372 Rainbow Rd ' .
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' DAVIE COUNTY HEALTH DEPARTMENT
' . Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
, (33G)751-8760
Account #: 990003231 Tax PIN/EH#: 5851-87-3956
� .T Billed To: Charles Dunn Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility Residence Property Size: 18 acres
ATC Number: 3777
�
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.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FjVE YEARS.
/ / r�
Environmental Health Specialist's Signature: �L�G� Date: -s l� �
CERTIFICATE OF COMPLETION
� **NOTE** The issuance this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been instal in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Syst s,"but that the system will function satisfactorily for any
given period of ime. —
SJ� 4
60 1opx3K�P'�r�c�
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Septic System Installed By: f XJ Lv H-
Environmental Health Specialist's Signature: ����.��/ Date:�
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT �•�
, . . � Environmental Heaith Section .�'��_a�
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)75]-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003231 Tax PIN/EH#: 5851-87-3956
Billed To: Charles Dunn Subdivision info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility Residence Property Size: 18 acres
ATC Number: 3777
**NOTE**This Improvement/Operation Pecmit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 S� #Baths_��
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement wlPlumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑
Lot Size � Type Water Supply�_ Design Wastewater Flow(GPD)�lp� Site: New�Repair❑
�( f f �
System Specifications: Tank Size��AL. Pump Tank GAL. Trench Width l�� Rock Depth� Linear Ft.�
Other: �
Required Site Modifications/Conditions:
�
IN[PROVEb9ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9• of installation. Telephone#is(336)751-8760.****
�
� Sb eJ � ��a�
�
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Environmental Health Specialist's Signature: Date: � ��
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT ��
, � • Environmental Health Section � /� v
, , P.O.Boa 848/210 Hospital Street y
' Mocksville,NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
� Account #: 990003231 Tax PIN/EH#: 5851-87-3956
Billed To: Charles Dunn Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006
Proposed Facility Residence Property Size: 18 acres
ATC Number: 3777
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AL7THORIZATION 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
PERNIIT 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 #People #Bedrooms �, #Baths�_ .
Dishwasher�Garbage Disposal: ❑ Washing Machine:l� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � � � Type Water Supply�� Design Wastewater Flow(GPD)_�'�C2 Site: Ne�Repair�
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width c�� �ltock Depth��Linear Ft�d
Other:
Required Site Modifications/Conditions:
Ih1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent 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)751-87G0.****
Environmen al H 1 h i li ' i ' � Date: �O�� �
t ea t Spec a st s S gnature: � / ��� /
DCHD OS/99(Revised)
...*-'
� , - , � � �V' � � � � CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
• D : Davfe County Health Depai�ment
�AY } 2 2a(� Environrriente/Hea/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
pVVIRONMEMU� � � (336)751-8760
TANT*** THIS APPLI TION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDE . efer to the INFORMATION BULLETIN for instructions.
'f 1. Name to be Billed Contact Person
�/ �-
Mailing Addresa ��(,F �� �� '�,/��_ Home Phone �(� ��f�
�z
City/State/ZIP `_�����y.� (',p � �J�� Business Phone -
2. Name on Permit/ATC if Diffarant than Above
a�a
Mailing Address City/State/Zip
3. Application For: Site Evaluation � Improvement Permit/ATC ❑ Both
4. System to service: �FI'ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
5. If Residence: # People # Bedrooms � # Bathrooms y
ishwashar ❑Garbage Diaposal �a i�ng Machine ❑Basement/Plumbing ❑Hasement/No Plumbing
� If Susinesa/Industry /Other: verify type # People # Sinks
# Commodes� # Showers � # Urinals # Water Coolers
'�T
IF FOODSERVICE: # Seats Estimated Water Usage (galions per day)
s. xype of water supply: L`l County/City ❑ Well ❑ Community
9. Do You anticipate additions or expansions of the facility tliis system is intended to serve? �Ycs [H'No
If yes,�vliat typc?
***IMPORTANT'"°**CLIENTS MUST COMPLL•TE THE REQUIRED PROPERTY INFORMATION REQUGSTGD '
I3ELOW. Either a PLAT or S1TE PLAN MUST BE SUBMITTED by the clicnt with THIS APPLICATION.
P• ' ensions: ' /r��!� �VRITG DIRCCTIONS(from 111ocksvillc)to PROPGRTY:
,
Tax OfGcc PIN: # J ��S��'��3 / .S C� ��g.f���-r !� .�,.> �.d.
I'ropert��Address: Road Name,�Q i r��ivuJ �.�•a �,��.�- '�l�c>1�� .ClD. f!-Fcd- //��,:,�,e
City/Zip � ��U � ��_ d� � �
If in a Subdivision providc inforn�ation,as follo�vs:
Name:
Section: Block: Lot: llate l�ome corners llagged: � �3 �
Tl�is is to certify that tl�e information provided is correct to the best of my lcno�vledge. I understand tl�at any permit(s)
issued iiereaftcr are subject to suspension or revocation,if tl�e site plans or intended use cl�ange,or if the inforination
submitted in tliis application is falsificd or cl�anged. I,a[so,uitderstand tltat I ant respatsiGle for nl!clrarges iircttrrerl fra�r
r��t.s�,nrr,��r,�,l. I,I�creby,give consent to thc Autliorized Representative of the Davie County IIcalth Department
to enter upon above described property located in Davie County and o�med by
to conduct all testing procedures as necessary to determi�ie the site suitability. :
DATE ��l� ' � � SIGNATURE `� (i� �'�V,2�G�%f�l�
THIS AREA MAY BE USED FOR DRA�VING YOUR SITE PLAN(Include all of tl�e following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
o� Site Revisit Cl�arge
Date(s): �
��� � O O
Clicnt Notitication Date:
' �U
� � � 3 � EHS: �
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Sign given Account No. � � �
Rc�•ised DCHU(OS/03 1� � Invoicc No. ` U ��
' DAVIE CO. ENVIRONMENTAL HFALTH
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. , . . DAVIE COUNTY HEALTH DEPARTMENT
. • � V Environmental Health Section
' ' ' Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003231 Tax PIN/EH#: 5851-87-3956
Billed To: Charles Dunn Subdivision Info:
Reference Name: Location/Address: Rainbow Road-27006 y. �
Proposed Facility: Residence Property Size: 18 acres Date Evaluated: ��GU�
Water Supply: On-Site Well Community Public f`�
Evaluation By: Auger Boring r Pit Cut
FACTORS 1 2 3 4 . 5 6 7
Landsca osition L�
Slo %
HORIZON I DEPTH " � j�
Texture ou �
Consistence
Structure
Mineralo
HORIZON II DEPTH � �' Q+�
Texture rou
Consistence /
Structure
Mineralo ./
HORIZON III DEPTH �� � •�
Texture ou ��
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-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
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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