1435 Main Church Rd + DAVIE COUNTY HEALTH DEPARTMENT �
, , �
' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003342 Tax PIN/EH#: 5820-72-9957
Billed To: Mike&Michelle Callahan Subdivision Info:
Reference Name: Location/Address: Main Church Road Ext.-27028
Proposed Facility Residence Property Size: 200 x 200
ATC Number: 3864
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF F VE YEARS.
Environmental Health Specialist's Signature: Date: �
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.
y
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Septic System Installed By: ✓ � ��' �'
Environmental Health SpecialisYs Signature: Date: `S fl��"S
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
, .�.' � Environmental Health Section �}
, • P.O.Boa 848/210 Hospital Street ���r Q — ` L� � �
' Mocksville,NC 27028
. (336)751-87C►0
- IMPROVEMENT/OPERATION PERMIT
Account #: 990003342 Tax PIN/EH#: 5820-72-9957
Billed To: Mike&Michelle Callahan Subdivision Info:
Reference Name: Location/Address: .Main Church Road Ext.-27028
Proposed Facility Residence Property Size: 200 x 200
ATC Number: 3864
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION FOR WASTEWAT'ER 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:!rJ Basement w/Plumbing:� Basement/No Plumbing: ❑
- Commercial Specification: Facility Type #People #PeopleJShift #Seats Industrial Waste:�
, Lot Size Type Water Supply� Design Wastewater Flow(GPD) �lv� Site: New� Repair❑
/
System Specifications: Tank Size/p��GAL. Pump Tank ' GAL. Trench Width c�(�i Rock Depth� Linear F ��Q
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISNED GRADE. ****NOTICE: 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,:40 n m to t•�0 n*r+ on the day of installation. Telephone#is(33G)751-8760.****
`v
f
Environmental Health Specialist's Signature: ' Date: // .
DCHD OS/99(Revised)
,, .�t � � � � . . ' .. . . . . . � . . . . � - . � .
' • , APPLICATION FOR SITE El/ALUATION/IMPROVEMENT PFJiMIT& � � (� ��
Davie County Health Department ty �
� Environmenta/Hea/th Section
P.O. Box 648/210 Iiospital Street
Mocksville, NC 27028 �UG 3 Q �Itn4
W
(336)751-8760
, �V!
***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS
INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions.
� �
���• \
� Name to be Billed �G � Contact Person � \
���-' � . t �
�� ' �Mailing Address � � ( � Home��e �
� Q-`� W',e� � /� .� I C
1��`��- C�/State/ZIP Business Phone� y q�"J3 Cp�,
��� � Name on Permi.t/ATC if Different than Above �rn`(� (,���6(�(f�� —�—
��� ` � ��� � `� � ��D��
Mailing Address �( YQ. City/State/Zip� (' S l `e, V�/.�/
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both
a. system to service: '4�" House ❑ Mobile Home ❑ Business ❑ Industry ❑ O�her
5. If Residence:� # People` y # Bedrooms �_ # Bathrooms �_
I ishNasher L'I Garbage Dispos�shing Machine I_I Basement/Plumbing I.I Basement/No Plumbing
G. If Dusiness/Industry/Other: Specify type @ People # Sinks
q Commodes N Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage �qallons per day)
7. Type of water supplyc County/City � Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Y�s No
If ycs,wh;�t typc?
***IA�I'OR7ANT***CLIENTS MUSTCOMPLGTCTHE REQU/RED PRQPERTY INFORMATION REQUESTED
BGLOW. �itl�er a PLAT or SITE PLAN MUST BESUBMI77'ED by thc clicnt with TIiIS APPLICATION.
1 l
Property Dimensions: p _.(� �,� �� 7 �VRIT�DI[tECTIONS(from Mocksville)to 1'ROPGRTY:
.. _ ,___,� " ��
i . t�
Tax Oflicc PIN• #��� ���� / �' �
�_ ( �t i
Property Address: Road Namc�,��C,����C�t'i ��� � ( �V�;C"C �� . ���'�
� �—t---� -��-
_ : �,ty,Z,P �o� ���L�.II�v ��.�2.� �� � � m�l.�
If in a Su6division providc information,as follows: 1� ' �
Namc: 1����p. l���� S�O 1�t .
Scction: Block: Lot: Datc Property Flagged: "^o� —�
'I'his is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issucd hcrcaftcr are subjcct to suspension or rcvocation,if thc site plans or intendcd usc change,or if the information
submitted in tl�is application is falsified or changeci. I,a/so,tulrlerstaild t/tai I mit respnusible jor n/!clrnrges incrrrred fronr
. ��,�.s pnni;�ar�o,r. I,hercby,givc conscnt to the Authorized Representative of thc Davie County Flealth Departmcn�,
to enter upon above described property located in Davie County and owned Uy �u �(`.���_�UR"-t"E-'-�Q�
to conduct all testing procedures as nccessary to dctermine the sitc suitability. t
DATG S� - c�S�—Z� � SIGNATUR�
�
TH1S AREA MAY B� USED FOR DRAWING YOUR SIT�PLAN(Include all of the following: istiag and proposed
property lines and dimensions, structures, sctbacks, And septic locutions).
Site Revisit Cl�argc
C�L �J Datc(s):
�s-�
Clicnt Notification Datc:
�-�'-�� �
CHS:
/- �� � ��
� Account No. �� ��
Revised DCHD(0 /99) , � [nvoice No. ��O �- ✓
�� .,
.
� 1, N J ✓ � I� _
� �
_ _ _ _ _ _ _ _ - R�W -#- Mam Church Rd.
R/W'--" _ —_ —_ —_ —-�—- � \
-------- ------------------- �. �
Main Ch urch Rd. � ��,�o Rd.
so �--,� ---- -------- ---- ------
�-------"---- � N 86°56'26"E - - —
—* ,,Y,w---�--,�.�►---20G�.00' '�.' -
- - -— _ 'vvo,, —.�'. —- � —""�' ' , '"___ _ _ - - R/W
R/W —- - — o
Iron prpe Vicinity Map
found � � C NO SCAL E J
(�1 N
1 �� , b �
—� � = o � �
� �..
b � 0 0. 804 A cre + — - � � � �,
�, � � _ o
�0 � � � - b �.
� � � � . � �� � R- .
00 aj � ,�j „� � �
'b � � o , � 1 '� _ __ _ ,, 1 ,2 � �
� � ,� - � ��,: �
�} � � '� i44 43 4t � � I
� � 48 /'�'7 46, ���� `� �i
►� � � I
n
Ul�Q O ' . ,
� � � Survey Fo�:
� Q �'� _ _ � �
� " Mi c1� ell e B. Call ah an
�
o , „ , Iron pin •
� found 75•Z� lron p!pe
� ;ion p�,� 100.24 , , „ found
roo.o4 found �_S g6 5225 W '—s 8� 0328 w Mocksville Twsp., Davie Co., N.C.
— - Iron pipe '--S 87°00'32"W �� �► 'I
r found � Lots 41-48 of SUNSET H/LLS - BLOCK D
� �izmie L. Barneycczstle � Scot T. Davzd�� i D B 118, Pg.�5 8� P/ot reference: 0.8. 30, P . 399
e . {�I
J.A. Groc � 148 I�.B. 177, Pg I I 9
,17.8. 52, Pg. 94 D.B. 422, Pq• I
IDeed �eference: D.B. 559, Pg. 866
Surveyed August 16th, 2004
I, Marty S. Cline, Professional Land Surveyor, hereby ceniiy TOX /D No.: G4080A0020
that this plat was drawn under my supervision trom an actuol
-'""-"'`� LEGEND
survey made under my supervision with a precision ratio of !�L�N,CAR���.� O � t14 rebar set unitss denoted olherwise SCO�@: � �� = 4�'
� ' ��'�+• ;%��;•�G\STERF'•.�9 � + � Unmarked point !n centerline of road
• � � • � -�- - Overhead ower line 40 0 40 80 120
; SEAL ; p
Witness my sea! and signa�ure this August 27th, 2004. � L-3361 .� = f�1 ' Power pole
�
/� � � ';y yo,' ; GRAPH/C SCALE - FEET
/ ` O F, .: � Notic�:
bcas tle.crd �
� / 1� / . ���1 "••.,SUR`�. • ��i
�� ;' - ,' � '•q�rY S.'�c�`?' Th�s S�Ney was prepared w;�hoU, ,he benefii of o �;,�e CLINE SURVEYING ac PLANNING
- � abstroct ond is made aubJect to any discreponcies whlch may 1 15 Evenin Star Dr.
be disclosed by a thorough ond accurore �it/e search. 9
PLS 3361 StC1t8SVl��@, N.C. 2862 'rJ
� (704) 546-5975 I
�
_ � � ' DAVIE COUNTY HEALTH DEPARTMENT
� �' . � Environmental Health Section
Soil/Site EvaluaHon
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003342 Tax PIN/EH#: 5820-72-9957
Billed To: Mike&Michelle Callahan Subdivision Info:
Reference Name: Location/Address: Main Church Road Ext.- 7028
Proposed Facility: Residence Property Size: 200 x 200 Date Evaluated: .�:��Q� �
Water Supply: On-Site Well Community Public v
Evaluation By: Auger Boring �'/ Pit Cut
°FACTORS 1 2 3 4 5 6 7
Landsca e osition ,L
Slo e%
HORIZON I DEPTH �, ��
Texture rou CL '
Consistence
Structure
Mineralo
HORIZON II DEPTH � L; �-
Texture rou G
Consistence .� / '
Structure /� - �
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: �i-v EVALUATION BY: •5���'�'/
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-Slighdy 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 �
Mineraloav
1:1,2:1,Mixed
ote
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 '
DCFID OS/99(Revised)
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