1390 Main Church Rd Ext i
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DAVIE COUNTY HEALTH DEPARTMENT
; �,,- � - ; Environmental Health Section � � _ 21-- �
� �� � - - P.O.Boz 848/210 Hospital Street �
, Mocksville,NC 27028
(336)751-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001892 Tax PINlEH#: 5820-83-6242
Billed To: Michael Johnson Subdivision Info:
Reference Name: LocatioNAddress: Main Church Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2986
**NOTE**This ImprovemendOperation Permit 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 PERMIT BEFORE INSTALLING SYSTEM.
Reside ial Specification: Building Type #People � #Bedrooms�_ #Baths �
,Dishwasher:� Garbage Disposa]X� Washing Machine:�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
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Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply L�� Design Wastewater Flow(GPD) ��� Site: Neyr.B�Repair❑ �
i
System Specifications: Tank Siz��GAL. Pump Tank GAL. Trench Width�1 Rock Depth���Linear Ft�Od'�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S IF 6��BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Dep or 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 installatio phoq�e#is( 6)751-8760.****
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Environmental Health Specialist's Signature: • � Date: -�� -�`�/
DCHD OS/99(Revised)
� �D .�..
, . � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001892 Tax PIN/EH#: 5820-83-fi242
Billed To: Micha�l Johnsan Subdivision Info:
Reference Name: LocatioNAddress: Main Church Road-27028
Pro osed Facilit : Residence Pro ert Size: see ma
ATC Number: 2986
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 C STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �d 2� �U l
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation 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
given period of time. �
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Septic System Installed By: � r e Y/JC G�
Environmental Health Specialist's Signature:� Date:��--�_���,� `
DC�ID OS/99(Revised)
�' �� fYla�l��•�a � �,Q �a-��-�sl
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� '� '�j ,�,,�,� ��� APPLICATIUN FUR SlTC EVALUATION/IMYItOV[R9CNT�'LRA9lT&ATC
� Davie County Health Department
�AUG 2 2 2U01 Environmenta/Hea/th secrion
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 �
�� ENVIRONMENTAL HEALIH (336)751-8760
DAVIE COUN?Y
***IMPORTANT**�* THIS APPI,ICATION CANNOT BE PROCESSED UI�SS �I1LL TIiE R�QUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruc�ions. �
1. Name to'be IIilled �.IC,�QeI . ,JQ� S�(� Contact Person _�-� ____ __ ____
Mailinq Address �`���tn��(L1��G`(��e Fiome Phone '� 7'"(�Q�p��O��r- �
City/State/ZIP w�5 I 1c , ���(7� IIusiness Phona ��j�p�-'qg���Q9
2. Name on Permit/ATC if Different than Above NQ � �(LyYLQ�
Mailing ]kidress City/Stat.e/Zip
� ����s�- a � �
3. Application Eor: Site Evaluation ❑ mprovement Permit/ATC II Both
4. systesn to service: UVHouse ❑ Mobile Home O Business f.l Indus�ry I.I OL-her
5. If Residence: # People _� � Bedrooms �_ # Bathrooms p�,��
I:�ishwasher U Garbaqe Disposal L�hing Machine l.l Basement/Plumbing il Basemenl-./No Plumbing
6. If Business/Industry/Other: Spec.ify type # People tl Sinks
# Commodes # Showers # Urinals N Water Coolers
ZF FOODSERVICE: # Seats Estimated Water Usa 2 (qallons per day)
.
7. �pe of watar supply: ❑ County/City Well II Community
e. Do you anticipatc additions or cxpansions of thc facility this systcm is intcndcd to scrvc? ❑ Ycs h1�lo
�ry�s,�y��ac cy����
***IdfPORTi1NT***CLIENTS AfUSTCOAiPLETCTIIG REQUIRED PROI'�RTY 1NrOItMATION IiI:QUES'I'�D
BGLOW. Gilhcr a PLAT or SITL I'I.AN�1UST 13CSUBd117TED by tlu clicnt �vilL Tl11S APPLICATION.
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P ' cnsions: WRl7'L DIRLCf[ONS(from 111ocicsvillc) to PRU1'l�,lt'1'1':
_ �" p'° 3"'�!
Tax Oflicc PIN: # S���-g 3�6�.�� f�01 �j �b �_a_v,�� Rd -�r�n �
Property Address: Road Namc Ma.in Ch . �. ��C-�-, ,f� GY). �11�� ., �����_
City/Zip �QG�SY(�,�e �`Zb� .�—C111�_� " P1'Yz.l'r1 /�.LI � �)G�' .
IC in a Subdivision providc information,as follows: �/1, �1(� �- GU'lU, j,�_��!/({'�,�� �
IYamc: �' 1� � 1�
C.e lM �.` - �o nc� [n
Scction: I3locic: Lot: Datc Property Flaggcd: C��
O
This is to ccrtify that thc information providcd is corrcct to thc bcst of my knowlcdgc. I undcrstand thal xny permit(s) �p�
issucd hcrcaftcr are subjcct to suspcnsion or rcvocation,if tl�c sitc plans or inlendcd usc cl�angc,or if thc information --
submitted in tl�is application is falsified or cl�angcd. I, nlsv,�urderslaud 1/�ut!am respnnsiGlc fi�r n!!clrurges iitcrrrred f'ruu�
ri��s an�r�u�;o,r. I, hcrc6y,givc conscnt to tlic Autl�oriud Rcnrescutativc of tlic Davic County Ilcalth Dcpartmcnl
to cntcr upon abovc dcscribcd property locatcd in Davic County and owncd by
------_........—---_..
to conduct all tcsting proccdures as ncccssary to dctcrminc 11�c sitc suitaUitity.
UATE ��ZZlO ( S(GNATUR� , �( J/.
Tfi1S AR�A MAY BE USED FOR DRAWINC YOUR SIT�PLAN(Includc all of tl�c follo�ving: Cxistinb and pruposcd
' property lincs and dimcnsions, structures, setbacks, and scptic locations).
' Sitc Rcvisit Cl�:�r•gc
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.. . • DAVIE COUNTY HEALTH DEPARTMENT
-• - � '� ' - � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001892 Tax PIN/EH#: 5820-83-6242
Billed To: Michael Johnson Subdivision Info:
Reference Name: Location/Address Main Church Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: ��� 6l
Water Supply: On-Site Well Community Public �
�,
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3. 4 5 6 7
Landsca e osition �-
Slo %
HORIZON I DEPTH �
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH !� �
Texture rou
Consistence
Structure i/
Mineralo �
- HORIZON III DEPTH
Texture rou
Consistence
SWcture
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON '
SAPROLITE '
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY: �G
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: t.S,� -f �� /Ll`GG� � �L�lJ'l✓ (iW�
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
tru ture
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 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
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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospttal Street _
. Courler #09-4Q06 -
Mocksville, NC 27028
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' Phone #. '(336)751 8760 :s . ... .... . .. ..... ._._.1..�,.�
September 5,2001
Michael D. Johnson
_ 501 Sunny Park Circle
Winston-Salem,N.C. 27103
Re: Site Evaluation/ Main Church Rd. E�ct.
Tax Office PIN: #5820-83-6242
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
September 5 , 2001. Based on information provided on the Applications for Site
Evaluations and after the evaluation was completed this site was found to be provisionally
suitable for the installation of a modified, oversized on-site sewage system.
Before Improvement Permit(s)/Authorization(s) to Construct can be issued the
appropriate application(s)must be filled out and the house/mobile home location staked
on each site.
If you have any questions,please feel free to contact this office. �
Sincerely,
/�4������•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s) _