1653 Jericho Church Rd (3) , DAVIE COUNTY HEALTH DEPARTMENT ��t'L� �-f—G O
' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001032 Tax PIN/EH#: 5727-94-3619
Billed To: Robert Erb Subdivision info: ����
Reference Name: Robert 8�Kathy Erb Location/Address d-27028
Proposed Facility: Residence Property Size: 3.5 Acres
**NaTE�*Thms�mprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 �n #People � #Bedrooms � #Baths�
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply C b Design Wastewater Flow(GPD) c��� Site: New� Repair❑
i
System Specifications: Tank Size ODd GAL. Pump Tank GAL. Trench Width� Rock Depth 1 2��Linear Ft
Other:
Required Site Modifications/Conditions:
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: ' Date: .�����
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001032 Tax PIN/EH#: 5727-94-3619
Billed To: Robert Erb Subdivision�info:
Reference Name: Robert&Kathy Erb Location/Address: Jericho Church Road-27028
Proposed Facility: Residence Property Size: 3.5 Acres
ATC Number: 2360
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:G����,�v � /"/1�oaC� ��� Date: �� '-�Z "�U
—�e
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion 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 that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: � � ����% U��0�1��D�1 �-�.{�J��
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Environmental Health Specialist's Signature Date: '7 � Ol�
DCHD OS/99(Revised)
A : . `
APPUCATION fOR S1TE EVAUlAT10N/IMPROVEMENT PERMIT&AT � � � � � " �
Davie County Health Department
Envi�+vnmenla/Hea/th Seclion � - 9 200�
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 �r��pAVI'E COlINT1��TH
***Il�ORTANT*** THIS APPLICATION CANNOT EE PROGESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed Jl D���� �` �JZ/} Contact Person �J� �� /`��`1/1''/ �/�-.',�
Mailing Addreae f�r; �G�/C/�u L'j/���.�'LL� ��'_ Home Phone �J / " ��-/ �
City/State/2IP n7U(',r f �/l L�� , �l/.� 2`7L�L,� Bnsineas Phone �� �,$�5�� Z3'J�
a
2. Namo on Pezmit/ATC if Different than Above �f�'��j
�-'
Mailinq !►ddreea /S��'2�lt) City/State/Zip
s. Appiication For: .� Site Evaluation ❑ Improvement Permit/ATC [�Both
/.-
a. syat� to se�,►ice: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other
s. =f Residence: � People ?r e Bedrooms 3 # Bathrooms �_
O DishMaeher O Garbage Diaposal �Wsahing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Buainesa/Induatry/Other: Specify type # People # Sfnks
� Co�odea � ShoMera # Urinals Y Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay)
7. Type of water supply: � County/City ❑ Well ❑ Community
a. Do you anticipate additions or ezpansions of t6e facility this system is intended to serve? ❑Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQ[JIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the client with THIS APPLICATION.
3�- �-
Property Dimensions: `7 v����' ��7 �� ��r'���� WRITE DIRECI'IONS(from Mocksville)to PROPERTY:
Taz Office PIN: # ,��7 2 7 - >�- ��f� �'�c�iF- `..� �/..�it.�C�ur' ������
� �
Property Address: Road Name JE�/�/�o L'/s�, ✓�� �.li' �'r.� �G/c�� S'�i9/'-r'/�'!� j'��
City/Zip 1°'l�C.es'�ictF iL'•C°. �S'�lf" A('Tt/,�9CLy Iri'9Ct�� /.Pl/C�
z�7v z�
If in a Subdivision provide information,as follows: st'Q�'v�� �C'� S�� /�'���
Name:
Section: Blcek: Lot: Date Property Flagged: _���� /��
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 chaage,or if the information
submitted in this application is falsified or changed I,also,understand that I am responsible jor a!!charges incurred jrom
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by,/c'.s.i3f�T � °y���>' E� F✓Z�
to conduct all testing procedures as necessary to determine the site suitability.
DATE ���r�D SIGNATURE C��/tiC/i��Y/ l/���L�
THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. D�Z
Revised DCHD(07/99) Invoice No. ���
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,t� � ' � DAVIE COUNTY HEALTH DEPARTNMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001032 Tax PIN/EH#: 5727-94-3619
Billed To: Robert Erb Subdivision Info:
Reference Name: Robert 8�Kathy Erb Location/Address: Jericho Church Road-27028 \
Proposed Facility: Residence Property Size: 3.5 Acres Date Evaluated: �� ��"�U
Water Supply: On-Site Well Community Public v
Evaluation By: Auger Boring �(l Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition ,L,
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH '` � °
Texture rou �
Consistence � ,
Swcture l p
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 , i
SITE CLASSIFICATION: EVALUATION BY:
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
MineraloQv
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-gaUday/ft2
DCHD OS/99(Revised)
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