170 Mocks Church Rd . • ��
• �' � DAVIE COUNTY HEALTH DEPARTMENT
� Environmentai Heaith Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
Account #: 990001798 Tax PIN/EH#: 5870-87-2275
Billed To: Amanda Miller Subdivision Info: I'r�
Reference Name: Location/Address: Mocks Church Road-27028
Proposed Facility: Residence Property Size: 2 acres
ATC Number: 2880
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: (� <U ��/
(� uis�eC� 1� Z�f o► 3�Bealr-o�ms
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate of Completion 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 gu antee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: �l'i'�
Environmental Health Specialist's Signatwe: Date:�� ✓
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' , ' Environmental Health Section �� �'���l
. '� � ' P.O.Boz 848/210 Hospital Street
� � Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001798 Tax PIN/EH#: 5870-87-2275
Billed To: Amanda Miller Subdivision Info:
Reference Name: Location/Address: Mocks Church Road-270�
Proposed Facility: Residence Property Size: 2 acres
**NOTEC* T'hi b�mprov8em�nt/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHOWZATION 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 I 1 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 STALLING SYSTEM.
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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 �/9 Type Water Supply� Design Wastewater Flow(GPD)� Site: New�Repair❑
/ ii �
System Specifications: Tank Sizg��GAL. Pump Tank GAL. Trench Widtlt��r �� Rock Depth� Linear Ft. �G�
Other:
Required Site Modifications/Conditions:
Il�'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a r res lt Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1: .m.to • . i��ephone#is(33G)751-87G0.****
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Environmental Health Specialist's Signature: Date: ��
DCHD OS/99(Revised)
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• ' ' � , APPLICATION FOR SITE EVALUATION/IMPROVEMENi PEfi 1� �CJI� � � � �
�1 q� Davie County Health Department � "'�'�""'"�"""�
(� , Environmenta/Hea/th Section � f �
�j� P.O. Box 848/210 Hospital Street � ,!��` JUN — � 2�0� �
Mocksville, NC 27028
(336)751-8760 E[lVftiOi;I„�fiT�,L hEE�LTH
DAViE CQLI,dTY
***IMPORTANT*** 'TIiIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORI�,TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �
1. Name to be Billed ���/��'(� M I U/��IL. Contact Person �1�n�-�.,r M r w�rL
Mailing Address �I� I�1�Lv✓� 1�0� Home Phone L g'1 ' Z� � � �
�n �V � r (� �l �1t3` ( 1 8(0 ���`�`�-2
City/State/ZIP i�l�(h-�V�LVG i N C ����CJ Business Phon� Z.�.r(�.�,
2. Name on Pezmit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: � Site Evaluation ❑ Improvement Permit/ATC �Both
a. system to service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People �_ # Bedrooms �_ # Bathrooms Z� S
� Dishxasher � Garbage Disposal �Washing Machine �Basement/Plumbing II Basement/No Plumbing
6. If Business/Zndustry/Other: Specify type # People # Sinks
If Commodes # Shoxers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage �qallons per day)
7. Z�pe of water supply: � County/City ❑ Well ❑ Community
8, Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑ Ycs �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
d �
Property Dimensions: � f1�� S WRITE DIRECCIONS(from Mocicsviilc)to PROPLR7'Y:
Tax Office PIN: # 5�6 -1� ` Q-1- 2215 H Wy 15�j`E R - }lW\/ $D l' S
�—�
Property Address: Road Name MUGK.S C(�1.l-P-C(� IZI� �' � MUG�S Gff7.(���� ��-
City/Zip }��V�C,� �i7U�10 ���
lf in a Subdivision provide information,as follows: ��)� M�CKS �I.���" '�D� �D��
Name: '�l!btS(�(�. � �V/1�t,tilTj o�l TD BE ��Nr�J p .
Section: Block: Lot: Date Property Flagged: �- ��'� � �
T6is is to certify that the information provided is correct to the best of my knowledge. I uodcrstand 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,also,understaird t/:at I ant responsible for a/1 c/rarges i�rcurred jron:
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owncd by
to conduct all testing procedures as necessary to determine the site suit ility.
DATE lO� � �D� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(lnclude all of thc following: Existing and pro�osed
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Chargc
� Datc(s):
- Clicnt Notificat�on Date:
�HS:
CS'��—�
' Account No. � � a
Revised DCHD(07/99) Invoice No. �� l �1/
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�• � � � DAVIE COUNTY HEALTH DEPARTMENT
- _ . , .
' � ' • Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME �v/�� / rr DATE EVALUATED__ ��lS'"��
PROPOSED FACILITY PROPERTY SIZE Q/��
SUBDIVISION ROAD NAME
Water Supply: On-Site Well Community Public v
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 ' 4 5 6 7
Landsca e osition ,[__
Slo e%
HORIZON I DEPTH �• /�3
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �!J'' ,�i
Texture rou
Consistence �
Structure
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: .v OTHER(S)PRESENT:
REMARKS:
LEGEND �
Landscape Position
R-Ridge S-Shoulder L-Lineaz 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 VFT-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
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(sui[able),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD(01-90)
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