1084 Rainbow Rd l ,
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• , . . DAVIE COUNTY HEALTfI DEPARTMENT �
' Environmental Health Section
� P.O.Boa 848/210 Hospital Street
- Mceksville,NC 27028
(336)751-8760
Account #: 990001791 Tax PIN/EH#: 5862-02-2420
Billed To: Feliowship Baptist Church Subdivision Info:
Reference Name: Location/Address: R�inbow Road-27006
Proposed Facility: Church Property Size: 2.11 acres
ATC Number: 2890
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 Counry 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: > Date: ��l
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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 guazantee that the system will function satisfactorily for any
given period of time.
. �
�Fu,I� n�f- /-�3 X3 � I a��°�e�
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, Septic System Installed By: . , ✓�'�
Environmental Health Specialist's Signature: Date:�"� G��
DCHD OS/99(Revised)
� ' - ' DAVIE COUNTY HEALTH DEPARTMENT
- , � ' • Environmental Health Section �� �' 9— d�
• . � , , P.O.Boa 8 4 8/2 1 0 Hospi t a l S t ree t
• Mocksville,NC 27028
, (336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001791 Tax PIN/EH#: 5862-02-2420
Billed To: Fellowship Baptist Church Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility: Church Property Size: 2.11 acreS
**NOTE��ThUs I-mpiovemendOperation 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 PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People #Bedrooms #Baths�
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:❑ BasementlNo Plumbing: 0
Commercial Specification: Facility Typ�����- #People #People/Shift� #Seats Industrial Waste: ❑
Lot Size i � G' Type Water Supply�'�_ Design Wastewater Flow(GPD)��� Site: New� Repair❑
System Specifications: Tank Size/��GAL. Pump Tank GAL. Trench Width���Rock Depth��Linear Ft.��
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 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
�
Environmental Health SpecialisYs Signature: Date: (D �J ��
DCHD OS/99(Revised)
•, � � .-,', •
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- �� � � � oar�
� ' ' APPLICATION FOR�lTE EVALUATION/IMPROVEMENT PERMIT&A
' Davie County Health Department
• Envinvnmental Hea/th 8ection J�N � a ZQd�
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 � ,. ENVIRONMENTAL HEALTH
DAVIE COUNTY
***II�ORTANT*** TFiIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORI�TION IS PROVIDED. Refer to the INFOR1�41TION BULLETIN for instructions. �
1. Name to be Billed��\(�����������(� Contact Person � ,Mn1C���i '
Mailing Address �, � � 1'��� �I � � Home Phone
��'�ld� �1�
City/State/ZIP ��'(1(�P ��\ � d��UU� Business Phone `�� �% l��Nn�
2. Name on Permit/ATC if Different than Above �
Mailing Address City/State/Zip
3. Application For: Site Evaluation [9�mprovement Permit/ATC ❑ Both
a. system to sezvice: � House ❑ Mobile Home ❑ Business ❑ Industry Other ��� .
5. I£ Residence: # People��,j� # Bedrooms # athrooms /-�
❑ DishWasher ❑ Garbage Disposal ❑ Washing Machine ❑ Bas�ent/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type N People # Sinks
# Commodes � ShoWers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Esta.mated Water Usage (gallons per aay)
7. Type of water supply: �CJ�Ounty/City ❑ Well � Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Ycs �J�Afa�
If yes,what type?
***IMPORTANT***CLIENT3 MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLr1N MUST BE SUBMI7TED by the clieat with THIS APPLICATION.
(� 4
Property Dimensions: � � � � I'1- WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Oftice PIIv: # 5 8 6 2, -(� L- -�(.�Z� (�--fi('� � S � � r�l��_n,(� ��
Property Address: Road Name Q d � .L (� �'
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c�cyiz�p ��'i�—�`�00� �V rv� � r h-�o h ��'�Il��ilr�—
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If in a Subdivision provide information,as follows: �' �,Lfrc� 1M``q 6 V�, �_�,
Name:
Section: Block: Lot: Datc Property Flagged: �� � �� -- ��0 �
This is to certify that the ieformation 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 tltat I am respo�rsible jor al!cllarges incurre�l from
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 � —'I — aG� SIGNATURE � fl\(1L � � L
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).
��}L Site Revisit Charge
��f�--f' Date(s):
Client Notification Date:
EHS:
Account No. I � � l
Revised DCHD(07/99) [nvoice No. d�� -3.�
. SR 1444
Rq/NgOw
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� D600000043 ���
5862�22520 �o�_.
(2 llA)
� 1084
2420
-�. ,,,: : . . DAVIE COIJNTY HEALTH DEPARTMENT
' • , , , . Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001791 Tax PIN/EH#: 5862-02-2420
Billed To: Fellowship Baptist Church Subdivision Info:
Reference Name: Location/Address: Rainbow Raacl-27006
Proposed Facility: Church Property Size: 2.11 acres Date Evaluated: ,���-�
Water Supply: On-Site Well Community Public-�
Evaluation By: Auger Boring_/l Pit Cut
FACTORS � 1 2 3 4 5 6 7
Landsca e osition
Slo %
HORIZON I DEPTH �< <�
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEP'TH �� .�
Texture rou
Consistence
Structure 19� /
Mineralo /`!? li
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
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 day 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-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloav
1:1,2:1,Mixed
N��
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
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' Da�ie Courity Health Department
��►6j� :. Environmental Health Section ` �, �. . .
� � �. P.O. Box 848 �
. ~ ,� 210 Hospital Street ..
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O U �'t "'�',:�<Courier# :�09i40-06 ' �� �• 1911
. . Mocksville;NC 27028
� ' � ' . � . �.�� .. 1�LJ .. . . .
Phone:(336)-753-6780 ' ON-SITE WASTEWA'P�R CERTIFICATION F�:(33s�-�s�-isao
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Name: �' ���hone Number�(�,�'�'j��' /�� I �(/2S (Home)
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Mailing Address: � � (Work)
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Detailed Directions To Sitec�,,���� /?7n_c�S L/r �1_Q� � S�, � ��,�/�n '� �a n� �i ,�
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Please Fill In The Following Information About The EXISTING Facility:
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Name System Installed Under: ' � rl,+��� Type Of Facility:�_��,{� r;j�
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Date System Installed(Month/Date/Year):��_n`��(?� Number Of Bedrooms:�Number Of People:
��I)A ���,:.
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Is The Facility Currently Vacant? Yes No If Yes,For How Long?
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Any Known Problems? Yes No If Yes,Explain:
.
Please Fill In The Following Information About The NEW Facility: �
Type Of Facility: �of 1���.,Q�,� �- ��w,cr�,�.m,.�Number Of Bedtooms: � Number of People�1�
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�y Poo1 Size: Gaz ge Size• Other:
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Requested By: ' � � ? � Date Requested:��' 0'2 p — �C)/f
(Signature)
, For Environmental Health Office LTse Only
Approve Disapproved • �
, _
Comments: • .
I Environmental Health Specialist ' Date:j�23�20f(
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• *The signing of this form by the Environmental Health Staf is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly foi any given period of time: .
Payment: Cash ec � Money Order # ��� Amount:$ Date: — � -
Paid By: Received By: �
Account#: �q� Invoice#:��,3f ,
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PIN: 5862022420
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. DAVIE COUNTY HEALTH DEPAR'I'MENT
• Environmental Health Section
. P.O.Boa 848/210 Haspital Street
Mceksville,NC 27028
(336)751-8760
Account #: 990001791 Tax PIN/EH#: 5862-02-2420
Billed To: Fellowship Baptist Church Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility: Church Property Size: 2.11 acres
ATC Number: 2890 �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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.i900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � J Date: (r��l
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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.
�
,�u�J� na N �.�3 X3 � ia J�°�c�
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'�, Septic System Installed By: `'"
� , . �
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�� Environmental Health SpecialisYs Signature: Date:�"� ��
�
DCHD OS/99(Revised) '
' �' •' • ' Environmental Health Section UJ� `l r �`�— L �
. � , . . P.O.Boa 848/210 Hospital Street
• Mocksville,NC 27028
, (336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001791 Tax PIN/EH#: 5$62-02-2420
Billed To: Fellowship Baptist Church Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility: Church Property Size: 2.11 acres
. **NOTE�*�Thus I-rripTovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATTON 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,Wastewafer Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � � #People #Bedrooms #Baths�_
Dishwasher: ❑ Garbage Disposal:❑ Washing Machine:❑ Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Typ�u� #People #PeoplelShift Sr #Seats Industrial Waste: ❑
Lot Size � / C Type Water Supply�� Design Wastewater Flow(GPD)�� Site: New❑ Repair❑
System Specifications: Tank Size/ff�GAL. Pump Tank GAL. Trench Width�,�`�Rock Depth�+Linear Ft.���
Other:
Required Site Modifications/Conditions:
iA'IPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISNED GRADE. ****NOT�CE: 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(336)751-8760.****
�
Environmental Health Specialist's Signature: Date: (D �.J v�
DC�ID OS/99(Revised)
; � ,
. , APPLICATION FOR�ITE EVALUATION/IMPROVFMEM PERMIT&A ��� u tiJ �
Davie County Health Department
' � Environmenta/Hea/th Section ��J � LI 2U(j�
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
. (336)751-8760 _ . ENVIRONMENTAL HEALTH
� DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
'� INFORMATION IS PROVIDED. Refer to the INFORI�iT20N BULLETIN for instructions.
, 1. Name to be Billed������C , ` �, (�—\- �� Contact Person • ` ,M�T���i
Mailing Addresa 1"� � � 1�Qx f � � Home Phone 1 �EJ����
City/State/ZIP �(����P _ 1V�\ � d-�UUb Business Phone `�' �% f��-Nn�.,'�"`�,z ie
2. Name on Pezmit/ATC if Differsnt than Above •
Mailing Address City/State/Zip �
3. Application For: Site Evaluation [9� rovement Permit/ATC ❑ Both
a. system to service: ❑ House ❑ Mobile Home O Business, ❑ Industry �` Other �-�r l
5. If Residence: t People � N Bedrooms # athrooms �
(J Dishxasher CI Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing (J Basement/No Pl�binq
6. If Business/Eadustry/Other: 3pecify .type # People i Sinks
' i Commodes $ Sho�ers -• � Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (qallons per aay)
7. �pe of xater supply: ��Gounty/City ❑ Well O Community
e. Do you anticipate additions or cxpansions of thc facility this system is intended to servc? ❑ Ycs �1.A}a��
If yes,w6at type?
***IMPORTANT***CLIENT3 MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMlTT'ED by the client with THIS APPLICATION.
� Property Dimensions: d� � 1 � 1 1� WRIT�DIRECTIONS(from Mocksville)to PROPERTY:
� Tax Office P[N: # J� g 6 �• -� L�o�C.�L� C�-EcC�"' � S � �'D I'���G`1(� �4�
Property Address: Road lYame d a" � .L (� 1- - ,B
.
c�ty�z�p�,�i 't�Cc � �. . �00��V rv� � r v��o r� �'�.�1t�—
c �- �
lf in a Subdivision provide information,as follows: ,�'���C� 1M��R 4 V� �T ,
Name: �
Section: Block: Lot: Datc Property Flagged: (�_� I� — r�- .FJO )
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,u�rderstand tliat I am respoitsible for al[c%arges iircurred jtom
this app/ication. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
. to cnter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE (r� —I — aGI SIGNATURE,�(�,D�(-11� � � �st
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAIY(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
�f ��i�}L Site Revisit Charge
J ��(-y Date(s):
Client Notification Date:
EHS:
Account No. � � � �
Rcvised DCHD(07/99) Invoice No. ��� .3 �
, � ;, . . 'SR�1444
. ' _.. . RAINgo�
- �392j no
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� m��52 °1056 ° 1060
�� 1536
. . � � 6�....
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\ •
D600000043 '�
5862022420 :'� �,�1
(2.11A) ��0� ,
. j
2420
�
- • 'r � � � DAVIE COUNTY HEALTH DEPARTMENT
, , . .
" - , , Environmental Health Section
� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001791 - Tax PIN/EH#: 5862-02-2420
Billed To: Fellowship Baptist Church Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility: Church Property Size: 2.11 acres Date Evaluated: ,�;�—�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring t l Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo %
HORIZON I DEPTH .< <�
Texture u
Consistence
SWcture .
Mineralo �
HORIZON II DEPTH �� „
Texture rou
Consistence
Structure �y /
Mineralo /�yj �
HORIZON III DEPTH
Texture rou
Consistence
Structure '
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WET'NESS
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
STI'E CLASSIFICATION: �'"-' EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: � . 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 clay C-Clay
CONSISTENCE
Moist
' VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-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-Granular ABK-Angular blocky
SBK-Subangulaz 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
' DCHD OS/99(Revised)
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