1476 Main Church Rd �
� . � . DAVIE COUNTY HEALTH DEPARTMENT �d
-- Environmental Health Section �� I � I p/
r.o.Bog sasnio x�P;t��s��t
� Mocksville,NC 27028
r (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001675 Tax PIN/EH#: 5872-73-7385
Billed To: Carl Smith Subdivision Info:
Reference Name: Location/Address: 1476 Main Church Road-27028
Proposed Facility: Residence Property Size: 200 x 500
**NOTE**Tiii b�mproveninent/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 STTE 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 � Type Water Supply�_ Design Wastewater Flow(GPD)�s�� Site: New la Repair❑
,. �D17.
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���Rock Depth� Linear Ft�` �� ,
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 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(336)751-87G0.****
�
r,ve F •
✓
Environmental Health Specialist's Signature: � . Date: '�l�d�
DCHD OS/99(Revised)
� ' ��
DAVIE COUNTY HEALTH DEPARTMENT
` � Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001675 Tax PIN/EH#: 5872-73-7385
Billed To: Ca�l Smith Subdivision Info:
Reference Name: Location/Address: 1476 Main Church Road-27028
Proposed Facility: Residence Property Size: 200 x 500
ATC Number: 2774
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section priar 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 WASTEWATE ON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � � , Date: ��'(��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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.
� �, � zoxsX�ti„
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Septic System Installed By:
Environmental Health Specialist's Signature: Date: '�'""f�--o / ✓
DCHD OS/99(Revised)
. -
....�___..n_--n-n----
�� � �� � u L'/ � PUCATIOiI FOH SITE fVALUATION/I�dPROVEMEM PERMIT&ATC
, Davie County Health Department
�� � 3 � Environmenta/Hea/Gh Sec�ion
r r.�• B�x 848/210 Hospital Street . .
Mocksville, NC 27028
ENVI DAVIE COUNTIf LTH (336)751-8760
***IMPORTANT*** TIiIS AEPI,ICATION CANNOT HE PROCESSED 'UNLESS ALL THE REQUIRED
INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
,
/ �� �rj-� '1 � '
1. Name to be Dilled ��]Y s � Contact Person /h
Mailinq Mldreas ��U �;h [�. j'��_ Home Phone _�GC (9_�b f
City/State/ZIP ��('�(�S�"li�� ����Buainesa Phone %/��— �(p �� _
2. Name on Permit/ATC iE Ditferent than Above
Mailing addreas City/State/Zip
3. Application For: 0 Site Evaluation 0 Improvement Permit/ATC � oth
a. syetem to service: ❑ House H Mobile Home � Business � Industry 0 Other
s. If Residence: N People �_ � Bedrooms _.�_ A Bathrooms _�
❑ Diahxasher ❑ Ga.=bage Disposal i7 Wsshing Machine ❑ Basament/Plumbing ❑ Sasement/No Plumbing
6. If Buainesa/Industry/Other: Specify type � People �1 3inka
# Commodes # Showera # Urinals #{ Water Coolers
IF FOODSEBVICE: # Seats Estimated Water Usage (gallona per a8y�
�. Type of water supply: � County/City ❑ Well ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is intended to servc? �Yes �'No
If ycs,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUES'I'GD
BELOW. Eit6er a PLAT or SITE PLAN h1UST BESUBMI7TED by t6e clicat with THIS APPLICATION.
Property Dimensions: �� � �6� WRITE DIRECTIONS(from Mocicsville)to PROPGRTY:
Tax Office PIN: #`��f?Z ' 7� - � ��_� �(LI ��`l/ � / � (l�/?
PropertyAddress: RoadName ��f7� maj}� ��� f�Q,�/�l (�'1, ��LX �'Jr�d /N.`
��ty,Z�p�na�ss�:�r� � � � � G,r�
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date Property Fiagged: T�3 rJ !
This is to certify that the information provided is correct to the best of my knowledge. I understand that s►ny permit(s)
issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsi6ed or changed I,also,understand that I am responsible for al!charges incurred fro�ri
rhis application. I,hereby,give consent to the Authorized Representative of the Duvie County Healtt�Department
lo enter upon above described property located in Davie Couuty and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE `� - � — � ! SIGNATURE +
--�-
'I'�IIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, set6acks, and septic locations).
� Site Revisit Chargc
� Date(s):
�- 7 � Client Notification Datc:
��, �-- 1-� -� �
EHS: �
� �� �
Account No.
_ � � ✓
Revised DCHD(07/99) �✓ Invoice No. � ?
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100 100
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G4080A0028
G4080A002701 G4080A0029
G4080A0027
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�a� � � 9975
� � , DAVIE COUNTY HEALTH DEPARTMENT
� � � N Environmental Health Section
. � � • Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001675 Tax PIN/EH#: 5872-73-7385
Billed To: Carl Smith Subdivision Info:
Reference Name: Location/Address: 1�t76 Main Church Road-27028
Proposed Facility: Residence Property Size: 200 x 500 Date Evaluated: `�`6�QT
Water Su 1 On-Site Well Community Public v
PP Y�
Evaluation By: Auger Boring /�_ �Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition L
Slo e% �---
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEP'TH <l ``� '��'`'
Textwe rou
Consistence J
Structure f _
Mineralo '
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo '
HORIZON N DEPTH �
Texture ou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON ' �
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � EVALUATION BY:
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
ois
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
ture
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
MineralogX
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 OS/99(Revised)
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