626 Howardtown Circle ,• , DAVIE COUNTY HEALTH DEPARTMENT
' • Environmentai Heaith Section
+ �� '' P.O.Boa 848/Z10 Hospital Street
Mocksville,NC 27028
(336)?51-8760
Account #: 990004102 Tax PIN/EH#: 5860-09-6631.B
Billed To: David Purkey Subdivision Info:
Reference Name: Location/Address: Howardtown Circle-27208
Proposed Facility: BasemenUBedroom Property Size: 9 ac
ATC Number: 4506
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 Treahnent and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE ARS.
Environmental Health Specialist's Signature: ���/ Date: L'/l ��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 tha�e system 'll function satisfactorily for any
given period of time. . 1
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Septic System Installed By: � -�f `1��-5 �• G
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Environmental Health SpecialisYs Signature: ��7'/� Date: �0 �
� DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Heaith Section P��
• �, ' ��-'� P.O.Boa 848/210 Hospital Street _ �_�/ 61'j
' � . Mocksville,NC 27028 q �J�
(336)751-87G0 6
IMPROVEMENT/OPERATION PERMIT
Account #: 990004102 Tax PIN/EH#: 5860-09-6631.B
, Billed To: David Purkey Subdivision Info:
Reference Name: Location/Address: Howardtown Circle-27208
Proposed Facility: Basement/Bedroom Property Size: 9 ac
ATC Number: 4506
**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�_ #Baths� ;
�
Dishwasher: �1 Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing:� BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift � #Seats Industrial Waste: ❑ �,
Lot Size ���' Type Water Supply W�'/ Design Wastewater Flow(GPD)�� Site: New�Repair❑
System Specifications: Tank Size���Q GAL. Pump Tank GAL. Trench Width�� Rock Depth� Linear Ft��
Other:
As stated in 15A NCAC 1f3A.19f39 5) �
Required Site Modifications/Conditions:
sccepted Systems may also bo used �
INIPROVEII'IENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G"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 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.****
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En ir nm tal Health ecialist's Si ature: ✓�"�` � Date: /� ��
v o en Sp gn
DCHD OS/99(Revised)
� •F._5„��'��,.,�
� ; •JAPPT�ICA_ �,C�d_, ., R SITE EVALUATION/IMPROVEMEN ��I'T�
—.�-'.�.�-"�-"' . �
�: , � � ��,_..,��,�i� Davie County Health Department .� SEP -
�.�..�� . � Envaronmental Health Sectzon � 2p�
4��" ¢ � �� ` P.O.Box 848/210 Hospital Street �
�� � . ; ��� � � �� � Mocksville,NC 27028 p
ENy1RG,vM,ENTAC H-
(336)751-8760/Fax (33�751-8786 ���ECOU�r�p LTy
i . -�: �` "i3;tiF,�j ��
k „�� � , � ��� �g _ �
��Application For�..:.C�-Si�e� a a ion/Improvement Permit ❑ Authorization To Construct(ATC) L�Both
�.�`�'... .
***IMPORTANI"`**THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION �
Name to be Billed �a'✓�� �• ��'"k� -s�. Contact Person Sst-m� �- —
Billing Address O 1�'1;1/; ��. Home Phone �'-5 - ��'�' S- �
City/State/ZIP �'YI o�-�s vi//� � Business Phone S�5- O�(
��� �
Name on PermidATC if Different than Above csAn�E j� ,
Mailing Address City/State/Zip ,
�
PROPERTY�INFORMATION ��f �
NOTE: A survey'plat or site plan must accompany this application. �'{"" '
(Pernut is valid forj�months with site p�n,no expiration with complete plat.)
Street Address looZ G /�D��/'�fdcJ�i/�-/�"��L City /�dckScl� //e, Tax PIN# �$l�009(0(o.3I �
Subdivision Name Section/Lot# Lot Size `i :> �.-� �
Directions To Site: /��� �� r.�a�d�o�n G'�� �� , u�'� r��i�i�`", ���2 M�Ji/�5 o�s�- .
rl�ht' _
Date House/Facility Corners,�Flagged q O
If the answer to any of the following questions is"yes",supporting documentarion must be attached.
Are there any existing wastewater systems on the site? ❑Yes�o ��,�pYl '
Does the site contain jurisdictional wetlands? OYes o � /� ��
Are tliere any easements or right of ways on the site? QYes C�10 , �/�D
, Is the site subject to approval by another public agency? ❑Yes C►3'�o . f����
Will wastewater othet than domestic sewage be generated? ❑Yes f7'�To
IF RESIDENCE FILL OUT THE BOX BELOW
_ #People #Bedrooms #Bathrooms Garden Tub/Whirlpool es ❑No
_ Basement: �es ❑No Basement Plumbing: �es ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW ,
Type of FacilityBasiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals �
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) ;
FOODSERVICE ONLY: #Seats I
Type system requested: 9�onventional &t�ccepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water C�Tew Well ❑Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [�3'�Io
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information subnutted in this application is falsified or changed. I understand that I anz responsible for all charges inca�rred
from this c�pplication. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to detemune�pliance with applicable laws and rules on the above described property located in
Davie County and owned by l A- % Ltr�� �
Y L���J�
,/ � ��'- " � .
'�� Site Revisit Charge
Property owner's or owner's legal represe, 've signature
� Date(s):
� � �� Client Notification Date:
Date '_ EHS:
Sign given UYes ❑No Account# !UZ-
Revised 2/06 Invoice#
, -�� DAVIE COUNTY HEALTH DEPARTMENT
"•• ' ' Environmental Health Section
� � . Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004102 Tax PIN/EH#: 5860-09-6631
Billed To: David Purkey Subdivision Info:
Reference Name: Location/Address: Howardtown Circle-27028/
Proposed Facility: Residence Property Size: 9.5 acres Date Evaluated: �//9��0
�sew+��-� ���C'
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring Pit ✓ Cut ✓
FAGTORS 1 2 3 4 5 6 7
Landsca e sition
Slo e%
HORIZON I DEPTH
Texture grou
Consistence
Structure
Mineralo
HORIZON II DEPTH '` f�
Texture rou '
Consistence /� �{"j
Structure ,�
Mineralo � -�`,•
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo -
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � ,
SITE CLASSIFICATION: �`� EVALUATION BY:- �`�GV �
—�
LONG-TERM ACCEPTANCE RATE: �� OTHER(S)PRESENT:
REMARKS:
LEGEND
T, n s pe Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Ts�T� .
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
MQ1St _ ,
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
� �
• NS-Non sticky SS-Slighdy 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-Subangulaz blocky PL-Platy PR-Prismatic I
MineraloQv
1:1,2:1,Mixed
N�t� _
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/OS(Revised)
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