327 Ollie Harkey Rd ` ' ' DAVIE COUNTY HEALTH DEPARTMENT �'`�
� �; � Environmental Heaith Section (..i d �—�—s— v J
P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001655 Tax PIN/EH#: 5803-54-4123
Billed To: Michael Ivester Subdivision Info:
Reference Name: Location/Address: 011ie Harkey Road-27028
Proposed Facility: Residence Property Size: 2 acres
**NOT�**�Ttiibginprov�em�ent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON 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 'HOl�SC #People .3 #Bedrooms_� #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: u Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size�Q`�� Type Water Supply ���-- Design Wastewater Flow(GPD) �(OO Site: New�Repair❑
,r �► �
System Specifications: Tank Size��0 GAL. Pump Tank GAL. Trench Width�J(o Rock Depth �� Linear Ft�
Other: 3 17��TQ.IL�uTio� ��Xc�. �,�ST�.�� 1...�cS ` �O.C. n�..� .� ,
Required Site Modifications/Conditions: _I�1 S'fAL�- or� C-p�1Tc�.'�,� �S�v� L�a7'��, � �,�p" �j,,,�, ���j
— - 1 S' �w+
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6`�BELOW �P
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the day of' stallation. Telephone#is(3361751-�(�0.*��G�
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Environmental Health Specialist's Signature: Date: �a � ✓
DCHD OS/99(Revised)
. � �ir
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001655 Tax PIN/EH#: 5803-54-4123
Billed To: Michael Ivester Subdivision Info:
Reference Name: Location/Address: 011ie Harkey Road-27028
Proposed Facility: Residence Property Size: 2 acres
ATC Number: 2760
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 and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONS S V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 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.
133'
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Septic System Instalied By: �-1'�A^� ����
Environmental Health Specialist's Signature: Date: 3
DCHD OS/99(Revised)
� � /.�:c�� 7'iJ�S
� ��R����� 0 �; �5�..-�-� r ,,
U
� � 6� APPLICATION FOR SITE EVALUATION/tMPROYEMENT PFRMIT&ATC
Davie County Health Department
ENVIRON�IIENTALHEALTH Envi,ronmenta/Hea/thSe�dion ' �
DAVIECOUNTY P•O. Box 846/210 Hospital 3t-xeet
Mocksville, NC 27028
(336)751-8760
***II�ORTANT'�** THI3 APPLICATION CANNOT BE PF20CESSED UNLES3 ALL THE REQUIRED
INFORMATION I3 PROVIDED. Refer to the IN1'ORMATION BULLETIN for instructions.
i. rrsma to � eiiiea T )(�N f�EL 2i>,�Si E� Contaat Paraon �'lICN�11�L �(���7'F�_
ltailinq I�ddross �yG,��Qa��IY L� �l�C/� /�� Homa phono �l���a-Q��
citY/ar.�rA/z=r y�dK��lv����_/U.�'. �7o.S��� Businoae Phono �Dy .�7�5 O�l/j .��-
2. Nam� on B�rmit/ATC i! Ditforont than l►bovo t��-- _�3{0 (� � / "- � !3
Mailinq ]kldross City/Stato/Zip m�
3. Application For: �31te Enaluation ❑ Impronement Permit/ATC �goth 3 Z?l'�
�
�. sYer.� to so��o:. f� House ❑ Mobile Home 0 Business ❑ Industry ❑ Other
s. If Reaidence: � People _,_� i Hedxooms �_ f Sathrooms ..3
�P Diehxasher t7 Garbaqo Diaposal � Haahinq MaahinQ � 8aaamant/plumbinq CJ Haswoent/xo Plumbinq
6. 2i Businoss/Induetzy/Othor: Spacify type # Paopla � Sinks
� Com�odoa i Shoxors � Urinals � l�ator Coolars
IF F'OOD3ERViCE: # 3eata Estimated Water Usaqe (Qallons po= aay�
�. Type of Nater supply: ❑ County/City � Well ❑ Comuu�unity
e. Do you anticipate addltions or ezpanslons of the facility this system is intended to serve? ❑Yes �5 No
If yes,what type?
*�*IMPORTAN7'***CLIENTS MUSTCOMPLETETHE REQUIRED PROPER'fY INFORMATION REQUESTED
$ELOW. Either a PLAT or SITE PLAI�MUST BESUBMITT'ED by t6e client wlth THfS APPLICA'�i ION.
Property Dimeasioas: __�^ A CP.t_S WRITE DIREGTIONS(trom Mocksviite)to PROPERTY:
Taz Ofiice PIN: # ������� ��� (b! /�U'��TK - Ll�'��:l Y G'ffto'�iCK �p -
PropertyAddress: RoadName o[LrE �a��K�y a��1� H��2xE�' R►� AY ��7 OLLI� NA���
City/Zip �ET1.t1EE1� � c� � �OUSE d/U'
If In a Subdivision provide lntormaHon,as follows: ��FT
,
Name:
Section: Block: Lot: Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowiedge. I understand that any permit(s)
issued hereaRer are subject to suspension or revocation,if the site plans or intended use change,or it the informatioa
submitted in thts appltcation is falsified or changed I,also,understand tha!I am responslble jor a/1 cha,ges lncurred jrom
Ihls appllcation. 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 owaed by .7�i .�i/E�STE� _
to conduct all testing procedures as necessary to determtne the site sultability. G� Y �
DATE 3/Il�/D ) SIGNAT[JRE �c.�� �i_��.�
THIS AREA MAY BE USED FOR DRAWIl�IG YOUR SI'TE PLAN(Include all of t6e following: E�sting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
. Site Revisit Cbarge
o� E < y RD
Date(s):
Ho� co�� �Tog CllentNoHfication Date:
asE ,
�{ousE �;�]-- --' EHS:
TS�pr��
TAJvK
Account No. l��J
j
Revised DCHD(07/99) % Involce No. � �
, �:,�► DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001655 Tax PIN/EH#: 5803-54-4123
Billed To: Michael Ivester Subdivision Info:
Reference Name: Location/Address: 011ie Harkey Road-2 028
Proposed Facility: Residence Property Size: 2 acres Date Evaluated: � '27 �
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 L C�- S,C�
Consistence SSS4' r S ,s� '�
Structure G2 C
Mineralo � � �� 1
HORIZON II DEPTH (p - Zt� _ 1
Texture rou
Consistence ;s : �a. ` 5
Structure Ag1c �k
Mineralo ; ► � �
HORIZON III DEPTH 20 . 4 -
Texture rou � �
Consistence F- .F`S
Structure IC � ,
Mineralo \: `
HORIZON IV DEPTH 3 �- --3(a
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .'� � S�
�
SITE CLASSIFICATION: EVALUATION BY: �� �'`f�`�
LONG-TERM ACCEPT�NCE RATE:�� OTHER(S)PRESENT: ��C�-IA� � ��T�—
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 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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granulaz 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
DC�ID OS/99(Revised)
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