150 Friendship CtAccount #: 990003841
Billed To: William Fuller
Reference Name: William
ATC Number: 4305
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5728-60-2543
6"M-SM0Mt•Tilray i:3
9gOl Location/Address: Friendship Court -27028
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 I 1 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTR CTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: IV //,P&,
**NOTE** The issuance of this
has been installed in
Disposal Systems," b
given period of time.
CERTIFICATE OF COMPLETION
Septic System Installed By:
J�
/
described on Improvement/Operation Permit
Section .1900 "Sewage Treatment and
he system will function satisfactorily for any
zpp h d
f eV,),o-0
t�
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
.. DAVIE COUNTY HEALTH DEPARTMENT �,,� S 1 001,E
A, __c Environmental Health Section a3lob
P. O. Boz 848/210 Hospital Street 11
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990003841
Tax PIN/EH #: 5728-60-2543
Billed To:
William Fuller
Subdivision Info:
Reference Name:
William
Location/Address: Friendship Court -27028
Proposed Facility:
Residence
Property Size: 2 Acers
**NOTE* This ImproqRu:vement/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 14 #People_ #Bedrooms #Baths s�
Dishwasher: d Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine: W Basement w/Plumbing: 2TOe Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size f Type Water Supply Design Wastewater Flow (GPD) �-710 Site: Newt Repair ❑
System Specifications: Tank Size�QGAL. Pump Tank
Other:
GAL.
Trench Width C S'�'ro Rock Depth li _ Linear Ft
.�0
Required Site Modifications/Conditions:
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.****
F
Environmental Health Specialist's Signature: !/� Date:
DCHD 05/99 (Revised)
IR -3 -Ob
/ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERK C
Davie County Health Department UAN
Environmental Health Section ` 6 2006
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028/RO,�rM
(336) 751-8760
***XatifPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFOIUTATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
I. Name to be Billed (,k),dtra, a8cl Fu'lier Contact Person
Mailing Address �15 o nla nd Home Phone :BA - 13 C11 - 3 1
City/State/ZIP (2pulI�NC .,9,21)'71 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
v?3-0
3. Application For: � Site Evaluation K Improvement Permit/ATC ❑ Both
4. System to Service: 1k House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: Conventional ❑ conventional modified ❑ innovative Maccepted
6. if Residence: it People _ # Bedrooms -= t it Bathrooms
Dishwasher []Garbage Disposal Washing Machine Xasement/Plumbing ❑Basement/Ido Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals It Water Coolers
IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day)
S. Type of water supply: 171' County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes W"No
If yes, what type?
***I,3IP0RP-1N7--* CLIENTS MUST COAfYLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
IIELO,V. Either a PLAT or SITE PLAN 1KU.ST BE SUA fITTED by the client ivitli TIIIS APPLICA'T'ION.
Properly Dimensions:
Tax Office 11IN: ft —1
Properly Address: Road Name
n —
City/Zip
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (frons Mod(sville) to PROPERTY:'
o 1I4
c1.% (..
Date house corners flagged: /' y- 1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
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 an: responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department
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 — _ D SIGNATURE 1� % _ F7t c ��\! IA
TIIIS AREA PIIAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sign given
Revised DCIID (05/03
Site Revisit Charge
Date(s):
Client Notification Date:
EIIS:
Account No. 3O 7/
Invoice No. sa 0
w
WILLIAM H. JOYNER
D.B. 78, PG. 333
APPLICANT INFORMATION
Account #: 990003841
Billed To: William Fuller
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5728-60-2543
Subdivision Info:
Location/Address: Friendship Court -27028
Property Size: 2 Acers Date Evaluated:
Community
Evaluation By: Auger Boring XZ Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH49
Texture group
Lfr,L ,
Consistence
r_
Structure
T
Mineralogy
HORIZON H DEPTH
Texture groupG—
Consistence
'
Structure
/L
Mineralogy
HORIZON III DEPTH
L,
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
'
SITE CLASSIFICATION: �/ C "kms EVALUATION BY:
LONG-TERM ACCEPTANCE RATE:
`i
REMARKS: _[ _Yv /-� ,
1/-) OTHER(S) PRESENT:
I �-_,rl
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
),' ohl
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wd
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
]Votes
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 05105 (Revised)
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I , .
January 19, 2006
William T. Fuller
515 Panhandle Road
Gold Hill, NC 28071
Re: Tax Pin. #5728-60-2543
Friendship Court
Dear Mr. Fuller:
As requested, a representative from our office visited the aforementioned site on
January 18, 2006. Based on the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, it was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
A44A& 4?_714aA-
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
':ALM
El
R