227 Mohegan Trail • ` ' ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003947 Tax PIN/EH#: 5754-03-8247
Bilied To: Jerry Daniel Subdivision Info:
Reference Name: Location/Address: Mohegan Trail-27028
Pro osed Facilit : Residence Pro ert Siz • 1. r
As stated in 15A NCAC 18A.1969(5)
ATC Number: 4397 accepted Systems may also be used
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 Trea ent isposal Systems). THIS
AUTHORIZATION FOR WASTEW T i V ID FOR A ERIOD OF I YEARS.
Environmental Health Specialist's Signatu e: Date: � �
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion 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. ��b
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Septic System Installed B . (,1'6 �
Environmental Health Specialist's Signature: y'Y af'� Date:
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
•� . "�' Environmental Health Section
� , P.O.Boz 848/210 Hospital Street �y �
Mceksville,NC 27028 �U' q\4�P�
(336)751-87C0 �` �,
IMPROVEMENT/OPERATION PERMIT C��
Account #: 990003947 Tax PIN/EH#: 5754-03-8247
Bilied To: Jerry Daniel Subdivision Info:
Reference Name: Location/Address: Mohegan Trail-27028
Proposed Facility: Residence Property Size: 1.389 acre
**NOTE�*Th�is Impro4ement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHOWZATION 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 1NTENDED 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: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size �•JC,�����Type Water Supply�ELL Design Wastewater Flow(GPD)� Site: New�Repair❑
' +, �
,System Specifications: Tank Size ���GAL. Pump Tank GAL. Trench Widtt�� Rock Depth� Linear Ft,�
As stated in 15A NCAC 18A.19�9(5j
Other: � ����c�� �y(�� acceated Systems may also h� ���ci
Required Site Modifications/Conditions: `�'1S'��,L (��L9+��"TUc,Q, If�CCP �� T�pr� �E.�L� �O vFF
-r� uJ�
Ih1PROVEI�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparirnent for final inspection ofthis
system between 8:30 a.m.to 9:30 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 SpecialisYs Sign D �
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DCHD OS/99(Revised)
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� r y APP,bI I OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
a � � �.--��� Davie Count Hea1th De artment
�y�--- �, Y P
;-;.i�` ���--' �6 ` Environmental Health Section
� ` ` ` 1 � 20 P.O. Box 848/210 Hospita1 Street
:' 4.... .,. pe� -
'���,� '+ `_; Mocksville,NC 27028
�i� �=t ME�p�.K�� (336)751-8760/Fax (336)751-8786
�1\R�h�E�,O�N�
A plication�ForD rte Evaluation/Improvement Pernut ❑ Authorization To Construct(ATC) oth
* IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED LTNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed ��- r� .,�,,-�, ,• F � Contact Person < 1a r .r �, i�.,,; e__�
Billing Address �i�h��,,,.1� `i� . Home Phone 3 3 G - � �r y - �, G y /
City/State/ZIP �1� e IC.S i.l; �1 � �, r'_ �'7��2� Business Phone � �e
Name on Permit/ATC if Different than Above ��y�P�
Mailing Address City/State/Zip _ �
� PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany this application.
(Pernut is valid for 60 months with site plan,no expiration with complete plat.) `� ,/
Street Address ��r) h N ci .�av cT a� . City ;.�n c,�Cs v. l�x Tax_PIN#�7J�7 '�3—�o�-Y�
Subdivision Name � Section/Lot# � i-sE Z Lot Size
Directions To Site: (k c � S' , .� � �`(��_� ,a,v �'�'r;�,;` - ��, ry�i ).e ra�-,. 1.�i��l�i+� i� �
� � < � f, - ti- � s��c� h ' I - r�� 7�
> S -� s � -
Date House/Facility Corners Flagged soZ Q
If the answer to any of the following questions is"yes",supporting documeritation must be attached.
Are there any existing wastewater systems on the site? ❑Yes C+�3�To
Does the site contain jurisdictional wetiands? ❑Yes QNo
Are there any easements or right-of-ways on the site? ❑Yes allo
Is the site subject to approval by another public agency? ❑Yes allo
Will wastewater other than domestic sewage be generated? ❑Yes l]No
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms � #Bathrooms :� Garden Tub/Whirlpool ❑Yes .,�.No
_ Basement: ❑Yes o Basement Plumbing: ❑Yes J�`No
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: Q�Conventional ❑Accepted ❑Innovative ❑Alternative �Other
Water Supply Type: ❑ County/City Water ❑ New Well 1�E�isting Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �-No
If yes,what type?
Tlus 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 understancl that I am responsible for all charges inca�rred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to eternune compliance with applicable laws an�rules on the above described property located in
Davie County and owned by���b�������7���•
✓
', = �-G � Site Revisit Charge
Prope er's or legal representative signature
Date(s):
_��_�. j"� Client Notification Date:
Date __.... EHS:
Sign given ❑Yes ❑No Account# �:>%/_�
Revised 2/06 Invoice#
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� _ ` • DAVIE COUNTY HEALTH DEPARTMENT
• • ' � Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003947 Tax PIN/EH#: 5754-03-8247
Biiled To: Jerry Daniel � � Subdivision Info:
Reference Name: Location/Address: Mohegan Trail-270 8
Proposed Facility: Residence Property Size: 1.389 acre Date Evaluated: � � ��
Water Supply: On-Site Well �� Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition
Slope%
HORIZON I DEPTH -� O ' I
Texture grou � �
Consistence ; �'
Structure 'S�
Mineralo
HORIZON II DEPTH 2 - �D-C
Texture rou ,�r. 5'G�- a
Consistence ( � S
Structure ` � < <
Mineralo
HORIZON III DEPTH - �' �
Texture rou S� �
Consistence
Structure
Mineralo �r1G
HORIZON IV DEPTH Z-
Texture rou
Consistence
Structure a '�
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON •
, SAPROLITE .. �
CLASSIFICATION
'-`..LONG-TERM ACCEPTANCE RATE fl L U•� r
SITE CLASSIFICATION: . � EVALUATION BY: '� � � - -���`-'�
.
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS:
LEGEND
T.�ndsca�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
T�ur�
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
.ON�I�T .N . ,
a'I91SL •
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
NS-Non sticky SS-Sligh[ly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
�rusiilr�
SC-Single grain M-Massive CR-Crumb . GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
1:1,2:1,Mixed
N�tes
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(unsui[able)
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
May 8, 2006
Jerry Daniel
215 Mohegan Trail
Mocksville,NC 27028 ,
Re: 1.389 Acre Tract/Mohegan Trail
Tax P1N# 5754038247
Dear Client(s):
As requested, a representative from this office visited the above site May 5, 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: � � ������ Wastewater Design Flow: ����1�
System Type: �onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
System Location: � S I�. � �I�J�Ct, Valid: e'S Years ❑No Expiration
Site Modifications/Permit Conditions: S�q� ��� ��p�� ,�� }p�A)�L�����
�� D�
nvir t ea h eciali t at
ps-i.p.letter 2/06