2950 Hwy 158DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• ' i P. O. Boa 848/210 Hospital Street O
Mocksville, NC 27028ys'"
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002786 Tax PIN/EH #: 5850-05-6201 A
Billed To: Maxie Harrison Subdivision Info:
Reference Name: Location/Address: Foster Dairy Rd -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3603
**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: Xf- Garbage Disposal: ❑ Washing Machine: 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) Q -S4 b Site: New. Repair ❑
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
��
GAL. Trench Width( Rock Depth Linear F
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.****
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT �%d�.
Environmental Health Section �
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002786 Tax PIN/EH #: 5850-05-6201 A
Billed To: Maxie Harrison Subdivision Info:
Reference Name: Location/Address: Foster Dairy Rd -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3603
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: -�l Date: /n�.2 ��
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.
Septic System Installed E
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
A I TION 1`011 SITE EVALUATION/IMPROVENIE-NT PEIiMIT & A]C
Davie County Health Department�l� O .�
O 2 EnvironmentaiHeaith Section Q ]
P.O. Box 848/210 Hospital Street '0
Mocksville, NC 27028
(336)751-8760 l "�
***I TANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed j 1 („ q ea.C'M Contact Person m gy,1C N�+6se�l___
Mailing Address 4^ ^ L E 141 Ckjry �� U ��J? ��yl �e� � Home Phone 8CR O % ' 14150
City/State/ZIP 0-1),j 6 yew &/.6 Business Phone S)-rm C
2. Name on Permit/ATC if Different than Above
City/State/Zip
�J Improvement Permit/ATC Both
Mailing Address ��
3. Application For: CN Site Evaluation
4. System to service: P7 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People It Bedrooms _2 It Bathrooms
BDishwasher ❑Garbage Disposal 2 Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /other: verify type It People It Sinks
# Commodes It Showers # Urinals It Water Coolers
IF FOODSERVICE: #—S`eats Estimated Water Usage (gallons per day) _
1+3
8. Type of water supply: County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
k"IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli'1111S APPLICA'T'ION.
Property Dimensions:
Tax Office PIN: # 5 �—o `0 S— 6 �)L-6
Property Address: Road Name�o-��
City/Zip
If in a Subdivision provide information, as follows:
Name: S,� A
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
pend x U z4 zVES Xe1111
ji%JdLd le — %4014 /.S$ iJLJvD/tD S Clem„ —1.5
3tn54
Lpal(� S Af r .8 A �y �
D:Yte Ilomc corners flagged: (o _ � — 0 3
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
subinitted 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 Davie County Ilealtll 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 �`/ b� ice. SQ ,
DATE G J ol—6 3 SIGNATURE
"a S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
�s and dimensions, structures, setbacks, and septic locations).
Site
Site Revisit Charge
Date(s):
Client Notification Date: .
EHS:
Account No.
Invoice No. b�
L/
Pyr
PLC-'
.
a C- -`i
Imo,. 5 158
1�
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990002786
Billed To: Maxie Harrison
Reference Name:
Proposed Facility: Residence
Water Supply:
Evaluation By:
On -Site Well _
Auger Boring_
PROPERTY INFORMATION
Tax PIN/EH #: 5850-05-6201 A
Subdivision Info:
Location/Address: Foster Dairy Rd -27028
Property Size: see map Date Evaluated:
Community
Pit I i
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Sloe %
A0
HORIZON I DEPTH
A, v
Texture group
C '
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
G
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
,
SITE CLASSIFICATION: /X
LONG-TERM ACCEPTANCE RATE: , 'K
REMARKS:
EVALUATION BY: G/
OTHER(S) PRESENT:
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)
ENVIRONMENTAL HEALTH SECTION
P. 0. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone #, 4(336)751-8760.
June 20, 2003
Maxie Harrison
6641 Monford Drive
Lake Hickory RV Resort
Conover, NC 28613
Re: Site Evaluations/ Foster Dairy Road Sites A,B,C, and D
Tax Office Pin : #5850-05-6201
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
June 20, 2003. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/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,
Agk44&' g;�A.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/df