130 Pondview LnDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003353
Tax PIN/EH #: 5862-24-7946
Billed To: Alan Cain
Subdivision Info:
Reference Name:
Location/Address: 130 Pondview Lane -27006
Proposed Facility Shop
Property Size: 1.80 acres
ATC Number: 3873
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 IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: 7letl
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.
Nol
Septic System Installed By:
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
V�12-p tyT
M
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section L
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003353
Tax PIN/EH #: 5862-24-7946
Billed To: Alan Cain
Subdivision Info:
Reference Name:
Location/Address: 130 Pondview Lane -27006
Proposed Facility Shop
Property Size: 1.80 acres
ATC Number; 3873
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 (S #People #Bedrooms A14 #Baths /
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industria11l Waste:
Lot Size • �''1�-� Type Water Supply &AVDesign Wastewater Flow (GPD) �� Site: New ValRepair 13
System Specifications: Tank Size /PnAL. Pump Tank GAL. Trench Width Rock Depth Jv Linear Ft.hj
Other:
Required Site Modifications/Conditions: — Ka G41 -1-F "1046' hd /D I
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISIIED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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 (336)751-8760.****
I
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Environmental Health
DCHD 05/99 (Revised)
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Date: 1// / 104'�
LL Qa
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
EnvironmentaiHeald? Section RDrZEECP.O. Box 848/210 Hospital Streetll�yMocksville, NC 27028(336)751-8760 p
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES AL THE REQUIR
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETfor }Il tions.
�E
1. Name to be Billed Contact Person /
Mailing Address .n IIt ^'s Home Phone
City/State/ZIP -Adm-2eecr Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For:�te Evaluation )❑�nprovement Permit/ATC ❑ Both
4. System to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry they
_410
5. Type system requested: onventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals f # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: X County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 8<0
If yes, what type?
"**IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensio
Tax Office PIN: # ,S lU �� / / cl I
Property Address: Road N eam �9aAe( LA el") L-11
City/Zip AV Vic" /J e
If in a Subdivision provide information, as follows:
Name:
WRITJ DIRECTIONS (from Mocksville) to PR PERTY•
�
�JLi
Section: Block: Lot: Date home corners flagged: 5;�- / 1i'/`
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred front
this application. 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 owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE In — A, ) SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
77-,-, •�
Sign given C5
Revised DC D (05/03
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. 3
Invoice No.�
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- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
• NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewa a Systems Permit Number
Names r� N a- s C1 _ Date - N2 16 9
Location 13 `� 1_' • s""i .� 2 ` b Q Cc\ 4; R� Q T� ,C .� r' 00 I Subdivision Name `' Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business -- Industry
No. Bedrooms —. No. Baths — —� No. in Family — Public Assembly Other
Garbage Disposal YES Q NO [E� Specifications for System:
Auto Dish Washer YES ®/NO Q
Auto Wash Ma:hive YES -[;/NO,,
TypeSupply
YP Water
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site`plans or the intended use change. y
0
Improvements permit by
Q
L
Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by — •�
J I
Certificate of Completion Date � � A9r
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
APPLICANT INFORMATION
Account #: 990003353
Billed To: Alan Cain
Reference Name:
Proposed Facility: Shop
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5862-24-7946
Subdivision Info:
Location/Address: 130 Pondview Lane -27006
Property Size: 1.80 acres Date Evaluated: 1 jc�,p
Water Supply: On -Site Well / Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L. -
Slope %
HORIZON I DEPTH
p- 1
Q- 2
Texture group
61,
Consistence
G -CI '
Structure
Mineralogy
HORIZON II DEPTH
19
Texture group
C, -
Consistence
__
Structure
c
-
Mineralogy"7G
HORIZON III DEPTH
r 3
Texture group
Consistence
Structure
Mineralogy
AL
HORIZON IV DEPTH
-1
Texture group
Consistence
SS Sim
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: 04
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT: &i A
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
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
Mineralogy
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 - gal/day/ft2
DCHD 05/99 (Revised)
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