1110 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �� 3/� � ' � /
' _ ,"' , P.O.Boa 848/210 Hospital Street < <
- , Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001589 Tax PIN/EH#: 5812-34-8130.gc
Billed To: Gary Cleary Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2729
**NOTE** This Improvement/Operation Pecmit 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
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �7' #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 U�c Type Water Supply�_ Design Wastewater Flow(GPD) a�o a Site: New❑ Repair❑
,� �
System Specifications: Tank Size l�7�1 GAL. Pump Tank /��GAL. Trench Width�� Rock Depth� Linear Ft.l�
oth�: �"s� ;���s ���,� 1,a�-�
Required Site Modifications/Conditions: io�/ h�'� �le ` �`Pl� 'l S i /'C ,�h�
IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30�.m da of installation. Telephone#is(336)?51-8760.****
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Environmental Health SpecialisYs Signature: Date: c���1`�
DCHD OS/99(Revised)
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' • DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
r.o.Bog sasmo x�p���sh�t
Mocksville,NC 27028
(336)751-8760
Account #: 990009589 Tax PIN/EH#: 5812-348130.gc
Billed To: Gary Cleary Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2729
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 WASTEWA C NS UCTION IS V D OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �..�J��
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 talcen as a guarantee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: /"'��G�r/'��
Environmental Health SpecialisYs Signature: i���/ --- --- Date:�/��l`�`'r�
DCHD OS/99(Revised)
. �.� _��', APPLICATION FUR SITE EVALUATION/IMPROVEMENf PERMR&AT
. . ' Davie County Heaith Oepartment D � � � � � �
Envdronmen�l Heu:/tfi Se+r�ion
P.O. Bo: 848/210 8ospital Sts�et ,
. Mockaville, NC 27028 • ��� I� �I ��
(336)751-8760 ,
***IMt�ARTAI�IIT*** THIS 718PLZCATION CANNO? 9� PROC688SD VIRa$S 11LL Ha Ra�tRldIENTALHfAI�
INFORbATION I$ pRaVIDaD. R�f�r to th� IND'OR�ATIOZt HULLETIN tor fAUN1Y
1. x.a. to b. sill.a n� e ar..oue.oc a.s.on �v-t-�.'C l�.i �CiJL1WJ l�J�^
�� �... 1'1� ��?���; ��a�� �� sa. �. 7�'I -�,o�b
��]r/sc.c./szp 1' L��P 1�Z S�� \,'�i �� d-70a-� su,sA... Phon. _��� 'S t�� D
2. Itas� os► p�sait/71TC i! Di!l�r�t th� ]1bo��
ltailinQ llddr��� CitY/8tiat�/Eip
a. !►pplication Sore � Sit� valuation ��s�ezst p�rmit/]1TC � Hoth
i a. er.c.� to s.�o.: 8�' ous• � Mobile Hom� O Husiness � Iadua O Oth�r
�Y
' s. _! it�sid�ac�: f peopie �' • Hadrooms ,�_ • Sa�throoms �
�'as.hwul�r p oarbaq� Di�po�al l9'Nu� �.�sA. o a...�..,c�ai�s� a s.,.�.nc�xo 'ri,�s�
6. It suai��s/I�du�try/Oth�rt 8p�oily typ� ! D�opl� � 81nks '
f Coavod�� � 8ho�r� � Uriaal• * K+tt�r Cool�r�
_�' a'OODSLRV=C�: � Ssa►ts aatimated Na�r Osaq� tvuloa. p.r a.Y�
7. �p� o! Kater supply: Couaty/City 0 N�.11 ❑ Community '
e. Do you anHcips�te addltIons or e�analoas of the facWty thts syatem L intended to�erve? O Yes 0 No
If yes,w6�t type?
**"IMPORTANT"**CLIENTSM[ISTC�OMPLETETHE REQU/RL�DI'ROPERTY INFORMATION REQUFSTED
BELAW. E[t6er a PI.AT or SITE PLAN MUST BE SUBMITTED by t6e tUent w�lth TN1S APPL1CATlON.
Property Dlmenslon�: �0�3 X � i� X 37a /� Gl�P�` WRITE DIRECTIONS(from Mock�ville)to PROPERT'Y:
Tu 08ice PQV: # � ���=3 1 " � �� U• 9'c F • a -F
Property Addreas: Road Name e �,� �� � � � G �
, Cicy/Zip�uc�C S��L�� �� l��✓ 1 C..< C h.-f; ,
V ia A Subdivision provide iuformaHon,as follows:
• Name:
Section: Block: Lot: Date Property Plaggeds '���"� �
This i�to certify tbat t6e intormallon pmvided ia con�ect to t6e best ot my kno�viedga I nnderstand t6�t�ny permit(a)
isaaed 6ereafter ere aubject to easpenaton or revceallon,if the eite pl�na or Intended aee e6snge,or if the informeHon �
enbmitted!n t61s�ppl[csHon i�faislfted or chunged. l,also,anders�and�hat I ant raporulbl�jor a/l cborges Jxcumd jroni
tbls oppltcallo�r. 1,6enby,give conaent to the AnthorFied Repreaentative o!t6e vl Coanty A �16 Depsrtmeat
to enter npon abave deacribed property located in Davie Coanty and o�vned bj►�
to conduct all teaNng procedara as necessary to determine the dte tnitabW .
DATE �1'� � '7 ^D I SIGNATURE
e
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include�ll of t6e folto�ving: Ezlating and proposed �
property Ilnes and dimena[ons, etractares, eetbacka, �nd sepde Iocallons).
Site Revlsit C6a'rge
Date(a):
, Cllent Notificallon Date:
EAS•
Account Na !��
Revised DCHD(07/99j Invoice Na �� � `� `'�
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� APPLICATION FOR SITE EVALUATION/IMPROVEJNENT PERMIT&ATC /�
� Davie County Health Department
�° 7 � il. Environmenta/Hea/ti�Section �Cr 2 Q
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C�� �•� � P.O. Box 848/210 Hospital Street ���?�
u�r rsocxsvi.11e, Nc 27o2s
� �, �� (336)751-8760
***I�ORTANT*** THIS APPLICATION C�IDTNOT BE PROCESSED UNLESS ALI, THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions.
1. Name to be Billed j�' /i�G�Gf�[--� (n/� ���'� Contact Person �����
Mailinq Addresa �� / CE���n� C./'�: Home Phone % /�^ � f7 ��
City/State/ZIP �(7� /�S�/���/[J �` �•. Busi.nesa Phone �� �'- �O ��� '�
2. Name on Permit/ATC if Different than Above
Mailinq Addreas City/State/Zip
3. Application For: B�ite Evaluation ❑ Improvement Permit/ATC ❑ Both
a. sYat� to service: �HouSe ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
s. xf Residence: p People oC A Bedrooms � # Bathrooms -�
.I`rDishxasher I:{.Gs�r�bage Diaposal ashing Machine '-�asement/Plumbing ❑ Basement/No Plumbing
6. IP Buaineae/Industry/Other: Specify type A People # Sinka
M Co�odes � Showers �1 Urinals * Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (qallona per a8y)
�. Z�pe of water supply: ❑ County/City B�ell ❑ Community
a. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �o
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with TH[S APPLICATION.
Property Dimensions: � ��� """"� WRITE DIREGTIONS(trom Mocksvillc)to PROPGRTY:
.� ! �� 3`� " �� 3 � ,J � � ,,, L� �.c�._.�-(
Tax Office PIN: # � � � (
�
Property Address: Road Name H.Bef�� C�-/� • s�"' ��-✓r'"� �"� ' ^5`~ T�''`"�������
��-^�— � �c.�t�t c..u[acc.F�''�-�-
City/Zip a�,ls . �r,!-�,.��.��.:�
. . �y.,..�-c ,CA s-L � w� — ���-0�'7
If in a Subdivision provide information,as follows: -e_-1- � o � �-� G-.�
�
Name: ��' � 7 ` VU /,"C'F R�--`".�'..' `� �, C�d r
/ / / ryx/t
Section: Block: Lot: � Date Property Flagged: ( �j a�J� ° �''="'�`
r�66+�
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) �!�
Lssued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the iaformation ,�.���Y
submitted in this application is falsitied or changed. I,also,understand that I am responsible jor al!charges incurred jrom
thls application. I,hereby,give consent to the Authorized Representative of the Davie County Healt6 Department r'r v-
to cater upon above described property located in Davie County aad owned by
to conduct alI testing procedures as�necessary to determine the site suitability. ,
DATE � l � Z��� SIGNATURE i��� L.✓C�%« �---
TfIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Egisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
� 6 �✓'r✓�- Date(s):
Client Notification Date:
EHS• .
Account No. l
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Revised DCHD(07/99) Invoice No. J
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DAVIE COUNTY HEALTH DEPARTMENT .
� � �° ' ' • � ' Environmental Health Section
. � �
. � Soil/Site Evaluation
APPLICANT INFORMATION - PROPERTY INFORMATION
Account #: 990001464 Tax PIN/EH#: 5812-348130
Billed To: Michael Wallace Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27028
Proposed Facility: Residence. Property Size: 3.41 acres Date Evaluated: /Y�'�.Z��l�
Water Supply; On-Site Well Community Public
Evaluation By: Auger Boring �/ Pit Cut
_ „ -b
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo e%
HORIZON I DEPTH '� ��
Texture rou � l''i!i (% S"G
Consistence
Structure
Mineralo '
HORIZON II DEPTH `� `� � �.
Texture rou �' �
Consistence � I -f
Structure ��-
Mineralo -� c�
HORIZON III DEPT'H
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: �/"\S - EVALUATION BY: �/
LONG-TERM ACCEPTA CE ATE: c- ' � ��v� OTHER(S)PRESENT:
� J �, m� ,
REMARKS: � `� ��y
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
oi
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
truct re
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloav
1:1,2:1,Mixed
otes
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
DC�ID OS/99(Revised)
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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
• Courier #09-40-06
� Mocksville, NC 27028
Phone #: (336)751-8760
October 27, 2000
Michael Wallace
199 Leanne Lane � '
Mocksville,NC 27028
Re: Site Evaluation/Liberty Church Road .
Tax Office PIN: #5812-34-8130 -
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
October 26, 2000. 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, .
�k������•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di �
Enclosure(s)