300 Lutz Ln (3) , DAVIE COUNTY HEALTH DEPARTMENT � f— � v /
' : - • Environmental Health Section
r.o.sog sasnio x�p���sr��t
Mocksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001411 Tax PIN/EH#: 5832-61-8751
Billed To: Wayne Lutz Subdivision Info:
Reference Name: Location/Address: 300 Lutz Lane-27028 .
Proposed Facility: Residence Property Size: �a,+ �an,
**NO'T�**'I`tiib�mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION FOR WAST'EWATER 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 PERNIIT 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 Ob��c Type Water Supply �l� Design Wastewater Flow(GPD) ��/0 Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��Rock Depth� Linear Ft:���
ocn�: �.,,��,� l/`�- � � � '�(�'r-�
Required Site Modifications/Conditions: �+�'' �
,,
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the 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. the a of installation. Telephone#is(336)751=87G0.****
. �
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Environmental Health S ecialisYs Si ature: Date: ��� � � �
p � � �
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001411 Tax PIN/EH#: 5832-61-8751
Billed To: Wayne Lutz Subdivision Info:
Reference Name: Location/Address: 300 Lutz Lane-27028
Proposed Facility: Residence Property Size:
ATC Number:
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmen.tal
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie Counry 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: --- - �""� Date: �( � ' �a
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. hap 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be t as a a ee that the system will function satisfactorily for any �
given period of time.
lao er+��
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Septic System Installed By: �/ �'1 Gl /J7/)'1 c��S �
Environmental Health Specialist's Signature:�/Y(;[/� Date: �0 � -!�U
DCHD OS/99(Revised)
. �' �" -
APPUC,ATION FOR SifE EVALUATION/IMPROVEMEf�iT PERMIT&AT � � � � � u �
• • Davie County Health Department
Environmenta/Hea/tlt Se�ion S� � 8 Zd��
P.O. Box 848/210 Hospital Street
Mocksnille, NC 27028
(336)751-8760 ENVIRONMENTAL HEAITH
DAVIE COUNTY
***I1�ARTANT*** THI3 APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQIIIRED
INFORI�ATION I3 PROVIDED. Refer to the INFORI�ATION BULLETIN for instructions.
i. rr,� to � siiioa ��}yytl� /_ u?Z Contaat Poraon ��th7E
Msilinq ]►ddsaaa �(7[� L(�Z L,� Home Phone �33�- 9 Q 8-�/6 /
City/8tata/ZIp /��'kSU/LC�,.�, �'l/C.' �`70Z� Busineee Phone � Q�✓N E
2. Nama on Pesmit/l►TC i! Diflorent thaa I►bova
Mailiaq llddrass City/ te/Zip
3. Appiication For: fYSite Evaluation Improvement Permit/ATC Both
a. sYstsm to sor,.ica: � House �Iobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: � PeOple t Bedrooms � � Bsthrooms �
O Dishwaaher fJ Gasbaqa Disposal htaahing Machine (1 Saeament/Plumbing (J Sasament/No Plumt�inq
6. I! Husinass/Industry/Othor: Spoaily type # People � Sialca •
• Commodos � Showara � Urinals � Water Coolera
IF FOODSERVICE: # Sests Lstimated Water U9age (qallone par day) �
7. Type of aater supply: 0 County/City Tell D Community
e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes �� . ,
• If yes,w6at type?
***IMPORTA/VI�**CLIENTS MUS7'COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by t6e clieot with THIS APPLiCATION.
Property Dimensions: �b�f A G WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Ta:Of�ice PINe # _'�832 -��- ��S� �b/ �✓ TO eA/V+4 ��
Property Address: Road Name L �r z LI�/ y�/z 1�]�c.fS o.v �� N�4
City/Zip 1°Y10 C,�.''v/L l� r/G h"T ON L✓�'z Lli�
2 7 n z�j ��E o �7-
If in a Subdivision provide information,as follows: .�/?� 7� �c'T �F ,�",/'/S T�Nb
Name: _y�'1 U /3 L£, I-� G�'l E
Section: Block: Lot: Date Property Flagged: ��� / /� a
This is to certify t6at the information provided is correct to the best of my l�nowledge. I understand t6at any permit(s)
issued hereafrer are subject to suspension or revocation,if the site plans or inteaded use change,or if t6e information
submitted in t6is application is faisified or c6anged I,also,understand that I a►n responsible jor all charges incarred from
tkls application. I,6ereby,give consent to the Anthorized Representative of the Davie County Healt6 Department
to enter upon above described property located in Davie County and owned by l�tl,,�.�� � !/�7
to conduct all testing procedures as necessaty to determine the site suitability.
DATE %- 1�" �d 0 V SIGNATURE �
THIS AREA MAY BE USED FOR DRAWING YOiTR SITE PLAN(Include all of the following: Ezisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
� Site Revisit Charge
� Date(s):
�� ��- Client Notification Date:
� t� ! EHS:
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DAVIE COUNTY HEALTH DEPARTMENT
� . ' " • Environmental Health Section SECTION LOT
SoiUSite Evaluation _
APPLICANT'S NAME r��'�� �Z DATE EVALUATED /D �Z -Z�U
PROPOSED FACILITY PROPERTY SIZE �f�iC'
SUBDIVISION � ROAD NAME �C[�2 L�—
Water Supply: ' On-Site Well � Community Public
Evaluation By: � Auger Boring Li� Pit Cut �
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH " �
Texture rou �
Consistence �
Structure
Mineralo
HORIZON II DEPTH '� '�
Texture rou �
Consistence '
Structure . / ,�
Mineralo ,r
HORIZON III DEPTH "
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture ou
Consistence
Structure
Mineralo -
SOIL WETNESS
RESTRICTIVE HORIZON :
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE "
SITE CLASSIFICATION: � �� � �� EVALUATION BY: � /
LONG-TERM ACCEPTANCE RATE: , � OTHER(S)PRESENT:
REMARKS: ���5'��1't'N ���/�f��
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
,
is
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
Mineralog�
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(01-90) �� �
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