693 Main Church Rd - . • DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
' ' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
.
, IMPROVEMENT/OPERATION PERMIT
Account #: 990001679 Tax PIN/EH#: 5739-49-1393
Billed To: Edward Bamharclt Subdivision Info:
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility: Residence Property Size: 1 1/Z acres
ATC Nurr�ber: 2782
.� **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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.
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:0
Lot Size ! `��i(` Type Water Supply ��{/Design Wastewater Flow(GPD) c��j Site: New�Repair 0
� .� ..�DO�
System Specifications: Tank Size�QQ�GAL. Pump Tank GAL. Trench Width� Rock Depth/2� Linear Ft�
Other: •
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 u 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)751-8760.****
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Environmental Health Specialist's Signature: � Date: �����
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 #: 990001679 Tax PIN/EH#: 5739-49-1393
Billed To: Edward Bamhardt Subdivision Info:
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility: Residence Property Size: 1 1/2 acres
ATC Number: 2782
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 NS UCTION IS VALID FOR PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �iU Date: ����`�/
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.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: � /1�
Environmental Health Specialist's Signature: Date: `l�����
DCHD OS/99(Revised)
..:.:� -
- � ' • APPiJCATiOiI FOf�SITE EVALUATION/IM1IPROVEh1EM'PEiiR91T&ATC
� � nq � n� Davie County Health Department
` �� � Envirnnmenta/Hea/tfi Section
P.O. Box 848/210 Hospital Street
i�� �,tt � 4 `��� Mocksville, NC 27028
V (336)751-8760
** HIS PLICATION CANNOT 8E PROCESSED UNLESS ALI, THE REQUIRED
ED. Reter to the INFORMATION BULLETIN Por instructions.
1. Name to be Billed �(.V/7r��, �vf7�'!✓�/}/'v!1 Contact Peraon
Mailing Addresa ( ���j.l�✓ C� •�4 G( Some Phone ��� ��E7� _ _
City/State/ZIP �D G' l�ivl'!1� Huainess Phone �1.7 l �G6�
2. Name on Pezm3t/ATC if Different than Above
Mailing Address City/3tate/Zip
3. Application For: Site Evaluation �Improvement Permit/ATC ❑ Both
a, syet� to sen.ice: L�House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
s. =f Residence: # People �_ A Bedrooms � # Bathrooms �_
�ishMasher ❑ Garbage Diaposal �K'Washing Machine ❑ Basemeat/Plumbing ❑ Hasemant/No Plumbing
6. If Bueinesa/Industry/Other: Specify type � People W Sinks
� Commodes / Showera � Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per a$y)
7. Type of water supply: ❑ County/City [�Well ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes C�Vo
If ycs,what type?
***IMPORTANT***CLIEN'I'S MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTGD +
BELOW. Eit6er a PLAT or SITE PLAN h1UST BESUBMITTED by the clieat with TNIS APPLICATION.
Property Dimensions: 1Y /�}G,e�,1.( WR1TE DIREC'I'IONS(from Mocksville)to"PROPG(iTY:
Tax Office PIN: #'x ��� / ^��-13� 3 �1 S IS'� -t� ///�Q-�� �� �u
i
Property Address: Road Name�j.li C�, �(/� � � y}�/L.,PS d �/ ���
City/Zip mQ(L�Cv j��P o`Z�(� .
If in a Subdivision provide information,as follows:
,
Name:
Section: Block: Lot: Date Property Flagged: —���
This is to certify that the information provided is correct to the best of my knowledge. I understand that pny permit(s)
issued Lereafter are subject to suspension or revocation,if the site plans or intended use cLange,or if the information
submitted in this application is falsified or changed I,a1so,undersland that I am responsible for al1 charges incurred from
(his application. I,hereby,give consent to fhe Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testiag procedures as necessary to determine the site suitability.
DATE �— � � � SIGNATURE �y�'✓�`�i( � ���'Li��r
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Chargc
Date(s):
Client Notification Date:
EHS: .
Account Na � � [
Revised DCHD(07/99) Invoicc No. �`"C � '5 ✓
�G� /--� !�`�U '�._.
. ���.' r � . . , . � .
. V J
DAVIE COUNTY HEALTH DEPARTMENT
� ' ' � Environmental Health Section �
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001679 , Tax PIN/EH#: 5739-49-1393
Billed To: Edward Bamhardt Subdivision Info:
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility: Residence Property Size: 1 1/2 acres Date Evaluated: �/�lj-� /
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 � �
Swcture �
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: EVALUATION BY: ' �
LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-$houlder 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
Structure
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloEv
1:1,2:1,Mixed
N��
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
DC�ID OS/99(Revised)
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