1069 Milling Rd � .� DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003945 Tax PIN/EH#: 5748-89-2560
Billed To: Steve Hatley Subdivision Info: J�(�L� �j!I/�q �
Reference Name: Steve or Linda Location/Address: 2S
Pro osed Facilit : Residence
ATC Number: 4385
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 CON T ON I VA PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa Date:
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.
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Septic System I stalled By: 6Yn.Yr t 11� �
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Environmental Health SpecialisY Signatur : �� Date: �1
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DCHD OS/99(Revised) �,� �
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.
, --. DAVIE COUNTY HEALTH DEPARTMENT f�
� • Environmental Health Section � � �
� ' P.O.Boz 848/210 Hospital Street Q�
Mceksville,NC 27028 ���
(33G)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003945 Tax PIN/EH#: 5748-89-2560
Billed To: Steve Hatley Subdivision Info: �6(P9 �����N 2�
Reference Name: Steve or Linda Location/Address: .-
Proposed Facility: Residence Property Size: 1 acre
**NO`I���*�iis�mproveme5iit/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 PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People � #Bedrooms .3 #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: � BasementlNo Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � '� Type Water Supply�t� Design Wastewater Flow(GPD) �� Site: New�Repair❑
System Specifications: Tank Size �+��GAL. Pump Tank GAL. Trench Width 3�� Rock Depth� Linear Ft. Z�
och�: 3��Sr� P�-na.� �Y.� _ .�'r�a> ��J__'_ar-T• ►�� .S��Tr�•—
Required Site Modifications/Conditions: `��1��.� C€?J'rOl� � '� �d� � �� ��
� �
I1�IPROVEMENT/OPERATI PER � OUT- APPROVED EFFLUENT FILTER. RISER(S) F G "BELOW
FINISHED GRADE. ****NOT CE: ct representative ofthe Davie County Health Deparhnent for al inspection ofthis
system between 8:30 a.m.to 9:30 a. .or : 0 .m.to 1: on e day of installation. Telephone#is(3 C►)751-87G0.****
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Environmental Health Specialist's Signature: •Date: u ?�' ��
DCHD OS/99(Revised)
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• ►: � �' APPLICATION FOR SITE EVALUATION/IMPROVEMEN
Davie County Health Department D � �S fl � [�
Environmental Health Sectiotz
P.O. Box 848/210 Hospital Street APfl � 2 2006
' Mocksville, NC 27028
/ (336)751-8760/Fax (336)751-8786 QVVIRO� ENTALHEALTN
VIE COUfJ1Y
Application For: Site Evaluation/Improvement Pernut ❑ Authorization To Construct( o
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed ��� �qtl.E" N
S� TI l Contact Person � � �3 �
Billing Address �2 y W�STSIOE Q�Z. Home Phone 7 S/ 3�`f�S'
City/State/ZIP �2��S v�CLE /VC- 2 7 U Z� Business Phone�x �� �
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip -
PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany this application.
(Pernrit is valid for 60 months with site plan,no expiration with complete plat.)
Street Address �(�J SFI/� CY1 ', ►'�2 City��1v1� �� Tax PIN# �7+-���1 �S«'
Subdivision Name Section/Lot# Lot Size ( �i CQE
D' ections To Site:
m�Et �F �a-t �a 6 7 m�c c �,v9 ��d
Date House/Facility Corners�lagged
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �o
Does the site contain jurisdictional wetlands? ❑Yes �No
Are there any easements or right-of-ways on the site? ❑Yes B3�io
Is the site subject to approval by another public agency? ❑Yes C�Pd'o
i
Will wastewater other than domestic sewage be generated? ❑Yes 81Qo
�1
�'IF RESIDENCE FILL OUT THE BOX BELOW
#People _� #Bedrooms _ L #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
_ Basement: ❑Yes 0No Basement Plumbing: ❑Yes OIQo
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Typesystemrequested: �LConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:�County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
"the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incan�red
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to rnune c�,rn lian wit�pp ' abl laws an rules on the above described property located in
Davie County and owned by � ��� �
. . `.a .. �� j� ,
��-'�'� '�—"'�- Site Revisit Char e
g
� Property owner's or owner s legal representative signature
Date(s):
- � � � 2 — G� Client Notification Date:
�Date EHS:
Sign given ❑Yes ❑No Account# �
Revised 2/0�.�� — Invoice#
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.� - DAVIE COUNTY HEALTH DEPARTMENT
. , ' � Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003945 Tax PIN/EH#: 5748-89-2560
Billed To: Steve Hatley Subdivision Info:
Reference Name: Steve or Linda Location/Address: Elisah Creek Dr.-2�7,0_.2._8l
Proposed Facility: acre Property Size: 1 Date Evaluated: t��� /�(p
t
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition l^ (,_
Slope % �7�,
HORIZON I DEPTH p- 1 p • � O—� %J�
Texture grou �,�L'
Consistence �;3 � ,
Structure
Mineralo _ /ttii�c�tD
HORIZON II DEPTH 1 - � �
Texture rou Ci-� G�15� a $�
Consistence SS S SS S
Structure � S� ` � $3
Mineralo
HORIZOI�III DEPTH �
Texture rou -
Consistence
Structure
`: Mineralo
; HORIZON IV DEPTH
'Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICT'IVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE '�.
SITE CLASSIFICATION: `� EVALUATION BY: � '
LONG-TERM ACC ANCE RATE: �•� OTHER(S)PRESENT: ��i ���L� _
REMARKS: � ... "'r�1 .-n)Ll.�- ,� '� 4w a 2�'�� .. _,
I�
LEGEND
i.andscane 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
T�ctlug
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
CONSI T N . .
�'�41S.t
VFR-Very friable FR-Friable Fi-Firm VFI-Very firm EFI-Extremely firm
�
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
�I1iS�lltg
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
'neralogv
1:1,2:1,Mixed
lY�t.es
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-gal/day/ft2 DCHD OS/OS(Revised)
/
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` , .
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/Fax (336)751-8786
Apri125, 2006
Steve Hatley
124 Westside Drive
Mocksville,NC 27028
Re: 1 Acre Tract/Elisha Creek Drive
Tax PIN# 5748892560
Dear Client(s):
As requested, a representative from this office visited the above site Apri125, 2006 to
perform a site evaluation. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed, the site was found to be provisionally
suitable for the installation of an on-site sewage disposal system.
This Improvement Permit DOES NOT authorize the construction of a wastewater system.
An Authorization To Construct a wastewater system must be obtained from this office prior to
the construction/installation of a wastewater system or the issuance of a building permit(in
compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement
Permit is subject to revocation if site plans or the intended use change.
Improvement Permit
System To Serve:�� � � ��C-� Wastewater Design Flow: ��`�
System Type: ❑Conventional L�lAccepted ❑Innovative ❑Alternative ❑Other
System Location: ��.�L a� '�����r-�= Valid: �'S Years ❑No Expiration
Site Modifications/Permit Conditions:
�F
� �� pCi
nvironme ' ist te
ps-i.p.letter 2/06
��bI� Tax Map:fJ���6' ��1 '�j�(O O
e '';.� Address:
, � .�`� ��i_��c �'1"� C
Ins ller: '
��J '��` EHS:
� 2 Date:
1�{ _� �
Operation Permit Inspection Checklist
Location and Separation Distances � i�
1. Distance from septic tank/pump tank to foun 'on/basement � `� �
2. Distance from system to well if applicable feet
3. Any other setback(.1950)requirements
Supply line �J ti
1. Material supply line is constructed of �1r L diameter l inches "
2. Length of supply line(2'min.) Z'
3. Amount of fall in supply line(1/8"per foot min) Z'' •
4. Distance from ST/PT to the nitrification field/dist.device) �_� feet
Septic TauWPump Tank �
1. Visually inspect top of tanks(s),irnerior&exterior walls,baffie wall and bottom
2. Any honeycombing or exposed rebar present7 Circle: YES or NO �
3. Visually inspect sanitary tee,lids,and air vent for proper installatio and sealant
4. Tank Serial Numbers: STB�,12S `I F}p-(O�o 1��� �l/�
5. ST w/in 6"finished grade?�ircle: YES or NO
6. Date of manufacture: ST '"ZQ ��I.� PT /� �
7. Liquid capacity of tanks ST 6U o PT
8. E$luent filter type
9. Pipe penetration seal present?Circle: YES r NO �1�
10. Riser(s)present7 Circle: YES or No Type �11T
11. �ic�ise�-6"above finished grade?Circle: YES or NO
12. D;�A*�^^�^,�A��Circle: YES or NO
�-� �(� �'.�u�-
Nitrification Field 6� � �� � „ �, � .
1. Septic Tank ouflet elevation �,C, � � D S ,�,-�C1
Z. Trench Depth Readings(inches) - `' - �� �
� 3. Number of Trenches 3 Distance between trenehes�' �
4. Trench Width 3 ' •
5. Aggregate material type and size 3 4 5 6 57 (Circle) �
6. Aggregate Depth(inches)
7. Nitrif cation lines installed on contour7 Circle: or NO
8. Innovative system type DJ�� Installer certified for installation?Circle: YES or NO
9. 2' earthen dam between S (orT a-box)and beginning of nitrification line?Circle:YES or NO
10. Stepdowns
a. 2'undisturbed earthen dam(s) Circle: YES or NO
� � b. Proper rise over stepdowns?Circle: YES or NO
c. Solid pipe used? Solid,Corrugated or other?
d. Elevation of each stepdown
e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO •
Distribut' n Devices
1. Type�-R,�x Is the device watertight? Is it level7 �2.7.
2. Distance from Dist. device to trenches 2� � feet
3. Record elevations:Inlets � -
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DAVIE COUNTY HEALTH DEPARTMENT
, • , Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
S�'�.E.V`(- l��-k 12.�,� ��C �I� " 5�l�l�d-�6�i- 2 51�a
E�i 5 c {l ('��22.fL l� •
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit �, Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH - fo
Texture grou
Consistence
Structure �
Mineralo
HORIZON II DEPTH
Texture rou + Q
Consistence
Structure I.r� Ic.
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 B :
LONG-TERM ACCEPTANCE RATE: ` OTHER(S)PRESENT: ✓1 �'
REMARKS: �
LEGEND 5L ���� �� _�� t�
i.�ndscape Posi ion � �
R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope �- ,�-y,p��
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope � , �
� � �,�1'�1 Sp���c_����
S -Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Silt 1 /�
SICL-Silty clay loam SIL- Silty loam CL-Clay loam SCL-Sandy clay loam , '�1/�,��t�r� G�" �� �"
SC-Sandy clay SIC-Silty clay C-Clay �+ �_ �� � /_��
CONSISTENCE G�� 7 �
D.'ISl1S� /� '
VFR-Very friable FR-Friable FI-Firm VFT-Very firm EFI-Extremely firm r��`� ���� �J�
� .
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �
� r� ,r , � �_�� �
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular b oc
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
1:1,2:1,Mixed
�S ,
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[o soil colors with chroma 2 or less
Classification- S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD QS/OS(Revised)