1388 Liberty Church Rd � , ' , DAVIE COUNTY HEALTH DEPARTMENT �� 'Q•_ �I
• , � Environmental Heaith Section �
P.O.Boa 848/210 Hospital Street
lv
Mocksville,NC 27028
(336)751-8760
Account #: 990002058 Tax PIN/EH#: 5812-37-2689
Billed To: Michelle Callahan Subdivision Info:
Reference Name: Location/Address: Liberty Church ROad-27028
Pro osed Facilit : Residence pro ert Size: 1 acre
ATC Number: 3016
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWAT O ST CTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /dGC Date:,/� ��� ��_
CERTIFICATE OF COMPLETION
**NOTE** 'I'he issuance of this Certificate of Completion shall 'ndi te the system described on Improvement/Operation Permit
has been installed in compliance with Article 1 f G. .Ch ter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY tak s a ar tee that the system will function satisfactorily for any
given period of time. .
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Septic System Installed By: �./.��(/�1�
Environmental Health Specialist's Signature: Date: p2� `�(� ��
DC�ID OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
` ����-� - Environmental Health Section � � � !� � � �/�
• ,.�` P.O.Boz 848/210 Hospital Street �
� Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002058 Tax PIN/EH#: 5812-37-2689
Billed To: Michelle Callahan Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27028
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 3016
**NOTE**T'his ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION 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 #People #People/Shift #Seats Industrial Waste: ❑
Lot Size /�(� Type Water Supply� Design Wastewater Flow(GPD)S�r ii� r� Site: New�Repair❑
�
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Widtt���Rock Depth��Linear Ft.1�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROV FLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of a ie 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 p.m.on t e of installation. Telephone#is(33G)751-87G0.****
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Environmental Health SpecialisYs Signature: Date: �� `���c/
DCHD OS/99(Revised)
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; .. . � �
,,,. '' ' ' ' QP?Ll�ATlUN FOR SITE El/ALUATION/IMPROVEMENT PERh�P� C� 2 '
Davie County Health Department r L� Q � �
Environmenta/Health Section ��
' P.O. Box 848/210 Hospital Street �(Q
Mocksville, NC 27028 � z Q 2QQl
(336)751-6760
4VVlRONM
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALI, H
INFOF2L�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructa.o
'i
1. Name to be Billed Contact Person J � Q,�1GZ/'V
Mailing Address I��10 � Home Phone ����0' '�9�' �q �
City/State/ZIP ✓1�1 � Business Phone �p" ��- � �p
2. Name on Permi.t/ATC if Different than Above
Mailing Address City/State/Zip
3. Application Fo=�Site Evaluation Improvement Permit/ATC ❑ Both
4. system to servicec � House �Mobile Iiome Business ❑ Industry ❑ Other
5. If Residence: � People � # Bedrooms � � Bathrooms - oLi
� X Dish»asher CI Garbage Disposal I�Washing Machine L1 Basement/Plumbing II Hasement/No Plumbing
/ ' /�
6. If Business/Industzy/Other: Specify type � # People # Sinks
N Commodes � Shoxers # Urinals # Water Coolers
IF FOODSERVICE: # Seats � � Estimated Water Usage (gallons per aay)
7. T�pe of water supply: - �5l County/City ❑ Well U Community
/
e. Do you anticipate additions or cxpansions of the facility this system is intcndcd to scrve? ❑Ycs �No
lf yes,w6at type? .
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION RGQULS'CGD
BELOW. Eithcr a PLAT or SITE PLAN MUST BESUBMI7TED by thc clicnt wiN�THIS APPLICATION.
Pro�crty Dimensions: �w�- WRI"I'l:UIRCCI'[ONS(from Mocicsvillc)to PliOPF.R'I'l': t
Tax O�ce PIN: # ����3� ��I� f�'�u �o D I �✓n. ���- ��
�
Property Address: Road Name��f 4 C f�- /�'� • (�i ber+u nlv K c�. ��..�o 'f'1-U�1 C5 D1V
c�riiz�P�l�.o�.r�����t �Ic, �70�.8' 1'i�h=�• o�o�a�-��L hrsr�le. I�oC�
If in a Subdivision provide information,as foUows: �i htr F�. �.fi. K�(,
Name:
Scction: Block: Lot: Datc Property Flaggcd: ��Z7'b j
This is to certify that t6e information provided is correct to the best of my knowledgc. l undcrstand tliat any permit(s)
issucd hercafter are subject to suspension or rcvocation,if thc sitc plans or intcndcd usc change,or if thc information
submitted in this application is falsified or changed I,alsn,rurderstand thut I a�tr respo�tsible for ri!/clturges i�rctrrred fro�u
t/ris application. I,hereby,givc consent to thc Authorized Representative of the Davic C unty Healti�Dcpartmcnt
to cnter upon above described property located in Davic County and owncd by �(�,�d�(, ��ulY-+- � x� a�ru.rJ)
to conduct all tcsting proccdures as neccssary to dctcrminc tl�c sitc suitabi 'ty.
DATE II- o�CO-O� � SIGNATURE
THIS AREA MAY BE USED FOR DRAWIIYG YOUR SITE PLAN(Includc all of thc following: Existing und proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Cl�argc
� Datc(s):
� Clicnt Notification Datc:
�
EHS:
' � � , ��, .
�� !�- Account Na ����
` �� �'�..,/
�._..1 �' ,
Revised DCHD(07/99) s ` - 't_;`���\ Invoice No.
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� • DAVIE COUNTY�IEEAI,TH DEPARTMENT
, • = �•. �. �' . Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002058 Tax PIN/EH#: 5812-37-2689
Billed To: Michelle Callahan Subdivision Info:
Reference Name: Location/Address: Uberiy Church Road-27028
Proposed Facility: Residence Property Size: 1 acre Date Evaluated: /���J�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition .L;r` L '
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON II DEPTH � '� � �'
Texture rou
Consistence
Structure �2�
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 ,
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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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