both .
' a. syst� to sesvi�e `❑ House•�' • Mobile Home O Business ❑ Industry ❑ Other
�f . -
5. � I£ Residence:�� .�.'� # People ,�_� , # Bedrooms Z- A Bathrooms �
_ ' ,, ,.a /. 1 _
ly/Di@hnasher � ~[7 Garbage Diapoaal�\ - ryTiashinq Machine ❑ Basement/Plumbing ❑ Basement/No Plumbinq
- ,� �
6� 'If.+Bustnesa/Induatry/Other:. Speci£y type ' 8 People 8 Sinka
aytf , l . . ' � .` � �
f. � �.� ♦,i _ . r . .
� Coaodea � Shoxera � Urinals � Water Coolers
� t '1;�'� ''r 1';.- C �� .
` �''`[• IF FOODSERVICE:t�:'# Seats Estimated Water Usage (gallona per asy) ' �
• � - ^ . ,.,�,�ti �
� �°�; +;I � r'�:" � ;-
'�4` �;a .Type of;water`�supply: County/City ❑ Well 0 Community.
�1 �,:Y. . .1 � . �'+.�
f .
� '`5 s -.Do you`anticipat additions or eapansions of the facility this system is intended to serve? ❑Yes' �No
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�. 'I�'J'�s,wba�t,type? ' �� ' . .
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***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: �a-- °�`� WRITE DIRECTIONS(trom Mocksville)to PROPERTY:
Taa Ofiice PIN: # � / � 1. - �� �6 ! � �-1wy /.S$ l�'o �/}�N � '
. -Property.Address: Road Name J�i�-►�/1/ 1'�U ' � li �N
✓ City/Zip 1'Yl D£l�SU����°� Z 7�zY ,�V �4�l[7h/�'�-' �1 at L d� D N ��
� If in a Subdivision provide informatioa,as follows: ��/�� (-���L,�- �Q�/!l� �/1t 11� ��IJ$��^
� � �
Name: ft-!2�
Section: Block: Lot: Date Property Flagged: `�' a�- � �
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pertnit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use cLange,or if the information .
submitted in this apptication is falsified or changed I,also,understand that I am responsible for a!l charges incurred from
lhis appllcallon. I,hereby,give consent to the Authorized Representative of the Davie County Health Department`
to enter upoa above described property located in Davie County and owned by
to conduct.all testing procedures as necessary to determine the site suitability. 1 '
� �;3�. �
DATE �f `d' 7- 6� SIGNATURE � L' �
E _
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THIS AREA MAY BE USED FOR DRAWIlVG YOUR SITE PLAN(Include all of the following: Eaisting and proposcd
property lines and dimensions, structures, setbacks, and se4tic locations). ,
. � �� 7V 1 . . _ "
f��i- ti 7� Site Revisit Charge ,
�^� ';'
� �� Date(s): 'r,�
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`— � ^,,,t � Client Notification Date: _ '' � �';;
� + 5 k'
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EHS: � ,�r' '���
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�� Account No. k! � b '�, �
p � �E;
Revised DCHD(07/99) Invoice No. 6 � �-
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�� � N� Thia map or drawin9 and cmy acc
�dC��2 E]P Th(s property Ta eubjeet to ali enaem�ts, �igAt—of—ways, documenta ars tumieh�d tn the �
sfreets and aasesaments, if ony, as the same may oppear of theroon ond no aReratfona or uaz
rocord in the office of the Regiater oi Deeda,qerk of Court, ta
Town or Coun Tax Offlce or which havs been a uirod �'�°d unleas outhoriz�d D+
tY T0Y �9 bY Stone Land Surveytng Co,
proscrlpWe uee. This aurvey le subject to any taets that may
be diaeloaed by a fuil ond accurate title s�arch, NOT fumished �1ap�t for rocondation.
�B �f7@ as of this date.
S 86°08'05"E ,2• ' Procioion 1:10.000+
. 200.04' �o.. �
l l� Tax Lof 13
�� Tcx Map H-6 �
r`� n/f Lucy S. Al/en
0"_ DS 154 O PG 92 COURS�
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L 1
L-2 :
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1" E1R N 10°51'15"E 540.27'
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(-�� T-Ba w/cap - ---------- --- ---- ,rotrrt use �o�-r2�crowi D
L�r _� _ _---_--- N 10°50'SU"E 418.Si' �P
_ Tax Mop H78 � � �'°-�s �� � f29s T-Bar w/cop —�' o�.—=-�
n/f Lester Martin Bowles �0� P °g�O � � 0 334.12' S 10°5�)'4
vnd �fe � PP � ar.aa• ~—
Ina BoWles ' �
DB93APGS - �
c�a,na Poo� �-- ��N
. �X, ?J 0 � °� _ S 80°09'45"E
� _� q " �� 158.48'
L �� �4 Tax Lot 1;
200.21'. �o•X,�• � � ° Tox Map �i-
N 87°40'35"W wo�H«»e o �__ n/f Norman Be'! :
frrat s.c uP) \ s4.so• ond Wifs
b Phyltis Calt Sr
'.. ' ' �' PP DB 121 O FG
178.21' �.
N 80°12'35'
� Tax Lot 12.01 Tax Lot 12
95.45' IRS 84.57' T Bar w/cop
1dc1/2" E!P —
180.02' S �1°00'10"W 334.03
' Total �
Tox Lot 7 �
Tax Map H-6 1
Tox L�±
, • LEGEND � Tax Mcp
R/Vf�—Right—oi—Way� �_Center_Une n�f ; Croi�� f
pP _�� ��� Gnter Une �
^9 P° EP — Edge of Povement Q�d �lj
OR — E,xtsting Iron Rebar FC —Face of CurL
P —Pant pP — power Pole Audrey f're:
CM- Concrete FAonument ht Pole - D8 100,���
IRS— Iron Rebar Set 1/2" �H �n Hoie
PJL— Property Ltrro R wa . �,"'r' ,,a
C A— Control�ed Access C — Chord Distonce Tox Lof 8 ' '` r^� :,
P 0 —Part ot ,,.`�:�
RCP — Retnforced Concrete Pipe g Sight Ecsement Tox Mep N-6 •'.��•��'-:
CAIP— Com+gated Metai Pt DB— Deed Book ��•.�"i�
CPP —Cortuqated Plaatic �p,e Pe - �at eook, n/f Ted Johrtson Robertson _ :'_•;>'f:.�
e CB — Catch Bce�n �
—F— 100 year Fiood Boundary ` ,�.—,
—0—Overfiead Utilitias FPS_ e ee�Post DB 69 O PG 384 1 declare that an ..'7 `- �
—X— Fence BoC �ck o� Curb — �
. wW-w,r.�r�.�.� we surveyed th��oper,t�wai:i:.
,60 0 60 <120 180 this plat� �';c', ',: , •
1 1''
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GRAPHIC SCALE — FEET . -= �':•,..,•��'.;
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' DAVIE COUNTY HEALTH DEPARTMENT
� ' ' I ; � Environmental Health Section �
- . Soi]/Site Evaluation �
APPLICANT INFORMATION PROPERTY IlVFORMATION
Account #: 990001506 Tax PIN/EH#: 5759-13-1077
Billed To: Talia Carter Subdivision Info:
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: RESIDENCE Property Size: 1/2 ACRE Date Evatuated: , �
Water.Supply: On-Site Well Community ` Public �
Evaluation By: ' Auger Boring � Pit Cut
FACTORS 1 2 3 4 _ 5 6 7
- Landsca sition �
Slo % 1-
HORIZON I DEPTH ` --7
Texture ou G G L
Consistence
Strticture ;�L
Mineralo 1� �� �
-HORIZON II DEPTH �ZZ —Z
. . Texture rou ' G �
� Consistence
Structure
� Mineralo '� 1 �•
HORIZON III DEPTH -V - � .
� . Texture rou � �� 'i, '
Consistence f ° ��',
Structure 5 G � ';'
Mineralo i: I; � � "��;, ;��'
HORIZON N DEPTH. ° ��._��;,`
Texture rou �* [, ' '�
�
Consistence ' ;
Structure
. Mineralo
SOIL WETNESS _ • '
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE O•
SITE CLASSIFICATION: � EVALUATION BY: lI
, 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
ois .
� 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 �
tru t r
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-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 �
� DCI-ID OS/99(Revised)
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