384 Ralph Ratledge Rd . � .
'' . ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �
' ' P.O.Boa 848/210 Hospital Street
- Mocksville,NC 27028
� ' (336)751-87G0
Account #: 990003737 Tax PIN/EH#: 5810-39-6845
Billed To: Dave Nelson Subdivision Info:
Reference Name: Location/Address: Ralph Ratledge Road-27028
ATC Number: 4320 As stated in 15A NCAC 18A.1969(5)
accepted Systems may also be usetl
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This 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 WASTEWA ONS IS OR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: Date: 2!
� CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with icle 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
' Disposal Systems,"but shall in�W be taken as a guarantee that the system will function satisfactorily for any
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Environmental Health SpecialisYs Signature: Date: `7 1� t9L
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
. ;,. ' ._,."' Environmental Health Section n
• P.O.Boa 848/Z10 Hospital Street �,�11�
Mocksville,NC 27028 «�-1�p(�
' �� (336)7S1-87(0 n1 `�
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IMPROVEMENT/OPERATION PERMIT
Account #: 990003737 Tax PIN/EH#: 5810-39-6845
Billed To: Dave Nelson Subdivision Info:
Reference Name: Location/Address: Ralph Ratledge Road-27028
Proposed Facility: Residence Property Size: 35 acres
**NOTE�*Th�islmproveme�ndOperation Permit DOES NOT authorize the construction ofa 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 Disposai Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type {"��E #People 2- #Bedrooms � #Baths 3
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑
Lot Size js•(�14CP� Type Water Supply V�"LL Design Wastewater Flow(GPD) 3� Site: New� 'Repair❑ '
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width 31�" Rock Depth �Z� Linear Ft. "fCD
� '1 As stated ln 15A NCAC 18A.1969(5)
��Z� Other: �f aST��Pt7rlE� �x� accepted Systems may also be used
Required Site Modifications/Conditions: I►ssra,.�oa �-�� 1� 1� �M wlqL, �-� 15�c�� p,�C��-r
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FiNISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection ofthis
��5� 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)751-87G0.****
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Feb 09 06 11:28a davie county envhealth 336 751 8786 p.z
APPLICATIO SITE EVALUATION/IMI'ROVEMENT PERMIT&ATC
' � � � Davie County Health Department
� � 4 Environmental Health Section
� P.O.Box 848/210 Hospit:�t Street
Mocksville,NC 270 Z8
n � 9 2006 (336)751-8760!Fa:(33 �'.�l 8786
ppli�a�!n For: ❑Site Evalu ' 1mFrov ent Pernut 6'Autha 'rtza+:on To Construct(A7 C) ❑Both
*"IMP APPLI' CANNOT BE PROCESSED U'dLESS ALL OF THIi REQUIRED j'
. Refer to the INFORMATION BULLfi'I'IN for mswctions. i/
�,�15
AP IN}�ORMATION
Name to be Billod 1/'d�E Pi ls°"� Conixct Person �✓�- '� S�h �� 0 �
. Billing Address ( Hc me Phone __ '_/� 'N�
City/StatelZIP Bus ness Phone � 7 �.- �� �
Name on PermidATC ifD�erent thnn Above �� �
Mailing Address _ _ City/StFde/Zip � ��5�/
PROPERTY INFORMATION �
NOTE: A uuvey ptut or aite pIm nnut acco�any this applicadon.
(Pemtit is valj r 60 mostk v�' s e plaa xpiration with conq lete plat)
Street Address / _������City :� ' Tax PIN# ���3 Q�o S'I�
Subdivision Name S tion/T.o Lot
Directio�o Site: / � u��t. ��(�,��L_ ,� 0
/10%C -0 .A - �� ,d��_ /M� ,
Date House/Facility Comers FIaggec
If fhe answer ro any of the following quaoaons is`�es",supporting documeuta:ion must be attached.
Are then any existing wastewat:r systems on the site? OYes�No..-...
Does the site conuia jucisdicdc�ml wedands? OYes.KfNo�-•-
Are there any eascments ot ri�tn�of-ways on the site7 OYes q�lYo
is the site subject W approval b�another public agrncy? ❑Yes'E]No
Will wastewater other than dom�tic sewnge bc gcncrated? ❑Yes�10
IF RESIDE E FILL OUT THE:�30X BkI.OW
#People #Bedrooms � #Bathrooms__ Gardrn'fub/Whirlpool�lYes pNo
Rasement: Yes CNo $asersu:ntPlumbing: �I'Yes ONo
IF NON-RESIDENCE FILL Oi;T THE BOX BELOW
Type of Facility/Business Total Square Foota��of Building_ #People
#Sinks #Commodes #Showcrs #Urinals
Estimated Water Usage(gallons per day) (Attach docurr.zntation of similar facility water consumprion)
FOODSERVICE ONLY: #Seats
Type system requested:�fConventional OAccepted ❑Innovative OAlurnafive ❑Other
Water Supply Type:G Counry/City W�u� �1Vew Well �Existing Well O Communiry Well
L'
Do you anticipate addiaons or txpansi�m;of the faciliry tlas system is mtmdul m servc?O Yes �IO No
]f yes.wbat type? �
This is to certify tfiat the information pro�ided on this appliation is true and cc tinct to the best of my Imowledge. I understand that
any pamit(s)or ATC(s)iuued hereaft�x are subject to suspcnsion or revocatio►if the site is altettd,the uitendod use changes,or if
the infonnation subtni[ted in this applicatiqn is[alsified or cfianged. I andersta ad lhat I am responsible jor a(l charges incurred
from this application. I hereby gcant riqh:of enhy to the Authorized Rtpresem ntive of tl�e Davie Coimty Health Departrnent to
conduct neeusary inspectio to det ' e compli widi��Plicable laws and rules oa the above desedbed property located in
Davie County and owcxd by����.(L�I/�N .
' Site Revisit C�arge
Property o 's r o r's legal npn:sentative signature
Date(s):
Client Nod6cotiaa Date:
Date EHS:
Signgiven OVes ONu Account8 3?3�
Revised 2/06 Invoice# ��
Z�
;' � lP.�}SC C.A-GI ' .
. a .
• , •'�D Tj 1V�,f�R1`�+.� � � �
APJ'LICATION 1'OR SITE EYACUA710N/l511'(iOYGft-Ni pEflSUi&ATQ �
• �.*'� �eJ-�-�;,5 ' Davio CounryHealth Ocpattmont .
• 33(,-�a Z. Environmenta/Hea/t/i Section �0 �
'-'�-PC�[7l� P.O, Box Bd8/210 Noapita2 Straot •
. M o o k s V i l l e, N C 2 7 0 2 8 � s`� I �
(336)751-8960 •
•rslllPORTANT+�*�.THSS ApPLIC11TI0N CANNOT BE PROCL•3SED pNyES9 ]1LL THE RL•'QUiRT..D . �` � �tl�`
INFOItH7►TION 23 PROViDED. Rafer to tha 22iFOItPATION SULLSTYN for inetruetione. �� ,f�,� � �
l. Nuao tu ba Dtll�d_(]A_��N��f o-.� Cone�ct Porobn�n 1� �/►,�1di.A'T-r,t I ��FG���H
Ne11inQ Addrasa�_3� K. � , �.,�p�T TC)G:J �. flf } ry�
_ �. uomo ahona _`�I'IZ.- ZE�B- O�/'i
Clty/9tau/ZIP�4l �•�. Glt-. �#�1 ��15�oDu�lnoa•?hOn�
3. Hamo on Y�rm1t/AtC it Dlftor�at Ch�a xbov� '
tt�lllnQ AEdree� � City/9[�t�/Zlp � �
7. 1lpplieation Fori �$iCo Lvalu�tion � Improvement Pnziuit/ATC � Doth t
�. 8yatcro to serviea��iouso Q L2obilc Homo ❑ Dua1a08e ❑ Induatly ❑ Othar
_ S.' 7Yp• o)•atem raqu09tWs q�Convontional ❑ ConvenCloAal modlti�d ❑ 1nAoratiro paCCOpted � - -'
/ �
s. 2f ftaaldoncos .A Peopla Z 1 De�ooms 3 o z�a�brooms �_
�lnhwaahar �Oarbag� Diapofal �wuhing Hachina Ons.emone/ri�a,inq ��ee�aont/fto vlun�lrinp � �
�. i! Duatn��a/Sn4uatry/Oehur� verily tyD• / P�oplo � sinko�=
i Commole�Z_ � +howors �
. . � 0 tlrlaal��_ / Hator CoolarA
IF FOODOERVICEt 0 Scata Eetimatad Water veagu (g�llona per day) �
•. iyps ot vatOs �upplyt ❑ Cotulty/City �;S�fell� O CommuniCy
s. co yo� .nctesa.co �d�lelons or cxpnnsions of tt�c��u'li(y this sys�cu�is(utcuJcJ to scrve?U�cs �o
If pes,�rltat typ¢?
"RklAIPORTd1V7"'�CLIENTShcUSTCOAIPLET6T11E REQU/REDPROhCRTY/1VPORM1UT10fVREQUCSTED
BCI.01V, TltheraPLATorSITF.pLANhlUSTAESUIlA/!TT/;'DbyfAetllent�vi�1tT111SAPPI.1GTfON.
!'roJurly Diu�ensiona: � � I�C J�S' 1VRITE DIRECf10N5(brout 111odcsriUc)tu PROI'ERTYr
.Tax OfTcc 1'JN: 11�.�� � O -3 y- ��ysS t-�-r 1 r o r� t� '� p�D�+-
I'roperty Address: Road 1Vamc Q��1�E1 i2r�7"[�t L� li��r�a�-r P c�a a 0 �'"�_
c►�y�z;n,ma, ��t(!�- N �a�1
If(n a Subdivlslon proviJc informalion,as follotivs:
N�mc:
Scclioa: Dlocic Lot: Aatc l�omc eorncrs DarreJ:
7'4is is to cn•flfy piat Il�c iulonn�tton proviAcJ is eorrcct to tLc bcst ot tny kno�r�edgc. I unJcrslaud fLat any pernril(s)
issucd hcrcaf�cr are svbJccc to suspcnsion or rcroalion,tf thC sitc plans or Inlcndcd usc chaugc,or iC fbc inforu�alion ,
subndcfcd in Uiis applicnttun is(a(siRcd or cliangcd t,afso,undcrsran�lUiatl anr rcrpo,uiLlejura!ld,nrgcsinairrcrlJrurn
t/ris oppiiertrlore. I,hcrcbp,givc tonscnt�o Uu Autl�orlud Itcprescutativc oC Wc DavlC Cou�tty IlcallL Dcparttncut �
lo cnter upou aLovc�cscribcJ property lonlcd Lt Davic Couuty and on•ncd by ,
con Ct AII(cSling pracCduTC315 ncccssary(0 tlCl � � uitabilily.
DATE SIGNA7'URI:
TIIIS AItEA DIAY B�US�D FOR DitAWINC R S1T� AIV(Iucludc a11 of tlic Collo�vint: Ezisliu�anJ proposcd
property IIriCS and dimCnsfOnl, structures, sctLacks, an scpHc locations).
Sitc ltcrtsit Clurgc
. Datc(o):
Clicnt NoliGcaliou DqtC:
�IIS:
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Sign glvcn____� ` . Aeeount No. � � /� S
Rcvlsod llCIID(OS/03 Invutcc No. �Q � �o �Q� �
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;;,. . -. • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' " Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003737 Tax PIN/EH#: 5810-39-6845
Biiled To: Dave Nelson Subdivision Info:
Reference Name: Location/Address: Ralph Ratledge Road-27028
Proposed Facility: Residence Property Size: 35 acres Date Evaluated: � ��(p�O�
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition L '�
Slo e% 1 O �Z�v � o'
HORIZON I DEP'TH p- —'� p - i p r
Texture rou L
Consistence S sS
Structure Gl�
Mineralo
HORIZON II DEPTH - 1 � -3 l'n -ZZ.
Texture rou � -
Consistence �
Structure � S �
Mineralo C7l
HORIZON III DEPTH J,�-- � 2
Texture rou D
Consistence P.
Structure � k !� fc
Mineralo $��,
HORIZON IV DEPTH -1 ,1- �
Texture rou
Consistence
Structure
Mineralo ... . ;
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE ,
CLASSIFICATION -
LONG-TERM ACCEPTANCE RATE .3 .3
SITE CLASSIFICATION: �� EVALUATION BY:S��":fT lx.l�l�-�' " ,
LONG-TERM ACCEPTANCE RATE: ��� OTHER(S)PRESENT: � ��n�
��s: � ��-t+ ��+--�"' �— A 93
LEGEND ,
i, n s ne P�sition
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
��.
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 �
ON4I4T ,N . . :
II'IQiS�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�'et
• NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
$ r, ,r . ,
SC-Single grain M-Massive CR-Crumb GR-Granulaz. ABK-Angular blocky -
SBK-Subangular blocky PL-Platy PR-Prismatic �
Mineraloev ' _
1:1,2:1,Mixed
�� .
Horizon depth-In inches _
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
3aprolite-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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DAVIE C4UNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
' Mocksville, NC 27028
Phone: (336)751-8760/ Fax: (33��751-8786
September 19, 2005
Dave Nelson '
5139 S.W.Hammock Creek Dr.
Palm City,FL 34990
Re: Site Evaluation-
35 Acre Tract/Ralph Ratledge Rd.
Tax PIN#: 5810396845
Dear Client(s):
As requested, a representative from this office visited the above site September
16,2005 to perform a site evaluation. Based on the information provided on the
Application for Site Evaluation and after the evaluation was completed,the site was
found to be provisionally suitable for the installation of an on-site sewage disposal
system to serve a three-bedroom residence.
House location, size and other design criteria may necessitate the use of an
alternative or innovative system. System design will be determined at the time an
Improvement Permit/Authorization to Construct is applied for and issued.
Before a representative of this office will revisit the site to issue an Improvement
PermidAuthorization to Construct,the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off. �
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
Jeff G.Beauchamp, .S.
Environmental Health Section
Enc(s)