317 Jack Booe RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
�=-OT� in��/��w�G� ofN � ��i 130 Article13cSewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number -
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Location
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' Gu iviaion Name Lot No. Sec. or Block No.
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Lot Size House Mobile Home Business Speculation
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No. Bedrooms
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No. in Family
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(�arbageO�000a YES[�� NO �rSpecifications for S?ystem:
Auto Dish Washer YES m NO C]
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Auto Wash Machine YES � NO C] .
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Tvoa Water Supply
~This pomnd\/oid if sewage system described below |o
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Improvements penn�bv
�*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of,completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
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System Installed by
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Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period oftime.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
1i l
Davie County Health Department
V / Environmental Health Section
V P. O. Box 665
1 Mocksville, N.C. 27028
` CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phoney�7a-905
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1. Permit Requested By � e --I\ L- W�� ���een B.Ce"usiness Pho?ev73'741-3 (7
2. Address 7 = . G her r y "� (' e e4- 5�;- /mss,, -'/A-
3.
-
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSe Lot No.
5. System used to serve what type facility: House Mobile Home Business
tet- IndustryOther
Business—
b) Number of people I W O
6. a} If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms –9 Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes
lavatory
urinal
showers
dishwasher sinks
8. a) Type water `supply: Public Private Community
b) Has the water supply system been approved? Yes •No
9. a) Property Dimensions l 7. ? 77
garbage disposal
washing machine
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? - --- -
This is to certify that the information is correct t the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directios tQproperty:
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DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R 0. Box 665
Mocksville, N.C. 27028
. SOIL/SITE EVALUATION
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Name �/1 � �� Date
Address Lot Size
FAr:TORR AREA 1 AREA 2 AREA 3 ARFA d
I) Topography/ Landscape Position
d)
PS'<:SP
S�
S
(:k
U
11
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
P
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S
�
S
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
(p
�
A
Ste -
WSJ
U
U
U
U
Soil Depth (inches)
S�
!
�
�S
U
U
U
) Soil Drainage: Internal
S
PS
S
S�
U
C
U
External
PS
(�
U
U
U
Restrictive Horizons
Available Space
PS
S
PS
Q
PS
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
5
6)
7)
8)
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
X-(
DCHD (4-82)
X�
S—SUITABLE Provisionally Suitable
/
Title.
Y
3
Date
Account #: 990001885
Billed To: Mike Holland
Reference Name:
Proposed Facility: Residence
ATC Number: 2958
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
MockrAlle, NC 27028
(336)751-8760
Tax PIN/EH #: 5812-86-5815
Subdivision Info:
Location/Address: 317 Jack Booe Road -27028
f!11ZrJ Property Size: see map
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 WASTEWATE NS ALI PRA PERIOD OF FIVE YE
Environmental Health Specialist's Signatur C. / Date: ,�
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 By:
Environmental Health Specialist's Signature :
DCHD 05/99 (Revised)
Date: zo -;2 -15---el-2)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990001885 Tax PIN/EH M 5812-86-5815
Billed To: Mike Holland Subdivision Info:
Reference Name: Location/Address: 317 Jack Booe Road -27028
Proposed Facility: Residence Property Size: see map
**NOTE *Thi sb)lmprovem8nt/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: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type PAQI--� #People I #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply �esign Wastewater Flow (GPD) J`—b Site: New 12Repair ❑
System Specifications: Tank Size 1CMGAL. Pump Tank GAL. Trench Width alp Rock Depth 12 Linear Ft. IOO'
Other:
Required Site Modifications/Conditions: o.J
t -:S `fl 0.0-1
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 tla day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's
DCHD 05/99 (Revised)
1\jE1Q i S��^��= 4c,
<5b' x.3(0 'k/2,,
Date: 7i
�CE
AUG 2 0 2001
HEALTH
IN FAIT SITE EVALUATION/IMP1IOVEMENT P' -.-"-
Davie County Health Department -
Environmental Health SectionPlease complete the highlighted areas) and
P.O. Box 848/210 Hospital Stre<=tM.
Mocksville, NC 27028 ���3/
(336)751-8760 P, -i V
1Knrwww Tri15 APPLIUNXION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
7INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to' be Billed `� T le- \-V1-)rt Contact Person
Mailing Address `�� �1t Home Phone J (orrb-
City/State/ZIP M�luvla� Business Phone-5iCla, - S7S(v
2. Name on Permit/ATC if Different than Above
6
Mailing Address Zmpkvemen
/State/Zi
Upl
3. Application For: Site Evaluation
4. System to Service: ❑ House ❑ Mobile Home ❑ Business
5. If Residence: # People # Bedrooms
' Permit/ATC I I Both
ll Industry 1 thcr
# Bathrooms
U Dishwasher U Garbage Disposal LI Washing Machine 11 Basement/Plumbing II Basement/No Plumbing
6. If Business/Industry/Other: Specify type cXs� (1 # People \ # Sinks
It Commodes # Showers ` # Urinals (t Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City L] Well I1 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? 1-1 Yes o
If yes, what type?
***IMPORTANT*** CLIENTS MUSTCOAIPLETETHE REQUIRED PROPEWrY ;NFOILMATION REQUESTi D
BELOW. Eithcr a PLAT or SITE PLAN MUST BESUBMITT'ED by the client with THIS APPLICATION.
Properly Dimensions. fe_ �� J�.41S WRITE DIREC11ONS (from A1ocla%,ille) to PItOPt'RTY:
Taz Office PIN: root Ne+ ►'�J 16 SiRc,�600t- (t� Lc 1�
Property Address: Road Name r::-� f /Z nl� Or; ( `^t"9Y 0+•/ Lti "
City/Zip ors /?g,1
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot: Date Property Flagged: 5 t�
This is to*ccrtifythat the information provided is correct to the best of my knowledge. I understand that any pennit(s)
issued hereafter arc 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. 1, also, understand that I tun responsible for all charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Ilealth Deparhncnt
to enter upon above described property located in Davie., County and owned by
to conduct all t sting roccdures as necessary to determine the sites stability.
DATE « SIGNATURE
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).
41.),
� Site Revisit Charge
S�\-P-- 4C� Date(s):
C J Client Notification Date:
an �� EHs:
I P b �- �{� Account No. o
�,p 3
Revised DC HD (07/99) 3 � CSO N Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
FACTORS
Environmental Health Section
3 4 5 6 7
Landscape position
Soil/Site Evaluation
L
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #:
990001885
Tax PINIEH #:
5812-86-5815
Billed To:
Mike Holland
-• Subdivision Info:
CL,
Reference Name:
Consistence
Location/Address:
317 Jack Booe R -2710 8
Proposed Facility:
Residence
Property Size: see map Date Evaluated:
Water Supply:
On -Site Well
Community
Public
HORIZON II DEPTH
Evaluation By:
Auger Boring
Pit
Cut
r
;
FACTORS
2.
3 4 5 6 7
Landscape position
L
Sloe %
HORIZON I DEPTH
d — fi
Texture group
CL
CL,
C
Consistence
Structure
S
Mineralogy
HORIZON II DEPTH
tP '
Texture group
Consistence
;
$
_ :5
Structure
-.5614
Mineralogy
vl�_AA
HORIZON III DEPTH
3
Texture group
F
f 5w
Consistence
Structure
K
VL -
Mineralogy►
c
HORIZON IV DEPTH
Texture groupLe
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE I0
.
SITE CLASSIFICATION: L) EVALUATION BY: ► "IP
LONG-TERM ACCEPTANCE RATE: O . OTHER(S) PRESENT:
REMARKS: V%�N�. 1M I �L�I ►
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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