152 Lonesome Dove Ln . -- '
DAVIE COUNTY HEALTH DEPARTMENT
� ---' Environmental Health Section
' � P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003547 Tax PIN/EH#: 5850-33-9534
Billed To: David White Subdivision Info:
Reference Name: Location/Address: 152 Lonesome Dove Lane� •27028
Proposed Facility . Property Size: 47 acres
ATC Number: 4041
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE ARS.
Environmental Health Specialist's Signature: �� Date:
L/.3 '
,
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 taken as a guazantee that the system will function satisfactorily for any
given period of time.
� ��m����
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Septic System Installed By: (���,,.. ��Q�j�u� (
Environmental Health Specialist's Signature: _ � Date:
DCHD OS/99(Revised)
, . • DAVIE COUNTY HEALTH DEPARTMENT �
Environmentai Health Section � /�o_ °5
• . P.O.Boz 848/210 Hospital Street �� ��
; � ; - Mceksville,NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003547 Tax PIN/EH#: 5850-33-9534
Billed To: David White Subdivision Info:
Reference Name: � Location/Address: 152 Lonesome Dove E.����,:`�v-?7028
Proposed Facility g a r n ` �- �- Property Size: 47 acres �
ATC Number: 4041
**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 l l.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 1NTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type_ ,�j #People #Bedrooms___����#Baths �
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
� C
Lot Size C Type Water Supply� Design Wastewater Flow(GPD)�� Site: New❑ Repair❑
�/
System Specifications: Tank Size�AL. Pump Tank GAL. Trench Width�`�Rock Depth� Linear Ft�
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTtCE: 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 p.m.on the day of installation. Telephone#is(33G)751-8760.****
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Environmental Health S ecialist's Si ature: ���G Date: "�`
P �
DCHD OS/99(Revised)
. . � .
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. . � lU1 � U l'! la �..5�"„' ,
� D APPLI T FOR SITE EVALUATION/1M1iPROVEhfEM'PGi611T&ATC r ,� �.�-
-- :Davie County Health Department �`"— .
MAR 2 8 2005 Environmenta/Hea/thsection
.0. Box 848/210 Hospital Street
EJ�MMRONMENTALNEAIT}1 • Mocksville, NC 27028 1 S •
UAVIECOUNTY (336j 751-8760 �,� �
***ItlPORTANT*** THIS APPLICATION CANNOT BE PROCES5ED UNLESS ALL TIi� R�QUIR�D
TNFORMATION I5 PROVIDED. Refer to the INFORZdATION IIULLETIN for inatructiona.
�r t CL'
1. Namcs to be Dilled ���/j��h��� Contact Pernon p��/r/1/�,q�,)nf `j��-
Mailing Addresa �/r �Q��U iC }fome Phone ����-9 j�-_3R�/
City/Stato/ZiP _�1�'f��f�s�rr1l� /�'G �`I��� Businesa Phone 3�G-99S=�/��
2. Name on Purmit/ATC iP Dif£erent than 1�bove �
Mailing Addreas �Sf�� City/State/Zip ��m/�
3. Application For: ❑ Sita Evaluation '�1 Improvemen� Permit/ATC oCh
4. syatem to service: O House ❑ Mobile Home ❑ Business 0 Indus�ry {�J Othe ��,qtn�
5. Typa ayatem requested: ❑ Conventional ❑ convantional modified ❑ innovativo ���J ���(Y wc�S
6. If Residence: � PQople # Bedrooms N Batihrooms �_ 'F' �'�
Pr..�..�
❑Dishwasher ❑Garbage Diaposal ❑Wauhing Machine ❑Sasement/Plwnbing ❑Dasemant/27o Plumbing
7. if Businesa/Induatry /Other: verify type �� # Peoplo 1� Sinka �
# Commodes _�_ # Showors �� # Urinals II Wator Coolara
IF FOODSERVICE: # Seats Estimated Water Usaga (qalions per day)
8. Type oE water suppiy: � County/City �Well ❑ Community
9. Do You anticipate additions or capansions of thc facility this systcm is intcndcd to scrvc? �Ycs �No •, ._ _
Ifycs,�vliat typc?
' ***I11�1PORTANT***CLILNTS�11UST C0�11PLETETiIG RL•QUIRED PROP�RTY INrOIi11�IAT10N R�QUGSTGD
BELOW. Cithcr a PLAT or SITC PLAN A1UST BESUBAf1TTED by thc clicnt �vith TJiIS APPLICr\TION.
Propci•ty Dimc�isions: .�4�'i Acr�s \VRITG DIRCCTIONS(from Mocicsviltc)to PROPCRTI':
Taa orr,��rirr: f� S g S � ��� 3 � `��3 � J� £! � � w�, .✓ ��
Property AdJress: Road Namc /h"� �n,✓r�s�m� 7��v��W C�o s� G w� �/'��
, �
� . C;ty/Zip %'Vlocic s v;ilr N� �'2�' �� r.oL G�!`� �',� a ,� f 1
If in a Sabdivision providc iiiforn�ation,:is foll
Namc: � ��
Scclion: Block: Lot: Datc homc corncrs ilabecd: .���'��
Tl�is is to ccrtify tliat tlic iiiformation providcd is corrcct to tlic best of my kiioivlcdgc. I undcrstand tl�at any perinit(s)
issucd licrcaftcr are subjcct to suspcnsion or rcvocation,if tlie sitc plans or intcnded usc cliangc,or if tl�c iufornu►tion
subn�ittcd in this applic�tion is talsiGed or changed. I,also,�utderstanrl llrat I ain respousiLlc jor a!!cbarges irrctirred jruur
tlris npplicalio�r. I,IicrcUy,givc cotiscnt to tl�c AuUiorizcd Rcprescntativc oC tlic Davic Counly IIcaltli Dcparti�ic►it
to cntcr upon�bovc dcscribcd property located in lla��ic County 1�id otivncd by
to conduct all testing proccdw•cs as ncccssary to dctcrminc;tlic sitc suitability. -
DAT��, .��P 'd� SIGNATUIt� � A�lt� /Kr�vc'
. , r .
TIiIS AItEA MAY B�US�D.rOR DRAWING YOUR SIT�PLAN(Iucludc all of thc follotiving: �xisting�nd proposcd
property lines and din�ensions, structures, setbacics, aud septic loc:►tions).
� Sitc Rcvisit Char�;c
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� . Dacc(s):
�.s�,_,,w c S ti� / ,J � G Clicnt Notific�tiou Datc:
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, r'' �� . APPUCATION FOR SITE EVALUATION/IMPROVEMENTS PER 2 � 2 ��/]2
� Davie County Health Department D L5 L5 v L5
� � Environmental Health Section
. P. o. soX sss MA� 2 2 1996
�' ` . Mocksville, NC 27028
1. Apptication/Permit Requested B
� � r
Mailing Address��O �Cy� rst. S(,�G(. Home Phone 7[O�-3�l
,(��rk5v.��E.' �J. �_ .7 I�z� Business Phone ��1� '3�/ �
2. Name on Permit if Different than Above '
3. Appitcation for: ❑General Evaluation �Septic Tank Installatfon Permit
� 4. System to Serve: �House O Mobile Home p Place of Public Assembly
� ❑ Business ❑ Industry ❑ Other p Unknown '
5. If house, mobile home: Subdivision Section Lot #
. 0 BasemenVPlumbing
No.of People � � BasemenUNo Plumbing
No.of Bedrooms�3 L�'Washing Machine
No. of Bathrooms � O Dishwasher
Dwelling Dimensions yn� k �p� � p Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No.of People Served No.of Sinks
No. of Commodes No.of Urinals
No. of Lavatories No.of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Pubiic E�Private p Community
8. Property Dimensions -3 Qc�l�c.s Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem Is intended to serve? ❑ Yes l�No
if yes, what type?
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: PROPEIZT� IN�'OIZ,t�tTZON REQUZItEb:
�5$ -f-o ��1�� 1� e�nSS cu�
CI qe,�� Tax Of f i ce PZN: # ��QU(�(y.�p f�
I ► PIZOPERTJ AbbRESS� as foiiows:
�IIJA ����- �'N r����" Road Name:
�v ���.�tl
cL t�: /1/1c�cl�su� [(� �
SU$MZT A PLtiT WITH ?HIS APPLICttTTON.
(��,� (�� Revisions effective October 1� 1995.
V 1 �nj
This is to certify that the information provided is correct to the best of my knowledge,and I understand I am responsible for ali charges
incurred from this application. .
.,�1����, .z� P� ��:.� �1,�.`��2_��.�
DATE SIGNATURE
CONSENT�SITE EVALUATION TO BE DONE ON ABOVE DES RIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. Ca 2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct ali testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
m.��i ��. �1 � _ ` ` •
DATE SIGNATURE .
ocNo c�re3)
�,
, �� . .. � _ � . - � � �.
• . •
, . ; • ' Davie County Health Depart�ent
• � ENUIRONMENTAL HEALTH SECTIDN
; � � P.O. Box 66�
Mocksville, N.C. 2702b �
� AUTHDRIZATIDN FOR WRSTEI�qTER SYSTEM CONSTRUCTIQJ
iIssued in co�plian�e with Article 11 of
G.S. Ghapter 1'sOR, Wastewater Syste�s) �
+�*+�This fluthorization Fnr Waste►+ater Syste� Construction wst be issued by the Davie County Environ�ental Health Section prior� to
issuance of any Building Per�its. This For�/Authorizatian Nu�ber should Ge presented to the Davie County Building Inspections
Dffire v�hen applying for Building Per�its.+�+�
���i �� �// � L/ �, i�� naJT}�RIZATION't�!9ER
F1RlE /C T ��/7/ i f' DATE �/ c�_S✓/�� � d� t 1 . (f :i
NAlE ON IIPROVQ�NT PERNIT iIf different than above)
SITE LOCATI�! �/Lt I�✓ ��'`�
COM�NT5/C0�@I7IQr5 aV RUTFI�RIZATIQr TO [�NSTRUCT I�RSTEWATER SYSTEM
�TICE� THIS AU'THORIZATION FD�A5TE41ATER 5Y5TEM CONSTRIICTION IS VALID FOR R GERI�D OF FIVE i5) YEARS.
:+.:, �S. �� 1%
a :�%/. �
'�'` ENVI AL FEAI.TH ALIST
�,�`'• , ��
W`:� °DCHD 10/95 .
�.�. .i.�'� �� � �i� � .Y l M1i:' Y _5.I"�Ri:Y�W�'iNV/i(�Sif.w.4`N�bS�vwSa���k.y1L��...u.',t'if1�lY�dLlIrilAy�.4t.wi'1w♦ .i•r'�r��ttS�'L.'.�:�.��LS�Litl►i'�.•:,�r.ia.,._:I�+�tlFrl..
"�`�'"'"`''S�t I�i�S"��It1 e�C�n� t�ri��"9lT�iii f�rlc�bi�1�t: ..
I
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IMPRDVEMENT GERMIT BY /��. ��
f�CONTACT A f�PRESENTATIVE OF THE DAVIE COUNTY HEAI.TH DEPARTMENT FOR FINRt. INSPECTION OF THIS SYSTEM 8ET{JEEN
B:30-9:30 A.M. OR 1:�-1:30 P.M. ON TF� DAY OF INSTRLLATION. TELEPHONE � IS (704) 634-87E0.
�ERATION PERMIT SYSTEM INSTALLED BY
. �
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AUTHORIZATION N0. DPERATIDN PERMIT BY DRTE
f*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOUE HAS BEEN INSTALLED IN COMPLIf�iCE NITH
AATICLE 11 OF G.S. CHAPTER 130A, SECTIDN .19� "SE41�E TREATMENT AND DISPOSAL SYSTEMS'� BUT SHALL IN NO WAY BE TAKEN AS R
(�1ARANTEE THAT THE SYSTEM WILL FIq�TION SATI5FACTORILY FOR ANY 6IVEN PERIOD � TIME.
DCHD 10 �95
� , .. ..
' � DAVIE COUNTY HEALTH DEPARTMENT
"-�� ' Environmental Health Section
+�� ` +. Soil/Site Evaluation
NAME :DATE EVALUATED �/�T/�
ADDRESS . PROPERTY SIZE �7S�TC
PROPOSED FACIILTY /��S�r LOCATION OF SITE �iJli`�.�
Water Supply: On-Site Well �' _ Community Public
Evaluation By: Auger Boring � Pit */ Cut
FACTORS 1 2 3 4
Landsca e osition L, L .L �-
Slo e 7.
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �` �'0 � `' �` ''
Texture rou �
Consistence r �
Structure �
Mineralo
HORIZON III DEPTH i
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: G EVALUATED BY: �/'7Lr�i �
LDNG-TERM AC PTA E 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 �:lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-V=�.-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely finn
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structuro
,iC--5ingle grain M-Massive CR-Crumb GR-Granular ABK-AnQulsr blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mi neraloicy
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 w etness - Inches from land surface to free watec' 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'Yftz
�DCHD(01-901
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