208 McDaniel Rd 1 DAVIE COUNTY HEALTH DEPARTMENT � .� �—� 2"'
� • Environmental Health Section �
. , . P.O.Boa 848/210 Hospital Street
, . " , Mocksville,NC 27028
. - (336)75]-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002164 Tax PIN/EH#: 5870-13-13$8 .� �V
Billed To: Robin Campbell Subdivision Info: �
Reference Name: Location/Address: McD�niel Road-27006
Proposed Facility: Residence Property 8ize: 1 acr�
ATC Number. 3077
**NOTE**This Improvement/Operation 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
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �T/ #People 7i #Bedrooms� #Baths o�-
Dishwasher:f� Garbage Disposal: ❑ Washing Machine:.� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Faciliry Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size r�e Type Water SupplyC�6 Design Wastewater Flow(GPD) v�v Site: Ney� Repair�
.
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width����Rock Depth,�� Linear Ftc���'�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.****
/
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Environmental Health Specialist's Signature: �� Date: `
DCHD OS/99(Revised)
� �.�•
M ' DAVIE COUNTY HEALTH DEPARTMENT �
•, ', Environmental Health Section
` P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002164 Tax PIN/EH#: 5870-1&1388
Billed To: Robin Campbell Subdivision Info:
Reference Name: Location/Address: McDaniei Road-27006
Pro osed Facilit : Residence Property Size: 1 acre
ATC Number: 3077
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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � Date:�`����
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certifica of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in liance ' Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Syst "but sha ' NO Y 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: �J �9"� l �41
Environmental Health SpecialisYs Signature: Date:� ! � `��
,
DCI-ID OS/99(Revised) ' r
+�J�b. ��
, , . � � ,� oa �
�� . , APPLICATION FOR SITE EVALUATION/IMPROVEMFNt PERMIT&A
. -• '
� " Davie County Health Department •
Environmenta/Hea/th Section F�6� � � ZOOZ
P.O. Box 848/210 Hospital Street
_ Mocksville, NC 27028
(336)751-8760 ENVIRONMENTAL HEALTH
DAVIE COUN?Y
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
,
INFORI�TION IS PROVIDED. Refer to the INFORL�iTION BULLETIN for i t ctions.
1. Name to be Billed ��{�I h l�(.��Y7GL' Contact Person ��p �YY1� c�i�'
Mailing Address �!�. M �-�o�n,�e.i 2d Home Phone V1��5— / /I�
City/State/ZIP ,Advar�Ce IU C ��00� Business Phone
2. Name on Pezmit/ATC iP Different than Above
rtailing Adaress city/state/zip
3. Application For: GY Site Evaluation �Improvement Permit/ATC E�oth
4. System to senrice: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: � People �'l � Bedrooms �_ # Bathrooms �
LY/Dishxasher O Garbage Disposal 6Y Washing Machine O Basement/Plumbing � Basement/No Plumbing
6. If Business/Industsy/Other: Specify type # People � Sinks
# �ommodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Esti.mated Water Usage �gallons per aay)
7. Type of water supply: �County/City ❑ Well ❑ Community
s, Do you anticipate additions or eapansions of the facility this system is inteaded to serve? ❑Yes �o
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client wit6 THYS APPLICATI�ON.
�j 4
Property Dimensions:= � x �' 1 CLC/�- WRITE DIRECI'IONS(from Mocksvillc)to PROPGRTY:
Tax Oftice PIN: � # ���d � 3 � 3�' �o"1 � � �eF� � �l��a-(1�Z.2-f� Kd';
Property Address: Road Name �c/JOt�'1 I Qi� KG( (1J F-�- C51� /(/j G ��� �'' .
City/Zip�I r�van� AN���� 'QS�- I"1(3"US-� �{— `F'�12
lf ia a Subdivision provide information,as follows: 1� �P trt�
,�1,� .
Name:
Sectionc Block: Lot: Date Property Flagged: Z- Q O
This is to certify that the information provided is correct to the best of my krtowledge. I understaad that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed I,a/so,understand that I am responsible for a[I charges iircr�rred from
this application. I,hereby,give consent to the Authorized Representative of the}�avie County Health Department
to enter upon above described property located in Davie County and owned by ICD�'Ji n+ K2( i n�tp�P,[I
to conduct all testing procedures as necessary to determine the site suitability.
DATE �/� ���Z 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).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
� Account No. � � �
Bevised DCHD(07/��) Invoice No.
�� � �
/ � Z�.- �-�
� \ � � i
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. / ` " 7 -�
.
� �' Ir fou d e O `'�..- •
�' .� I I . "
i ,�'-cd � '�`
I / ° � � �
b�(\'�tS��t�0 \s '�Rs e�r I �
- � � � Q,�' 9 lron pin !� I r fo nd e '•
� �, T' 4 found 6� / Iron pipe �
\� � /�found� pb�j►d�6� at 210.03' 3.6/ l 1/0.77' found _ . .� ��
. �. � l�on pipe �—N 38°22'l2'W �� �
\ � ���+'9�� ,�b�,�a,o� found 144.38' To►al s 'G��
� s
�• � \ pk nai o � � � � �
��� � set 0� ie
\ � ��`''a�o ��h ��;L � `� `�
t� Q, . . .9 �• 'L ,. s ,l
lron pipe y�,d y� v �. � 5 ... �"'� �G
found �e9• I r found e� pk nail "''
i � j L- set �'�'`� ��9. �
� �t,� �g, 1 ", _ ' %,`�
�\ ��9 '� �f un�n �
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: �s� � .�� � �
. o� ,p�ti �,ti 1 � �
�, b�j6 g"�• � ��"S„ lron pipe
� � �, � � � found
o�,, g � },.,
� �
a �
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nail found at 1 ��:
� benl pipe �
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v .
,46.E�a9s.31' Totoi Iron pipe �
39 246,3�' found
lron pipe
found
.1�
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Tra c t 2 � ��,4
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27.488 Acres+- � 4,
�', •
�
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., . � .
� � . DAVIE COUNTY HEALTFI DEPARTMENT
, , Environmental Health Section
- , ,._. Soil/Site Evaluation
� APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002164 . ' Tax PIN/EH#: 5870-13-1388
Billed To: Robin Campbell Subdivision Info:
Reference Name: Location/Address McDaniel Road-27006
Proposed Facility: Residence Property Size:� 1 acre Date Evaluated: �2s�D2-
Water Supply: On-Site Well Community Public`
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 SC�L S',
Consistence
Structure
Mineralo
HORIZON II DEPTH c3 °' '�
Texture rou
Consistence r- �
Structure �� I j �� _
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: �a EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: � � i 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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloav
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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