245-247 Knoll Crest Rd DAVIE COUNTY HEALTH DEPARTMENT
.•_ � ._ Environmental Health Section
• .-�., � ' P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028 �� )���`?,'c%J'
(336)7.51 87G0 �� ��
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' IMPROVEMENT/OPERATION PERMIT
Account #: 990Q02012 Tax PIN/EH#: 5757-01-2730
Bilied To: Donafd Leonard Subdivision Infa ,
Reference Name: LocatioNAddress: Knoll Crest Road-27028
Proposed Facility: Residence Property Size: 5 acres
ATC Number: 2987
**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 I5 SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT 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� Design Wastewater Flow(GPD)�_ Site: New�Repair❑
System Specifications: Tank Size/��GAL. Pump Tank GAL. Trench Width�' Rock Depth���Linear Ft.3��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMTT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 y of installation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist s Signature: % Date: /� ��� 3 "!�I
DCHD OS/99(Revised) ,
��il..
. ' � �' ' ' . DAVIE COUNTY HEALTH DEPARTMENT
' - � Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002012 • Tax PINlEH#: 5757-01-2730
Billed To: Dona(d Leor�ard Subdivision Info:
Reference Name: LocatioNAddress: Knoll Crest Road-27028
P osed Facilit : Residence Property Size: 5 acres
ATC Number: 2987
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). T'his 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 WASTEWAT C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � Date: � ;�'��
CERTIFICATE OF COMPLETION
**NOTE** �e 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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Se tic S stem Installed B : C-�6 �Z�"v
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Environmental Health SpecialisYs Signature: Date: ��-'�'��
DC�ID OS/99(Revised)
� �. .,, _��� � Q `f � LICATION FOR SITE EVALUATION/IMPROVEMENT PEfi611T&ATC .
� Davie County Health Department
OC.� ' 2 2U�� Environmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
ENVIRONMENTA�HEALTH (336)751-8760
DAVIE CQUN?Y
***IMPORTANT*** TFiIS APPLICATION CANNOT BE PROCESSED UNLESS �ALL THE REQUIRED
INFORMATION IS PROVIDED. fer to the INFORI�TION BULLETIN for instructions. �
1. Name to be Billed � � Contact Person ✓ ���
Mailinq Address ��t�/U��/( ��`7� /PG1 �,/ Home Phone ����/�(J" ^'�v V
City/State/ZIP f��n �f�(Lr���� /V�� „//Q�C O Business Phone '7 S ,��_/�f- ��� S
2. Name on Pesmit/ATC if Different than Above
Mailing Address City/State/2ip
3. Application For: 0 Site Evaluation p Improvement Permit/ATC sth
4. system to sezvice: ❑ House' L�'Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People z # Bedrooms 3 # Bathrooms �_
�hwasher O Garbage Disposal U Washing Machine ❑ Basement/Plumbing II Basement/No Plumbing
6. If Business/Industsy/Other: Specify type # People # Sinks
�! Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estiniated Water Usage �gaiions per day)
7. T�pe of water supply: � County/City I��r+Tell l.l Community
e. Do you anticipatc additions or expansions of thc facility this systcm is intcndcd to scrvc? ❑ Ycs �
lf ycs,what typc?
***IMPORTANT***CLIENTS MUST COd�PLETETHE REQUIRED PROPERTY INrORMATIOIV Ii[:QUESI'CD
BELOW. Either a PLAT or SITE PLAN MUSTI3ESU6MI7TED by the clicnt with THiS AI'I'LICATION.
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Property Dimcnsions: ��`�� WRITG DIRCCI'(ONS(from Mocksvillc)lo PROPGR'fl':
Tax Officc PIN: #�� �� 1 � � � � .�. b d/ �� ��/���ll d 1�'1 �"�
Property Address: Road Name (l /l� !�//�/��S � T`Q ��A�/L7� �'� �� /L iV0 l/�/'�,s'�
/ i . I / J
: City/zip D�lC 4 t/j ���/V�,. (�/� k�G� � GI b 70 �/1l�G .�'�
�" � r �
If in a Subdivision providc information,as follows: ,U� l�� G�f�1�G� l+�!T f �G`'�
r
Namc: _ J 1� �/��/� �iQ�
Scction: Block: Lot: Datc Property Flaggcd: ������o��
This is to ccrtify that thc information providcd is corrcct to thc best of my knowlcdgc. 1 undcrstand thut any permit(s)
issucd hcrcaftcr are subjcct to suspcnsion or revocation,if thc sitc plans or intcndcd usc cl�angc,or if thc informalion
submitted in this application is falsified or changed I,also,rurderstaud tkat I nut responsiGle jor rr//chcrrges ivairred f'ront
11:is application. l,hereby,give consent to thc Authorizcd Rcprescntative of tl�c Davie County 1-icultl� Dcp.u•tmcnt
to enter upon above dcscribed property located in Davic County and owned by
to conduct all tcsting p occdures as ncccssary to dctcrminc thc sitc suitability.
DATE (U �/ V� SIGNATUR� ����'���� L .•
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of thc following: Existing and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Cl�arbc
�
l Datc(s):
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Clicnt Notification Datc:
� EHS:
� O Account No. v�/ �`
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• ;. �� - DAVIE COUNTY HEALTH DEPARTMENT
- ' " � ' Environmentoi Health Section '
' ' '� � � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002012 Tax PIN/EH#: 5757-01-2730
Billed To: Donald Leonard Subdivision Info:
Reference Name: LocatioNAddress: Knoll Crest Road-27028
Proposed Facility: Residence Property Size: 5 acres Date Evaluated: 1.3��/_
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure -
Mineralo
HORIZON II DEPTH ' %' 6�'
Texture rou
Consistence j
Structure /
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo •
HORIZON IV DEPTH
Texture ou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , �
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 1� 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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo¢v
l:l,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 wemess-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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