226 Peoples Creek Rd ��
' DAVIE COUNTY HEALTH DEPARTMENT
• ' ' Environmental Health Section � �� aS
P.O.Bog 848/210 Hospital Street
Mocksville,NC 27028
(33C)751-8760
Account #: 990003656 Tax PIN/EH#: 5789-52-5027
Billed To: Patricia Cope Subdivision Info:
Reference Name: Location/Address: Peoples Creek Rd.-27006
ATC Number: 4125
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLJST 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: �
CERTIiTCATE OF COMPLETION
**NOTE** T'he 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.
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� �Septic System Installed By: , .�i', �'—` �%�� � ���•r
Environmental Health Specialist's Signature: � i' Date: �L�.��_�—
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT /��.-� 2 � --O S
_ Environmental Health Section �
. , P.O.Boz 848/210 Hospital Street
� Mocksville,NC 27028
(336)751-87Cr0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003656 Tax PIN/EH#: 5789-52-5027
Billed To: Patricia Cope Subdivision Info:
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility Residence Property Size: 3.163 acres
**NO'1'E�*"Th�is�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 Speci �cation: Building Type #People� #Bedrooms_� #Baths��
Dishwasher: Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: 0 Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply�_ Design Wastewater Flow(GPD) 'L� Site: New�Repair❑
System Specifications: Tank Siz%pGAL. Pump Tank GAL. Trench Widtl� Rock Depth��� Linear Ft.'7�1��
A� zt�i�d ln 15A �.CAC 18A.1969(5)
Other: =�..�tE� g�,-t�m� may atso bg used
Required Site Modifications/Conditions: ,��
I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLU F S�. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Ith Department 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 d ��n. Telephone#is(33G)751-87G0.****
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Environmental Health Specialist's Signature: Date: � �p�
DCHD OS/99(Revised)
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, � �U"�l� � U lS
� , • APPUCATION FOR SITC EVALUATION/IAIYROVCM1tENT PER�ti TC
• �,� •, Davie County Health Department ���� 2 � ���
` �• En vironmenta/Hea/t/�Section
P.O. Box 848/210 Hospital Streo�
Mocksville, NC 27028 E;,;,•,y;;,;�1Tf.il�'',u:1
(336)751-8760 C.;';ECOt�dtY�
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to tho INFORMATION BULLETIN for inatructions.
1. Namo Lo be Dillad�/-t/ �`�iL/,/�' / �► / , ����� Contact Peraon
biailing Addross Z7'� j"�cT�"� (Jl. ��E' Fiome Phone ��(� �� �"`�
City/Stata/Z2P ��7�/(��k' ��� ����' Susinesa Phone / � C� �� U� o�C, �
2. Nama on Permit/ATC if Different than Abova
Mailing Addreas City/State/Zip
3. Application For: ��ite Evaluation �nprovement Permit/ATC �Both
4. syate�n to Service: @�Fiouse ❑ Mobile Home ❑ Business ❑ Induatry ❑ Other
5. Typo nyutem requeatod: ��onventional ❑ conventional modified ❑ innovativo pacCepted
5. If Re�idences S People � # Bedrooms � 8 Bathrooma J�
���hwaaher ❑(3arbage Disposal �lashing Machino ❑9asement/Plumbing ❑Basement/No Plumbing
7. If IIuninesa/Indust•ry /Othor: verify typa # Peopla fk Sinka
# Commodoa N Showera q Urinala R WaCor Coolero
IF FOOD5ERVICE: # Seato Estima�ed Water Usage (gallons per day)
8. Type oi watar aupply: � COunty/City ❑ Well ❑ Communitiy
[`
9. no you anticipate additions or cxpansions of tl�c facility tliis systcm is intc�idcd to scrvc? ❑Ycs �
If ycs,tivliat typc?
***IhlPORT'ANT'�**CLILNTS MUST COdiPLETETII� REQUII2ED PROPCR7'1'INFORhIATION RI:QUGSTGD
[3EI.0�'V. Githcr a PLAT or SITG PLAN 1L1UST BE SUIlA11TTED by thc clicnt with TIiIS APPLICATION.
Propert}'Ditncnsiotls: cJ. f G�) �• �VRIT�DIRGCTIONS(frun�Nlocicsvillc)tu PROPCRTI':.'
Taa OCGcc I'IN: # ��� �/ �l �����.-� / �
✓
Property Address: Road Name��r✓���S �E�� _ il/ %t�,�-- u� ���G":�z�� C�i-��
City/Zip /TCl��]f°C� �i/Y" � �i�-�-�� �'r-, l��- ���.L ��'��/�h- �""
f2�G'G(J J
If iii a Subditi�ision providc inforn�atioii,as follo�vs: �%�� 9� 7���a %<t�
Namc:
Section: Blocic: �Lot: Date l�ome corners tla ged: �� Z�-�J�
/� p� l�'� "�or'�� %o �l'.� _.
� �
17iis is to ccrtify that tlic information providcd is ca•rcct to thc bcst of my knotivledga I undcrstaud that any permil(s)
issucd licrcafter are subject to suspcusion or revocation,if the site plans or intendcd use change;or if tlic information
suUmitted in tl�is application is[alsired or clianged. I,also, tuiderst�lnrl tliat 1 nm responsiGle for al!charges inctrrrerl frour
tlris applicatio�r. I,hereby,give consent to tl�e AutGorized Itepresentative of tl�e Davic County�IIealll�lleparhne��t
to enter upoii above described property located in Davic County a�id o�vned Uy
to conduct all testing procedw�es as necessary to determine the site suit 'lity.
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llAT� CD � � SIGNATURI; � .�cr'✓ /� /
T�IIS AR�A MAY B�USLD TOR DRAWING YOUIt SI'1'I;PLAN(Licludc all of thc follo�ving: E�isting nnd proposcd
property liius and dimcnsions, structures, setb�cks, and septic locations).
Silc ltevisit Ch�rgc
�`��?atyz<� ��.i d�G�. `f�lt�f�- . Datc(s):
^ _ � � n���' -
y�� ��`�� �� Clicnt Notilicatiou Datc:
�IIS:
Sign given '. Account No. ���1�
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Reviscd DCIID(05/03 Invoicc No. ( � �--
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. DAVIE COUNTY HEALTH DEPARTMENT
' , � Environmental Health Section
' �, Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003656 Tax PIN/EH#: 5789-52-5027
Billed To: Patricia Cope Subdivision Info:
Reference Name: Location/Address: Peoples Creek Rd.-27006 �
Proposed Facility: Residence Property Size: 3.163 acres Date Evaluated: _��._O_�-
Water Supply: On-Site Well Community Public�,�,
Evaluation By: Auger Boring_ Pit Cut
FACfORS 1 2 3 4 5 6 7
Landsca e osition 1�
Slope % Q
HORIZON I DEPTH �'p �< <�
Texture grou
Consistence r-
Structure G
Mineralo -/ ,�!
HORIZON II DEPTH �� l.�
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: � OTHER(S)PRESENT:
REMARKS:
LEGEND
i, ndscape 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�Ctur�
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
ONSI�T�.N .
�415�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
StillsYurg
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
LI�
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/OS(Revised)
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