222 Knoll Crest Rd �
. DAVIE COUNTY HEALTIi DEPARTMENT
' Environmental Health Section n� �_�o_a�
� � � P.O.Boa 848/210 Hospital Street �/�
. Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 980002239 Tax PIN/EH#: 5747-91-7899
Biiled To: Kevin Champ Subdivision Info:
Reference Name: Location/Address: Knoll Crest Road-27028
Proposed Facility: Residence Property Size: see map
ATC N�b�r. 3130
**NOTE** "l�his mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATtON 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT 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 �C Type Water Supply� Design Wastewater Flow(GPD) �6 v Site: New� Repair�
System Specifications: Tank Size,�GAL. Pump Tank GAL. Trench Width c?�v��Rock Depth,���Linear Ft��J �
Other:
Required Site Modifications/Conditions:
IlF1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
F�NISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection ofthis
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: y �( �2 �
DCHD OS/99(Revised)
' � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002239 Tax PIN/EH#: 5747-91-7899
Billed To: Kevin Champ Subdivision Info:
Reference Name: Location/Address: Knoll Crest Road-27028
Pro osed Facilit : Residence Pro ert Size: see ma
ATC Number: 3130
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED 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 ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: v Date: '�—ot S 0 Z
CERTIFICATE OF COMPLETION
**NOTE** 'I'he issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article 11 0 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in N e taken as a guarantee tha system will function satisfactorily for any
given period of time.
�Do���
>-
Septic System Installed By: _G�
Environmental Health Specialist's Signature: ,�G�/� Date: ��S'`'a +
DC�ID OS/99(Revised)
,_ �� ,. ,. ' � j�l
APPLICATION FOR SITE El/ALUA710N/IMPROVEM1iENi PEIiMiT�c ��j �Q �
�� � Davie County Health Department � �
Envir�nmenia/Hea/th Section
P.O. Box 848/210 Hospital Street AI'R �
Mocksville, NC 27028 � ?QQ�
• (336)751-8760
f.tVNR�jyM�
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI,ESS ALI, THE
INFORI�TION IS PROVIDED. Refer to the INFORI�ITION BULLETIN for instruction .
1. Name to be Billed �/�p./�y�l��� /7 G i'N /� Contact Person �1p�Cy�� ��_S r�n
Mailing Address � o Home Phone 7��0 �0 L' v�'- "�-
City/State/ZIP �Dl�t Ji /I��L��Q�a Business Phone �l ��
2. Name on Permit/ATC if Different than Above
Mailing Address City te/Zip
3. Application For: [� Site Evaluation Improvement Permit/ATC 0 Both
4. system to sezvice: ❑ House �Mobile Home ❑ Business ❑ Industry � Other
5. If Residence: # People _d_ # Bedrooms _L� # Bathrooms �_
�Dishxasher ❑ Garbage Disposal Y�r Washing Machine � Basement/Plumbing U Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People @ Sinks
# Commodes # Shoxers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Z��e of water supply: ❑ County/City �Well ❑ Community '
e. Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST B�SUBMITTED by the client with THIS APPLICATION.
t
Property Dimensions: ��'e ���� WRITE DIRECT[ONS(from Mocksville)to PROPGRTY:
TaxO�cePIN: # � ��� � 1 �— �1) / / ��,,,��N �1� Tv /�n6 1�C��s t �G�
Property Address: Road Name ��/�°�(C/��S�" 2`'�' h,g/ T o n �o �� N r,c� ''Xia�_
City/Zlp . Ga h� ��-
If in a Subdivision providc information,as follows:
1�1ame: �
Section: Block: Lot: ' Date Property Flagged: y�� s'� �
This is to certify that the information provided is correct to the best of my knowledge. I understand t6at any permit(s)
issued hereafter are subject to suspension or revocation,if the site pians or intended use change,or if the information
submitted in this application is falsified or changed. I,also,uirderstand tliat I ara tesponsible for all cl:arges iuc�irred frar�
lhis app/icalion. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davic County and owned by
to conduct all testing procedures as necessary to determine the sitc suitability.
DATE �/���D 1� 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 IocAtions).
.� Site Revisit Charge
Date(s):
. Client Notification Date:
����<-- �� ? ? EHS•
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�,�-���—.c,// v�'/��
rl" C d h-�� Account No. ��
�.� 3 ✓
Revised DCHD(07/99) �b �'�"-` • � Invoice No..
� � �' � ��y
4p6 S8 II
0259 m . I
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�4.�oA> K500000054 �I
184 5747917899
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380
�8s (10.66A)
7899
3j9
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j �°' ,�$0 5.00A
�j,9 6689 �48
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2730
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\'� "' 6508
\ 10.86A '•�
15151 �''`\ r
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(6.54A) �` � � I
8109 /sos� 11�s2 � I
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��,� 18.70A
(10.51A) 6084
10.00A
a $9oa 2917 i
� (3.43A) `� j
0828 ^
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v
� DAVIE COUNTY HEALTH DEPARTMENT
� ` ' � '� ' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
HCCO:!!li �: 990002239 E 2x!='li�:!"-;�: 5747-91-7899
��isac; �c,: Kevin Champ _ SuG,u�v�s�o�� f��fo:
Neference �:�me: ��caiicni�;�aress: Knoll Crest Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: 1/-2 y'�Z
Water Supply: On-Site Well l/ Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo % �
HORIZON I DEPTH �� �/��
Texture rou �
Consistence
Structure
Mineralo
HORIZON II DEPTH '� , �
Texture rou �- G
Consistence � � '`�
Structure t'_ /
Mineralo �l ��,
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
SITE CLASSIFICATION: /'� EVALUATION BY:
�
LONG-TERM ACCEPTANCE RATE: � > OTHER(S)PRESENT:
REMARKS:
LEGEND �
Landscape Position
R-Ridge S-Shoulder L-Lineaz 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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
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(unsui[able) •
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
DC�ID OS/99(Revised) i
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