2516 Milling Rd �� DAVIE COUNTY HEALTH DEPARTMENT •
. ��'�c'_.
' ' ' Environmental Health Section �
P.O.Boz 848/210 Hospital Street ����' d 3
Mceksville,NC 27028
-� (33G)751-87C►0 C'� !-� -70 �
IMPROVEMENT/OPERATION PERMIT
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Account #: 9900015��QTNQ2 Tax PIN/EH#: �Er�fi�=63=8�8�
Billed To: Ronald�-,� Subdivision Info:
Reference Name: Mary Nichols Location/Address: Milling Road-27028
Proposed Facility: Residence Property Size: 7.078 acres
ATC Number: 3536
**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). T'HIS
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 � #Baths �
_,_� Dishwasher:X� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply ��� Design Wastewater Flow(GPD)_��� Site: New�Repa�ir,�d�
System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Widtl�� ��Rock Depth /� �Linear F�
Other:
Required Site Modifications/Conditions:
I1�IPROVEI�9ENT/OPERAT[ON PERMIT LAYOUT- APPROVED ' 'I L N FILTER. RISER(S)IF G "BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe D vie o n ealth Department for final inspection ofthis
system between 8:3Q a.m.to 9:3b a.m. or 1:00 p.m.to 1:30 p.m.on the day o in al ti n. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: Y ' Date: `V S v�
DCHD OS/99(Revised)
• DAVIE COUNTY HEALTH DEPARTMENT �``�
Environmental Health Section
� P.O.Boz 848/210 Hospital Street
' Mocksville,NC 27028
(336)751-87G0
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Account #: 9900015�1 Tax PIN/EH#: 5769-03-6�8#—
p FLT N t/`'
Billed To: Ronald Fee4er Subdivision Info:
Reference Name: Mary Nichols Location/Address: Milling Road-27028
Proposed Facility: Residence Property Size: 7.078 acres
ATC Number: 3536
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLIED 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 WASTEWATER CON T UCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �` Date: � J �3
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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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Se tic S stem Installed B : � t � �� �/
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Environmental Health Specialist's Signature: � � Date: � �
DCHD OS/99(Revised)
• ' -�� PPLICATION FUR SITE EVALUAl10N/IMPDOVEMFM PEfiM[T&ATC � � � �� `S � �'
���v��s� ,,� Dudle County Nealth Department
D �
� a �t�Y l`'' Envfronment�a/He�a/th Se�allon ( � 7;�,��
� �� . �p.o. sox 848/210 xoapital. street ,/ � QEC
J� Mockevilie, NC 27028 y �`b �
� • � � �
. (33f)751-876Q �l I
*�'*Zl�ORTANT**� THIS ]�PpLICATION CANNOT � PliOCS38lCD UNLLr38 ALL TH� REQUIRED
SNH'OI�TiON IS PRONZDbD. Refez to the INFORMATiON BULLETIN !or inatxuatioas.
1,�,�/ •
1. N.m. to b. a�ll.d , ��' • y'�, � , contuct n.r.on / �' ,CI S
Nailinq 1►ddru• ?(� I, i/✓� /� �C Boam� ?hon� `j� J��� �
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City/8bat�/LIp %,1'� ✓�. ��. � � Bu�i�u ?hon�
2. Nas� on ?�rait/]►TC i! Di!l�rust lhaa 11bow
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Nailinq 71ddr��• City/8t.�t�/Eip _"",-�_
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3. Application �or: Q Site Evaluation --� ❑ imp�rovament Permit/ ❑ Both
�. eY.t.. to s.roso.� f�ous� � Mobile Homa � Busineaa 0 Zadust4sy 0 Other �•� �
s. If Rssidence: � People � Sedrooma � # Bathrooms ��_
8 Diihrut►�r C3-�i�baQ� Dirpo�al B'NashinQ Machin� O Sasmnt/pluabiaq O 9aa�nt/No plumbinQ
6. I! Hutin���/Saduatry/Othrrt Sp�oity typ� � p��pl� � � Siake
# Commod�• i Bhox�r� � Urinal■ • Nat�r Cool�s�
IF E'OOD3ERVIGE: � 3eats Eatimated Natar Osay� toaiion. y.= a.Y)
�. Typs o! water suppiy: ❑ Cotuity/City N�11 ❑ Community
e. Do you anticipate additioaa or e:paneiona of the facility thts syatem Is Intended to aerve? 0 Yca �
If yes,what type?
*"*IMPORTANT""*CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either�PL.AT or 31TE PLAN MUST BE SUBMITTED by t6e client w�ith THIS APPLICATION.
Property llimenalon�: /, ///�J /�-� ✓ -�9�`WRIT�DI�REC`f10NS(from Mocksville)to PROPER'I'Y:
��i� _ /1-n_ � �c��l_ . ^/h /��/�r, �-� -� 7
Taz 08ice PIN: # i _
Property Address: Road Name r �� 'V' � L� ,7 ' " _�j �
� C1ty/Zip ��be��:�� /��. n��l�� �/��'-Ld1 ���i� �l ����`�
If in a Subdivision provide information,as loltows: l, � � � C �'�" t1/
Name: �u%' �.r. �� � � , � �/
.
Sectlon: �'. Biock: Lot: Date Property FlAgged: �� --l�' ��"Z"?
T61�i�to eertify�hat t6e in[ormatton providcd i�correct to the best ot my knawledge. I anderotand that any permit(s)
issned hereaRer are eubject to ewpenston or revocation,If the elte plana or Inteadcd use change,or it t6e tnform�tion •
aubmitted in this appiication t�falsiDed or changed. I,also,Wnderrtand tbat I ent responJlbl�jor all cbarges tnrurnd jrom
tbls appllcatlon. I,6ereby,gtve cousent to the Authorized Repreaentative o!the D,a�'e Coanty H�1th.Department
to enter upoq above deacribcd property locsted In Davie Coanty and owntd by ����'-r�f>_r_-,� __
to conduct all tesNng procedares As necessary to determine the alte ealtab Ity.
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DATE �i�;'"�—�s-�� SIGNATURE - � �°"''��L%-
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TH1S AREA MAY BE USED FOR DRAWING YOUR STTE PL.AN(Inciud �11 ot the follawing: E�sttng and propoacd
prnperty Iines and dlmenston�, etractarea, aetback�, and aeptic Iocallons)�
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' � ' ` • DAVIE COUNTY HEALTH DEPARTMENT
. • • ' Environmentai Health Section
, , , Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001511 Tax PIN/EH#: 5769-03-6784
Billed To: Ronald Foster Subdivision Info:
Reference Name: Mary Nichols Location/Address: Milling Road-27028
Proposed Facility: Residence Property Size: 7.078 acres Date Evaluated: /,-���r�
�
Water Supply: On-Site Well v 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
Consistence
Structure
Mineralo
HORIZON II DEPTH � � � '�
Texture rou
Consistence �
Structure /Z �
Mineralo 1/l �� �
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
SIT'E CLASSIFICATION: �� EVALUATION BY: ��
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: �I����✓ �'Z�� �" ✓�
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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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€N!llR�f�P.7€N�'AL H€ALTH �EC�fON
P. O. Box 848/210 Nospital Street
Courler #09-40-06
Mocksville, NC 27028
_ . Phone #: (336)751=8760 _. ,. . , .
December 20, 2000 �
Ronald Foster �
1876 Yadkin Valley Road
Advance,N.C. 27006
Re: Site Evaluation/Milling Road
Tax Office PIN: #5769-03-6784
Dear Glient(s):
As requested, a representative from this offce visited the aforementioned site on
December 18, 2000. Based upon the information provided on the Application for Site '
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of a modified, oversized on-site sewage system.
Before an Improvement Permit/Authorization to Construct cazi be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
/�4'7�.� ��a���j.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s)