195 Mortgage Hill Way ` . ' , DAVIE COUNTY HEALTH DEPARTMENT /��� ��
Environmental Health Section ,.��
P.O.Boz 848/210 Hospital Street �
Mocksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001040 Tax PIN/EH#: 5823-26-3173
Billed To: Carolyn Foster Subdivision Info:
Reference Name: Carolyn Foster Location/Address: Mortgage Hill Way-27028
Proposed Facility: Residence Property Size: 3 Acres
�* �T�G*�l�,�lbgr: 2372
N ts mprovement/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 y� #Baths�_
Dishwasher: �Garbage Disposal: 0 Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size� tR ' Type Water Supply ril/Cl� Design Wastewater Flow(GPD) ��d Site: New�Repair❑
System Specifications: Tank Siz%OD GAL. Pump Tank GAL. Trench Width�l�Rock Depth���Linear Ft. 'T��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)'751-8760.****
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Enviro s at e: r�i,�� Date:,f��DT'�J(�
DCHD OS/99(Revised)
� ,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990001040 Tax PIN/EH#: 5823-26-3173
Billed To: Carolyn Foster Subdivision Info:
Reference Name: Carolyn Foster Location/Address: Mortgage Hill Way-27028
Proposed Facility: Residence Property Size: 3 Acres
ATC Number. 2372
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 WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �U � Date: �% �y— �
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this 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 guarantee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: � . � /� 1' �t �
Environmental Health Specialist's Signature: ��j� Date: — �
DCHD OS/99(Revised)
� � � , APPUCATION FOR SITE EVALUATI�N/IMPiiOVEMEIJt PEdiAlR�C ATC �2 � � O'�`�'
`�� �/��� Davte County H�alth Department p l� ��< <5
Gu// ���`�✓ Env�►ronmert�a�Hea/th Sea6fon
,0e���� �fi�e����'�i�����p.o. eox e�e��i�+ �o�pital Str..t MAR I 3 2000
/ • Mockevili�� NC 27028
���y.— ��(�'7 ' � (336)781-8760
� �tJVI QfJP:1�NfAl �LTH
***IlII�ORTAN?4*• THI$•71PBLICATION Ca1NNOT � P�lOC6BS�D L1NLE$8 I1LL
INS'OItMATi02i IS PRCVIDED. tt�ler to th� IN�'ORMATiON BULL�TIN !or instrnatioas.
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�.s.1� aaesr.• cs�/naa/sir _ _
a. 1►pplioat.ion por: 0 Sit� =valuatioa 0 2mprov�m�at II�rmit/ATC .�' oth
a. sY.t,.. to s•r.i.w� U Hous• �Mobila Hom� U 8usin�sa O Iadustiy D Oth�r
s. I! R�aiMna�: / p�opl� ��� f SedroOms .�_ i Bathrooma r,
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7. Typ� ot wat�r aupply: t�rCouaty/City N�11 0 Commuaity
e. Do yoa�nHcipate eddiHon�or e�neions of the taetlity thb ryatem b intended to�erveT 0 Yes C�-Ai6
If yes,w6At typeT
*""IMPORTAMI'"**CLIEN'TS MIIS7'C�UMPtETETHE REQUIRF.D PROPERTY INFORMATION REQUESTED
BELOW. Either s PI.AT or 31TE 1'LAN bii/ST Bfi SUBMITTED by the elient �viW THIS APP WCATION.
Property Dimensloas: �C'.��5 ' __._ WRITE D1RF.Cf10NS(ine�*Ro��.lR•�!�oAnno�o�rv;
Ts:08Ice PIN: # :���,��02�''.��� CQOI '�Df,�'��'� `f A al.�j,`!!1�i II�,
Property Addrea�: Rosd Name �G4�/"y�'SG' �7/����y'� D�� /V l�l'1"�'1_ � t,(f`� l��
� Ciry/Zip���"`�L;'`ll� � Cbrh e,f-S � ��+1� . � � b
V In A Sabdivision pravlde InfornwNon,aa followe: f�1'�-K'��. �� 1.� �
N�me: �Q�
SecNoas Biceks Lot: Date Property F4�eds ,s7�� I' �
This ia to certify that t6e InlormsHon prowided is correct to t6e beat ot my kamvledge. I anderstsnd t6at�ny permit(s)
�saed hereaner are enbJect to�aspenalon or revocadoa�itthe eite plana or intended oae chsnge,or if the 9nformaHon
aabmitted in this appilcaHon Is taL�tfied or changed. I,also,anderstond tbat I ani rtsponslb/�jor ai!cbar,�es lncurred froni
tbls appllca�lon. I,6ereby,give eonaent to the Aathorized Repreaentative of t6e�e Coanty Ha�t6��ent
to enter apon above descHbed pr+operty loa�ted in D�We Coaaty and owned by Q�l��r1 �?�
to condnct sq tesNng procedara iu neceaaary to determine the dte�nihbWty.
DATE_ ��" � I^l�� SIGNATf)RE o�� . o��(��.�u11
aiai�i+i.�i�m�+=��ua�.�ru�'t l)NCA`W1NG YOUR 31TE PI.AN(InClude sll of the fo1101►iogi Ezi3ting�Iud propoeed
property lines and dimenaiona, ttractares, aetbacks, nad aepNc IocsHons).
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D�te(e)s
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This map is for PERC TEST
��� � h9sC and BUILDING PERMIT purposes
oniy. The Davie County
3 3 Tax Administrator's Office
assumes no liability for any
information contained on this map.
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14�8 March 13,2000 9:01 AM
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Parcel Identification Number
5823-26-3173
' � •, .
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001040 Tax PIN/EH#: 5823-26-3173
Billed To: Carolyn Foster Subdivision Info:
Reference Name: Carolyn Foster Location/Address: Mortgage Hill Way-27028
Proposed Facility: Residence Property Size: 3 Acres Date Evaluated: �� 3���
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �' �
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: If--� 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 day 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
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(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DC�ID OS/99(Revised)
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