987 Liberty Church Rd . � �" ��.
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r.o.sog sasmo x�p��i sc��t
Mocksville,NC 27028
(336)751-8760
Account #: 990003382 Tax PIN/EH#: 5812-21-9752
Billed To: Sherrill Brinkley Subdivision Info:
Reference Name: Location/Address: 987 Liberty Church Road-27028
Pro osed Facilit Residence. Pro ert Size: 64.5 acres �
ATC Number: 3903
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 ' n.1900 wage Treatment and Disposal Systems). T�IIS
AUTHORIZATION FOR WASTE AfiER CO CTI I ID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signatur : Date: �
i
` CERTIFICATE OF COMPLETION
*���OTE** The issuance ofthis 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
C�a given period of time.
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Environmental Health SpecialisYs Signa e: Date:�� �
DC�-ID OS/99(Revised) � _
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
� 1 P.O.Boz 848/210 Hospital Street ✓ ���
c Mocksville,NC 27028 �� ,
(336)751-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003382 Tax PIN/EH#: 5812-21-9752
Billed To: -Sherrill Brinkley Subdivision Info:
Reference Name: Location/Address: 987 Liberty Church Road-27028
Proposed Facility Residence � Property Size: 64.5 acres
ATC Nurpber: 3903
**NOTE** Th�s Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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 ��s�. #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 ���'\�'�ype Water Supplyltit�►�i7 Design Wastewater Flow(GPD)��( ei`� Site: New� Repair❑
r� �r �/ �
System Specifications: Tank Size��QGAL. Pump Tank GAL. Trench Width � Rock Depth �2 Linear Ft. 7`�
Other: � 1/J��T�L���/�G�Gr��
Required Site Modifications/Conditions: /i Vh�'-/� � � �SU� �fl�� ''
11�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe 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(33G)751-8760.****
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Environmental Health Specialist's Signature: '� Date: �� 1
� ;
DCHD OS/99(Revised) `
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, � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT �p �
�` Davie County Health Department �� � � [��
Environmenta/Hea/thSection U �
P.O. Box 848/210 Hospital Street � � :
Mocksville, NC 27028 � �CT ��- �i�04
(336)751-8760 ` 1
� . ***IMPORTANT*** THIS APPLICATION CANNOT BE P&OCESSED UNLESS LL TH ��i � �(jH
� INFORMATION IS PROVIDED. Refer.to the INFORMATION BIILLETIN for
1. Name to be Billed � � �r��[ / !\ • �U Y'//IP/\. /E� Contact Peraon S AM e :
Mailing Addresa P a • L� � � � T � � Home Phone / �/—c>��—�S� d
City/State/2IP V d � N S V i ��� _ �V` ��i���Busineas Pho� ?� `�� � � 1 /� �/
' 2. Name on Permit/ATC if Different than Above .S °` h Q
Mailing Addresa City/s�a��� � �
/r '
3. Application For: f� Sits Evaluation L� Improvement ermit/ATC ❑ Both
4. syatem to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requeated: � Conventional ❑ conventional modified ❑ innovative
� � 6. =f Residence: # People ot # Bedrooms 3 # Sathrooms 3
�Diahwashar ❑Ciarbage Diaposal ��Washing Machine �Basement/Plumbing ❑easement/No Plumbing
7. If Busineas/Industry /Other: verify type # People # Sinks
# Commodes # 3howers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimatad Water IIsage (gallons par day) .
e. Type of water supplys � County/City ❑ Well ❑ Community
9. ao you anticipate additions or expansions of the facility this system is intended to serve? �Yes ,�No
If yes,what type�
***IMPORTANT''`**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. '
Property Dimensions: � `f �7 � C' rr'S W�ic�E D�R�e I L[�frim Moc�tie)�PRO���Yf LX
(p N .�
Tax Office PIN: #�g � ��o� � '— � '7 S' � 2 f'��le C r.J �.e�
Property Address: Road Name / g � L >,�,r.� � � � r� �
City/Zip /vI C� �l�.s U i�ff. , /I/ ' � '� d � �
If in a Subdivision:provide information,as follows:
Name: ���
Section: Block: Lot: Date home corners t]agged:
�� l. sJ � y
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
'issued here�fter are subject to suspension or revocation,if the site plans or intended use change,or if the information �
submitted in this application is falsified or changed. I,also,u�iderstaiid t/iat I am responsible for al[cllarges incurred from
t/iis application. I,hereby,give consent to the Authorized Representative of the Davi County Healt epartment ,/
to enter upon above described property located in Davie County and owned by 5 e rYi �� �• Q Y I N I�[ � ' �
to conduct all testing procedures as necessary to determine the site suitability. �
i � � '.
DATE �D C.�'a b�� I I .Z� � � 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 locations).
. Site Revisit Chargc
' Date(s):
Client Notification Date: ,
_ EHS:
`�. �3 � � :
Sign given - �� Account No.
Revised DCHD 05/03 � �
Invoice No.
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, � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
� _ Soil/Site Evaluation .�___
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003382 Tax PIN/EH#: 5812-21-9752 :
Billed To: Sherrill Brinkley Subdivision Info: .
- Reference Name: - Location/Address: 987 Liberty Church Road-27028
Proposed Facility: Residence, Property Size: 64.5 acres Date Evaluated: �� 1 f�
�
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 � r ( - (2 ��
Texture rou . iGL 5;C.c..- i CE, �GL
Consistence � .r � < S
Structure 1t
Mineralo
HORIZON II DEPTH �� '" �� ( —?jp 2�
Texture rou :C., 'C.. 'C � 4
Consistence ;S � ;
SWcture � �
Mineralo %k �.�3X, �
HORIZON III DEPTH �'�" -� Q —
Texture rou G� • {-
Consistence ��
Structure _ ,� c�
Mineralo L� �
HORIZON IV DEPTH --
Texture ou .�, (�
Consistence C S S
Structure �
Mineralo S
SOIL WETNESS
RESTRICTIVE HORIZON '
� SAPROLITE
CLASSIFICATION .'
LONG-TERM ACCEPTANCE RATE O� . a•Z�' � .
SITE CLASSIFICATION: PS EVALUATION BY: ����]�c1C%i't''�'V
LONG-TERM ACCEPTANCE RATE: ����' O�3 OTHER(S)PRESENT:
Q� 1.., ` , �K� � .� _' ', . �, fi n,�� �1 . '1
REMARKS: �` tt
LEGEN �
Landscape Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
Moist _
CONSISTENCE
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
Mineraloev
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fi11-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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