210 Main Church Rd %� . . DAVIE COUNTY HEALTH DEPARTMENT �,� �— d I
Environmentai Health Section (��
r.o.Boz 848/210 Hospital Street �
.r � , Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990�01649 Tax PIN/EH#: 5/49-19-2127
Billed To: Mainville AME Zion Church Subdivision Info:
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility: Fellowship Hafl Property Size: see map
**N6TEC'�This�mprovemendOperation 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 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�/�hGl�.(,' People #People/Shift #Seats� Industrial Waste: ❑
�
Lot Size Type Water Supply�� Design Wastewater Flow(GPD) o�Q� Site: Nev�•� Repair❑
System Specifications: Tank Size,�j�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 of this
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.****
�
�
F ,�}//7/7/��� (/�C ��_
Environmental Health Specialist's Signature:������������ Date: J `?� C./
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 #: 990001648 Tax PIN/EH#: 5749-19-2127
Billed To: Mainville AME Zion Church Subdivision Info:
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility: Fellowship Hall Property Size: see map
ATC Number: 2771
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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,Secf .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER O TR N IS VALID A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: ' . Date: ��'—[��
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation 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 oftime. �3 ��N �
�� ��s�
� �a u��
��� �
C��
�
�
�- ��X3XaY�
Septic System Installed By: Giv
Environmental Health Specialist's Signature: ��iD�.0 Date: �'�"7� �
DCHD OS/99(Revised)
. ". /_S
. . � . , , .
" ' APPUCATION FOR SiTE EVALUATION/IMPROVEMFNT PERMIT&ATC D � �� �
Davie County Health Department
Environmenta/Hea/thSe+afson � Z ' �
P.O. Box 846/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 ENUIRONMENTAL HEALTH
DAVIE COUNTY
***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCE3SED UNLES3 AIrL THE REQUIRED
INE'ORMATION I3 PROVIDED. Refer to the INFORMATION BLTLZETIN for instructions.
i. x� to � a�i�.a t��i,nv.i.e.�e AM�' Z.i.ovc Cl2u1C�+12 contaot poraoa fV.i,P.P,i.e F. Sco�`.t
Msiliag l►ddroaa 210 Ma.i.►2 ChultCh Ro�id goma phona 336 492-7491
cis��st.��zzr Mock�sv.i.P�e, Nar,th Cana.�i,rta 27028 Bu�t�oss phono 336 751-3561 e.x�.2373
2. Nam� on P�rmit/]►TC i! Diflor�nt than �bovo
Mailinq rddr�ss City/Stato/Zip
3. Appiication For: ,,�.181te Evaluation ❑ Impzovement Permit/ATC ` �Both
t. systom to sos,►�co: 0 House 0 Mobile Home � Business � Iadustxy [� Other��� aw�h-ip
Ha.�X.
s. �f Residence: 1 People # Bedrooms # Bathsooms
[7 Dishxashor fl Garbaqo Disposal Q iPashia,t Haehis�o U Basomeat/Blumbiny U Has�at/tlo plumbinq
6. Zt Hu�in�ss/Industxy/Othor: 8pacilY type F'P.P,Qp(d1�Sh,t-�J� # Poople �Jr / Sitilcs 2
� Commodos 4 � 8hoxora � Urinals 2 � Hator Coolers
IF FOODSERVICE: # Seata 75 $stimated Water Usage tQ�loa.�a�- 200 when u4ed
�. Type of Mater supply: [J County/City ❑ i+�ell � Community ,
e. Do you anHcipate additions or e=paaslons of the facility this system is intended to serve? 0 Yes �No
If yes,what type?
*�*lMPORTANT't**CLIENTS MIIST COMPLETETHE REQ[lIRED PROPERTY INFORMATION REQUESTED
BELOW. Elther a PLAT or SITE PL.AN MUST BE SUBMI?TED by t6e cllent wtt6 THIS APPLICATION.
Property Dimeosions: WRITE DIRECTIONS(trom Mocksville)to PROPERTY:
Ta:Ofiic PIN: # J`l y �1 � � q �'� ��'7 Fnom MacFz�Sv.i,e.ee Nwu. 158 Non�h �a
Property Address: Road Name Mcr,i,rc Chu�tch Road Ma.i.n Chu�cch Road rA���tox.3 M-i.. �u�cn
� Clty/Zlp 27028 Le�4� Chu�cch on R,i.gh,t App�cox. ` 1/4 M.i.
If in a Subdivision provide latormation,as lollowa:
Name: ,
Section: Block: Lot: Date Property Fiagged:
T6is is to certify t6at the iaformation provided is correct to the best of my knowledge. I nnderstand that aay permit(s)
issued heceaRer are subject to suspensioa or revocatioa,if t6e slte plan�or iateaded nse c6ange,or it the information
submitted in t6L�application is falslfed or changed 1,also,uddersland tba[I am responslb/e jor a!1 ctiarges Incurred jrom
�hls applicatlon. I,hereby,give conseat to the Aut6orized Representative of the Davie County He,�ylth Depart ent
to enter upon above described property located in Davte County and owned by �G/N .eo-5 fh'L C v
to conduct all testing procedures as necessary to determine the site suItabi . /I1 ct'II��G ��' � ��on
DATE 3--2/�!v/ SIGNATURE � �
TH1S AREA MAY BE USED FOR DRAWII�iG YOUR SITE PL.A.N(Include all of the following: Eztsting and proposed
property Unes and dimensions structures, setbacks, and septic locations). �
/33 63 Site Revisit C6arge
t-- -- --50 — — -- -� � Date(a): —
,
O' Prs pos� FCI�(o wS�;P,�B_X 15
��� �� ; ,Ch�� x Clfent Notif�cation Date:
� � � � EHS:_
� '__..._ �...� _���.� J sePf;c 7�an K
�....�
'Y�;
�� Pc���js�=n+ `'� nccounc tvo. � �
��� . /
e e 0 �� I oc Z' V
R vis ( 7/99) nv i e No. �
Z s2
•- ` ; `� " ' . . DAVIE COUNTY HEALTH DEPARTMENT
. Environmental Health Section
{ . .. Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
• -----... ... 990001649 ' ._.. . .._._. . ... 5749-1J-2127
_...__ ._. MainvilleAME Zion Church ____..._.�.. ...._.
.. ..__ ..._. : ___ .. _.___. Main Church Roaa-27028
�: . ...�;, ��..:_.�_: Fellowship Hall �� .:{. �:.... see map ���� c. ��,.�.�;,. 1�-,2-�;�
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring . / Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition Li -
Slo %
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �� ��
Texture rou
Consistence /
Structure � /
Mineralo : i �'
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: OS EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS:
. 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 .
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
truct r
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(unsuitablej
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 �
DC�ID OS/99(Revised)
■■��������■���■�■■�■�■���■��■■■��B��O���■■■■��■■�■�■■■■�����0:■■�■
■�■■���■■�■�����■��■���■�■■�■���■■■�■■■■■�����■���■�����■■�■�■�■■■
■���������ee0���■�0■�����■■�■������■■■■■����■��■��■�O�v■��■�■0■�■
■��■���■■�■���■��■�■■�■��■��■■■■ ■�■■■■■����■�■■■�■����■���■���■■
■��■��■■■�■��a�s�■�es�■��■■�■■��■■��■■■■■■���■�■■ses���■��■�■��o�■
■�■■��������■�voo■v.�■■��■��■�■�����������■��■■■��■o����������s�■■
■����■���■�����■■�■�■�■■������■■���■�■■■�■■■■s■■■ee�■■�■�����■■��■
■�■��■���■�■■s���■��■�■■��s�■�■��■�■■■■��■��■�■■����■���■���■■�■■■
■�■����■���■■■o�s■0�se■■�■■�■�■�■��■■■■����■��■■�■�■■��■■■■■■■�■■■
■�■�■■�����■■■���■���■■■o■■�■■������s���������■���■��s■■�■�■■■�■�■
■���■■■����■■■���■���■���■���o■v��■����■■�■■�.�oo�o■o�■■■�■�����■
■�����■■�■�■�■■������■■�����■��■ ■■���■■■�■■�■��■�■��■■■��������■
■����o���■�■���■�■���■���■���������■���■■■■■■�■��■�■���■■�■��■■��■
■�■���■■�■�■���■�■�■■�■�■■�■■���■���■��������■■���■��ees��.����e■■
■■■�■�■■�■�■■■�■�■■�■■■■�■�����■■��■■■o■��■■■■■�■■�■�■■■■��■■■�■■■
■■�■■�■■�■�■■■■�o���■�■■�■■�■■��■��e■■��■■■■■■■�■��■�■■■■■�■■��■�■
■��■��■■�■o■■■■■■�■■■�■■�■■�■■■o■���■��■■■■■�■■■��■�a■■■■�■■s����■
■�����■��■�■■■■■■��■�■■�������■■■������■■����■e���■�■■■■��■■��■��■
■■���■��■■�■■■�������■■��■�����■������■■e■■������o��■■�■■■■��■��■
■■���■��■■�■■■������■■■�■■�����■ ■■�■�■�����o■■e■��■■■���■■�■■��■
■■��■■��■■�■■■■�■�■�����■��■�s�■�■■��■■■���■�■■��■■■■■��■���■■���■
■■���■■��■���■■■�■���e■�i������■��■��■■■■■■■■■■�■■■■■■�■■■���■���■
■■���■�������■■��������i��s�������■���■■■■��������■■■�■■�■■�■■�■�■
■e��■�����se�s■e��■���i■■■■■s�a���■■�■�■■■■■■■■��■��■■������■■�■�■
■■���■����■��■■■��■■�i■■�■�■■��■�■■���■■����■■■��■■■����■��■o��■■■
■■��������s�������■�i�■■�■�����■�■�■��■��■■������■�������■■■�■��■■
o����■���■��■■�■o���■o■■��������Si�_-�����������■■■■���■■■�■o�■�t■
■����■■��■���■�����■��■■e��■��•�.,■■�■■■���e■■e■■■�■■�■e�■■�■���■o■
■■■�■■■��■���■■��■�■a�■e■���.��■�■■��s■��■�■�■�■■■■■��■���■■a■o��■
■■���■■��■�■■■■t���■■■���.��■���■■■■�■■■�■��■���■■■■■■��■■■■■■■s�■■
s■���■���■��■■■o■n9�:��■■��■■■■�■■���o■■■o■��t�■��■■■��■■■■��■��■■
■■��■■■s���■�■■c�■������■■�■■����■■■■e���■�■���■■■�■■�■�■■���■���■
■����■���■���■�����■�■■�■��■����■■��■■■■�■�■�■■■■�■���■■����■■���■
■■■�■�■����������■■��■■e■■�■�■■��■■���■�■��■�■■■��■■■��■■■■■■■��■■
■�■�■■������������■�■■■■■■■■■■■■�■���■�■�����■■s��■���■■■�■��■��■
■��■■■■�■�■�■■■■■■���������o���■ ■■■■■���■�����■■���■■■������■■�■
■�■��■���■��������■■■■■■■■■■■■■■■■■■■���■■��■■■�■�■■■■■�■■���■■��■
■�■ve■■�o■■■■■�■■■�o�■��■�■■�■■��■��■■��■�■���■■���■��■■�■�o��■�■■
■�■�����■����■�e���■■■��■■■■■■■�■■��v���■■■��■�■��■����■����o�■�■■
■■■��■��■�������■■�■�■�■■■■�■■■��■�■■���■�■���■■���■���������■■■■■
■�■�■■��e������■��■■������■�■�■�■������■■������■��■������������■■■
■■��■��■■�■���■■�s������s�■�■�e����■��■�e■■■■■�■■■����s■�����■■■�■
�iiiiii�iiisiii�iiiiii�i�■�iiii�iiiiii,l�iiiiii�iiiiii�iiiiei�
■��■■�■■■�■■■■�o��o■■�■■�■■o�■�■�e■■�o�■■i■��■��■��■�■■o���■■■o�■■■
■��■��t�■■■■■��t����������v■��o���■■���■�■����■■��■e■■�■■�■■■■�■�■
■��■�■����■��■■■�■■��■■�■■�����■■■■��■■�����■■��������■����■���■�s
■■���■������������■�■■s�■������■■■�■����■■��■■■■■�■■■�o���■■��■��■
■■������e��e��■■e�■■■■■�■������■■■■�■�■e�������■e���■■v�����■■■■�■
■■���■■■■�����■■���■���■■�■■i�■�■■■���■■�����■��■�■��■��■■�■���■�■■
■����■■����■����■■�■�■���o■�i��■■�■■■■���■����■■�■��■■�■�������■�■
■�o���ot�■������■��■o���■o�■��■■ ■■■�■■�■��■■■■���■■�o���■■■��■■■
■■■���■��■■■�soe■■vt�s��e�■■oem�■����■■■���■■�■��■■��������s�■■s�■
■■■��■��■�■■��■■��oe■���������■■■■��=:::�■����■�■■■■■■��■■■■■�■■�■
■■■■■■■■��■�■■�■■�■�■�■■��■�::::���■■■���■e�����■��■■■����■■■■■��■
■��■�������■��■�■�■����■�■■�■■■�■■�•�■����■■�����■■��■■����■■■■■�e■
■■■■��■■■�■■■■■■■■■■■�■■�■■■■���■���■■■���■■■��■�■��■■■����■■■■■■�■
■■■■■�■�■�■e■■�■�■■�■■������■s■�■■r:�s���■����■��■■■■����■■■■■�■■■■
■e�����■�■�o■����■■■��■�■■��■������■���■�■���■■■�e■�����■■■■����■
■■■�■�■��■�■■■■■�����■���ra�����■ ■���■■■�e��■�.�■s��s■■■����s■��■
■��������■����■��■��■■■��►���������■■����■■���■■■�s�■■��■■■�������■
■����■���■����■�■��■�����c.7�■■■■�■■��■►��■■��■■�■■����■�■■���■�s■��■
■���■■��■■■■■�■■■������■����■■■��■■�■■���■�■■�■�����■■■���■■�����■
■��■����■�����■a■������■�■��■■■��■■�■■■��■�■�■���■■■o■■■■����■■■�■
■�■■�■■�■�■���■�■�■■■■�■����■■■■■■���■�����■■����■���■■����■■■���■
■���s■�■■�■�■■■■���������■■�■o■�����■■���■e���■���s■■■����■■.�■■■■
■��■s■■s■�e�■���■�■■■■�■��■■■����■■���■■���■���o■�■�������■■■■■■■
■�■■��■���■��■��■�■�������■�■�■■ ■■■■��■��■��■�■■�■■�����■■���■t■
■�■����■■�■■■■����■�■�■■�■■�■�■�����������■��■��■■��������■■■���s■
■�a■■�■■■�■■■■���■■�■�■■�■��e���■o�■���■■■■■���■■��■����■■■■�����■
■���■�■■■��■�■�■�■■�■■■��■�■�������■���■■�■��■�■■����■��■■�����■�■
■�■�■�■■■�■■■■�■■■���■■�■■�■�■�■■■■■���■s■■�■■�■■���■■■�■■����■��■
■�■■■v�■■��■■����■�■■e��■����■�■��■■�■���■��■■����■���■■■��■■■■��■
■�����■■■�e■■■�■■■�■�■����■■■■■��■■�■��■�■�■■�■■����■■■■�����■��■■
■���■�■����■����■■��������■■■����■���■■���■■�■��■��■��������■■�■■
■■■■���■�■■■■�����■■■■������■■■■ ■■■■��■■��■����■�■�■�������■■■■■
■t����■�������■����■■��■��■���■�■���■�����■a�■�����■■■���■�■■■■�■■
■■��■�■�■�■■��■�■��■■����■■�■���■�e■�■��■�e��■��■����■������■■■■■■
■�e�����■�■��■■���a�■�■■����■�■�■��■�■�■■�■��■��■����■■�■■��■■■��■
■����■�■■■■■■■���■■���■��■�■�■�■■■■■���■■■��■��■■�■�es■■■��■■����■
■��■���■■■■■■■���■■�■�■��■��■■�■■�■■����■■■�■���■�■�■■�■■■■■■����■
■■�■��■■��■�■■■���■�■■■��■�■�■�■■■■■����■■■�■■����■�■■��■■�■■����■
■����������■�■�■��■���■�■■���■���■■��■��■■��■�■■�■�■■�■■�■■e����■
■���■�■����■■■���■�■■■��■■�����■ ■�■■�■�■����■■■�■■■������■�����■
■������■t��■���■���■�■��■�■■��■■�■���■���■�■■����■�■■���■■�■�e�■�■