699 Main Church Rd DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section �
' `� -�:,�f P.O.Boz 848/210 Hospital Street
r _ .� Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002039 Tax PIN/EH#: 5830-50-2322
Billed To: Thomas Foster Subdivision Info:
Reference Name: LocatioNAddress: Main Church Road-2702$
Proposed Facility: Residence Property Size: 2.4 acres
ATC Number: 3 0 �°
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 pertnit(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 T��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: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Gl��1� Design Wastewater Flow(GPD)�_ Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.�
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/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 130 p.m.on the day of installation. Telephone#is(33C)751-87G0.****
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Environmental Health Specialist's Signature: , Date: ��ls" �/ �
DCHD OS/99(Revised)
• , �GL
. DAVIE COUNTY HEALTH DEPARTMENT
� � � ' � Environmental Health Section
' i• P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002039 Tax PIN/EH#: 5830-50-2322
Billed To: Thomas Foster Subdivision Info:
Reference Name: Location/Address: Main Church Road�27028
Pro osed Facilit : Residence Pro ert Size: 2.4 acres
_ATC Number: �� o�o ,
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 WASTEWATE O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �. ' � _ �• Date: /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.
P�Vv\
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l�°V
Septic System Installed By: �
Environmental Health SpecialisYs Signature: Date:��^-b J
DC�ID OS/99(Revised)
. '..��.._.'.-�',]1.. . . . ' . . � n�.
APPUCATION FOR SIIE EVALUATION/IMPROVEMENT PERMIT&ATC � � Lj �1 �
�`� ' " • � � Davie County Health Department �
�,�/ Envir+vnmenta/Hea/th Section N0V _ 5 ^L���
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(33 6)751-8 7 60 E�IVIRON�E��T�t NEALTH
DAVIE COUN?Y
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORI�TION BULLETIN for instructions. �
1. Name to be Billed y��DiY! 9 f' (' ��T�� Contact Person �C��� �/�/
Mailing ]Wdress /Q� ///4 i � C� �T Home Phone f��/ �7`J�q�
City/state/2xP /„Q���T��� //(f a�JQ?� susiness Phone ,fR'n'1t'i
2. Name on Permit/ATC iP Different than Above�G��p�'�/`
Mailing Address �[O � ���!/GG a� !�l.��CitY/State/ZiP ///�Lf�6C�/��//� //G��G��
� I-►3-o� �
3. Application For:�ite Evaluation ❑ Improvement�rmit/ATC ❑ Both
a. system to service: .� House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: N People l # Bedrooms � # Bathrooms _�_
y1 Dish�rasher ❑ Garbaqe Disposal yl-Washinq Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type i People # Sinks
, Ii,Commodes $ ShoWers , # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. 2�ps of water supply: ❑ County/City �,e( Well ❑ Community �
s. Do you anticipate additions or expansions of the facility this system is intended to serve? �Yes Y1 No
i
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM77TED by t6c clieat with THIS APPLICATION.
�
Property Dimensions: � � � ��G��'S WRITE DIREGTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # ���✓��•S�C�Y��� �c`�� Td .6`S� �/l/ /�4d,��
Property Address: Road Name r � D���" o n ��-�'� �'_/'D.�S � �d
City/ZiP�d�'i�S' �l i��� ��° .�4 r�/S f�i .� �`�' C�/'l�✓�
��tK��
If in a Subdivision provide�information,as follows: CO /�I � e ��
l�tame:
� Section: Block: Lot: Date Property Flagged: r( `� d �
This is to certify that the information provided is correct to thc best of my knowledge. I understand t6ut any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intendeci use change,or if the information
submitted in this application is falsified or changed I,also,understmrd t/:at I am responsible for aU c/rarges inci�rrerl fron:
this app/ication. I,hereby,give consent to the Authorized Representative of the Davie County Health Departmcnt
to enter upon above descri6ed property located in Davie County and owncd by
to conduct all testing procedures as necessary to determine the site suitab' ty.
DATE 7��d I SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
� Sitc Rcvisit Charge
�Z� � Date(s):
Clicnt Notification Date:
� �l � EHS:
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' DAVIE COUNTY HEALTH DEPARTMENT
� �� - �� ' ," Environmental Health Section
�• .., ,. �.. , Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002039 Tax PIN/EH#: 5830-50-2322
Billed To: Thomas Foster Subdivision Info:
Reference Name: Location/Address: Main Church R�7��
P r o p o s e d F a c i l i t y: R e sidence Property Size: 2.4 acres Date Evaluated: � �D�
Watei Supply: On-Site Well Community Public
Evaluation By: Auger Boring__� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH « �'
Texture rou [�, l,(i
Consistence
SWcture
Mineralo
HORIZON II DEPTH Q�' ��
Texture rou O
Consistence �
Structure /
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:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND � - -
Landsca�e 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
Mois
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 re
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
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
DC�ID OS/99(Revised)
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