2950 Hwy 158 (2)DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street O 3
Mocksville, NC 27028
(336)751-8760 l
IMPROVEMENT/OPERATION PERMIT
Account #: 990002786
Billed To: Maxie Harrison
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5850-05-6201 B
Subdivision Info:
Location/Address: Foster Dairy Rd -27028
Property Size: see map
ATC Number: 3604
**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 #People #Bedrooms #Baths
Dishwasher: ❑ 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(Al Design Wastewater Flow (GPD) c�-S I Site: New 0"' Repair ❑
System Specifications: Tank Size &&GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL.
11
Trench Width,,9C Rock Depth ZZ Linear Ft. M -R i
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.****
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Environmental Health Specialist's Signature: &W �z Date:
DCHD 05/99 (Revised)
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002786 Tax PIN/EH #: 5850-05-6201 B
Billed To: Maxie Harrison Subdivision Info:
Reference Name: Location/Address: Foster Dairy Rd -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3604
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 CON,S�TRRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /�/� Date: 1 L -F`
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.
1�
C
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
APPLICATION FOR SITE EVALUATION/IiIPROVE-MENT PERMIT & ATC
Davie County Health Department
EnvironmentaiHeaith Section
P.O. Box 848/210 Hospital Street
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 1_0}x! F3P.)? 1-'1J Contact Person
Mailing Address /1�'' „C K1e13/y hk7v'eeJuR �p(y�// MDn/Yvz��' FIomc Phone _60 0 Jam( % 0
City/State/ZIP 0,0 )eVFW &I.e. 2,W3 Business Phone 513rr-1C __ _
2. Name on Permit/ATC if Different than
Mailing Address
3. Application For: 2 Site Evaluation
City/State/Zip
^, "� .0
L,[Improveme t Permit/ATC ❑ Both
4. System to service: use ❑ Mobile Home ❑ Business
5. Type system requested: ❑ Conventional ❑ conventional modified
❑ Industry ❑ Other
❑ innovative
6. ,I�,f/Residence: it People It Bedrooms It Bathrooms
[O/Dishwasher []Garbage Disposal 2Washing Machine ❑Basement/Pliunbincg ❑basement/No PluLibing
7. If Business/Industry /Other: verify type It People It Sinks
It Commodes # Showers # Urinals It Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) __
8. Type of water supply: VCounty/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this systeni is intended to serve? ❑ Yes ❑ No
If yes, what type?
'IMPORTANT" CLIENTS /BUST COAIPLETCTHE REQUIRED PROPERTY INFORMATION REQ(JESTGD
BELOW. Either a PLAT or SITE PLAN A1UST BESU&VITTL•D by the client ii-itli THIS APPLICATION.
Property Diensions: �
mA C
Tax Office PIN: # o - c, S
Property Address: Road Naine 4
City/Zip
If in a Subdivision provide information, as follows:
Nanic:
WRITE DIRECTIONS (from Moclavillc) to 1'1t011"RTY:
f tD129d X 3 Ty f-/ m i e s Xeo ,
/2io e b,d l c' — rJ1 l u c/ %S c� %J L),1r D S eIemm —I -T -
3tn5 t iAST Tf`tf"m rnl2%ref �C�—
/--z s -der C<o7
Section: Block: Lot:.- Date home corners flagged:
03
This is to certify that the information provided is correct to the best of my knowledge. I understand that any periiiit(s)
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 clianged. I, also, understand that I run responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilea Ith Depar(In elH
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 6-a-6 3 SIGNATURE '-r r-'_
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
Revised DCHD (05/03
Site Revisit Charge
Date(s):
Client Notification Date:
EIIS:
Account No. , y-7 Vo
Invoice No. 7"O"AtF_
r G
6775
g'tl
l
158
(� t -j (16.48A)
9820
1_I / 1 1►M11 NI 4_ M. DEP4VUVUADEP:
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002786 Tax PIN/EH #: 5850-05-6201 B
Billed To: Maxie Harrison Subdivision Info:
Reference Name: Location/Address: Foster Dairy Rd -27028
Proposed Facility: Residence Property Size: see map Date Evaluated: 6 x�2y
Water Supply:
Evaluation By:
On -Site Well
Auger Boring_
Community
Pit !/
Public '
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
4—
-Slo
Slope
e %
HORIZON I DEPTH
Texture group
rc
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: 1 0
REMARKS:
EVALUATION BY: 4 �'
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
d ... ,.. Phone #, (336)75175760111'.
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,
Ag444 vs. 6;uaA.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/df