730 Howell RdDAVIE COUNTY HETH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street �¢
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002771 Tax PIN/EH #: 5823-60-8717
Billed To: Evon Crooks Subdivision Info:
Reference Name: Location/Address: Howell Road -27028
Proposed Facility: Residence Property Size: 17.41 acres
ATC Number: 3476
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 A/ #People S #Bedrooms #Baths
Dishwasher: tr Garbage Disposal: ❑ Washing Machine: Rill" 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) Site: New Repair ❑
LOO
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width—' Rock Depth Linear &-9V--O
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT AYOM
FINISHED GRADE. ****NOTICE: Coa arepre:
system tween 8:30 a.m t� 0 api. or 1:.m. to 1
i
A VED EFFLUENT FILTER RISERS) IF G "BELOW
Ie of the Davie County Health Department for final inspection of this
p.m. on thhekday, oaf installation. Telephone # is (336)751-8760.****
�j -',P
Fs'j- �- per,
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
Account #: 990002771
Billed To: Evon Crooks
Reference Name:
Proposed Facility: Residence
ATC Number: 3476
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section n
P. O. Boa 848/210 Hospital Street U`
Moclksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5823-60-8717
Subdivision Info:
Location/Address: Howell Road -27028
Property Size: 17.41 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �lkll Date: �J
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completi 11 indicate the system described on Improvement/Operation Permit
has been installed in compliance with Arti ell f G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WA t en rantee that the sy will function satisfactorily for any
given period of time.
pl-
F--*'
--
^Ir Septic System Installed By: L& P,
Environmental Health Specialist's Signature :f lr Date: _4�`�`ZIA
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department �j-
Environmenta/Hea/th Section D/
P.O. Box 848/210 Hospital Street I�
Mocksville, NC 27028
(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 �y1VA L1 4c 0.0 0 V a 6p— Contact Person _ 6110AI d Je 00/rS_
Mailing Address LHOk%f.�e, Home Phone A? —76S- —, A?4T
City/State/ZIP �•��C/�11 V/l �` x209 Business Phone
2. Name on Permit/ATC if Different than Above J14104 Ar A& les
Mailing Address City/State/Zip
3. Application For: ite Evaluation Improvement Permit/ATC Both
4. System to service: House Mobile Home Business Industry Other
5. If Residence: # People .r # Bedrooms 5 r # Bathrooms
--r
Dishwasher Garbage Disposal Washing 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: County/City Well
s. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes
If yes, what type?
Community
No
'**IMPORTANT*** CLIENTS MUST C0h1PLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
3ELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:f.� ei2U -/�cL At
Tax Office PIN: # VIN,
p 1
Property Address: Road Name 9004 /90t
City/Zip 0/0 rill f ✓/l/G A/ C
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Date home corners flagged:. 0`3
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 anz responsible fur all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth 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 xoZ�- oZ00 SIGNATUREy4c,��
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
Sign given Account No.
Revised DCHD (07/99) Invoice No. % ��'
------------------ I -
z
DAVIE COUNTY HEALTH DEPARTMENT
<'
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #:
990002771 _
Tax PIN/EH #:
5823-60-8717
Billed To:
Evon Crooks
Subdivision Info:
Reference Name:
Location/Address:
Howell Road -27028
Proposed Facility:
Residence
Property Size: 17.41 acres Date Evaluated:
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
c/ Pit
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position A— F
Sloe % 64
HORIZON I DEPTH 1-1 -- a
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence r
Structure
Mineralogy'
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 v
SITE CLASSIFICATION: EVALUATION BY:
Zhd/z
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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