774 Pine Ridge Rd r
, � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r.o.Bog sasnio x�p���sr��t
Mocksville,NC 27028
(33G)751-8760
Account #: 990001200 Tax PIN/EH#: 5745-31-9077
Billed To: Bobby Cope Subdivision Info:
Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.30 Acres
ATC Number: 2447
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 wage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA TION VALID FOR A PERIOD OF FIVE ARS.
,
Environmental Health Specialist's Signature � Date: � f1�
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit
has n installed in compliance with Article 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and
Di posal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
g' en period of time.
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Septic System Installed By:
Environmental Health Specialist's Signature: �_ Date: / ��`��
DCHD OS/99(Revised)
� �' � �, DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
� � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
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IMPROVEMENT/OPERATION PERMIT
Account #: 990001200 Tax PIN/EH#: 5745-31-9077
Billed To: Bobby Cope Subdivision Info:
Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.30 Aeres
**NOT�*�'�iibgrriprove�inent/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 �� �-�0��- #People Z #Bedrooms Z- #Baths Z
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size , v�,;�c.�i� Type Water Supply�,�VN�i Design Wastewater Flow(GPD) ��V Site: New�Repair❑
u i�
System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench Width � Rock Depth �� Linear Ft.2DO�
Other: � +�,�Q.I��TI,a�_—��
,'�!� ���.��p I
Required Site Modifications/Conditions: ���l.l� �cJ GD+�'1a�Q � �� '�� � �'''"�v F-t%� �
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IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISNED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department 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)751-8760.****
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Environmental Health Specialist's Sigr�a Date: ��
DCHD OS/99(Revised)
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• • APPLICATION FOR SITE EVAUJATION/IMPROVEMEM'PERMIT&A
� Davie County Health Department �
Envi�nmenta/Hea/th SE+crion MAY 2 4 %��`:�
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 `
***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORI�►TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. xama to be sillea lf � "`• O' � contact Peraon �U v""j' �n��
Mailinq Addreas � � Gc-S 7� !>�[ J Home Phone �G!) T'""'����
city/state/z=r �lLr���l� ./��02 �G����Sineas Phone '—
2. Namo on Permit/ATC if Different than Above � ��/yL L
Maili.nq 1lddress City/State/Zip
3. Appiication For: ❑ Site Evaluation ❑ Improvement Permit/ATC �
a. syatem to service: 0 House iYMobile Home ❑ Business ❑ Industry ❑ Other
5.. If Residence: � People _�_ � Sedrooms �2 � Bathrooms �
❑ Diahraeher ❑ Garbaqe Diapoeal ashing Machine C] Basement/Plumbing ❑ Sasement/No Plumbinq
6. Zf Huaineae/Induatsy/Other: SpeciPy type B People �i Sinks
� Coa�odea � Shoxera � Urinals � Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona �= any�
�. �pe of water supply: County/City ❑ Well O Community
e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes 0 No
If yes,what type?
***IMPORTANY�**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 1, �� !"T�n�s WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Taa Of�ice PIN: # �� ys�/- 9��� �U�� � //�e ��>e /`'�''
' �' / /71�1eJ /
Property Address: Road Name �/��/\ip�c-�� � t� � ;� '"��/�a C�� ��.����%''�-
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City/Zip i�oG/�cT�/�l�i`' .,�%�� �� e 2 ���/./�ir.
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If in a Subdivision provide information,as follows: �G S d � � ��� /
Name: `
Section: Block: Lot: Date Property Flagged: ..' '� � y�C,
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafiter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted ia this application is falsified or c6anged I,also,understand that I am responsible jor a/l charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to eater upon above described property located in Davie County and owned by
to conduct all testing procedures as nece to determine the site suitability.
DATE S��F� �� �� NATURE��.—r�y�(�/ /`"/ •�
� �_ � x�--�` -I
THIS AREA MA B�S D FOR D G YOUR S �(Include all of the following: Eaisting and proposed
property lines and�i ns' ns, structur , setbacks, and septic I ations).
� Site Revisit Charge
� � ( Date(s):
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Client Notification Date:
t , EHS:
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Account No. y 2 �
Revised DCHD(07/99) Invoice No. �'��
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DAVIE COUNTY HEALTH DEPARTMENT
. � � Environmental Heatth Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001200 Tax PIN/EH#: 5745-31-9077
Billed To: Bobby Cope Subdivision Info:
Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.30 Acres 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 osition
Slo e% �'v
HORIZON I DEPTH - - �O
Texture rou (� G
Consistence ' �
Structure L
Mineralo �: I '
HORIZON II DEPTH -� - �
Texture rou G �-
Consistence •
Structure L
Mineralo i ; I l:
HORIZON III DEPTH -� k -,3
Texture rou G�
Consistence r
Structure c
Mineralo % )
HORIZON IV DEPTH i
Texture rou
Consistence
Structure '
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE �`� � �
CLASSIFICATION � S
LONG-TERM ACCEPTANCE RATE n•3 �• c�• �
, .
SITE CLASSIFICATION: EVALUATION BY: C�� �
LONG-TERM ACCEPTANCE RATE: D'� OTHER(S)PRESENT: �oV ����
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 clay C-Clay
CONSISTENCE
Moist
n VFR-Very friable i`FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�' Wet
(� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
/J NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
(� Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky
� � SBK-Subangular blocky PL-Platy PR-Prismatic
�
�
/1/� Mineraloav
1:1,2:1,Mixed
Notes
f1,- �,� Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
n0 Saprolite-S(suitable),U(unsuitable)
n�l�� Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
` V�� Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD OS/99(Revised)
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