212 Ralph Ratledge Rd �� 3_��-�
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
P.O.Boa 848/210 Haspital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001488 Tax PIN/EH#: 5811-GO-4824
Billed To: Anita Proffitt Subdivision Info:
Reference Name: LocatioNAddress: Ralph Ratledge Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2641
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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA R ONSTRUCTION IS V OR A PERIOD OF FIVE YEARS.
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Envuonmental Health Specialist's Signature: � � �. Date: l�l6 d�
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation 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.
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Septic System Installed By: �� 1 L-�
Environmental Health SpecialisYs Signature: Date: � Z
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT �� 3-�"° i
;• : Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
, IMPROVEMENT/OPERATION PERMIT
Account #: 990001488 Tax PIN/EH#: 5811-60-4824
Billed To: Anita Proffitt Subdivision Info:
Reference Name: Location/Address: Ralph Ratledge Road 27028
Proposed Facility: Residence Property Size: see map
**NOTE*�"ITii bgmpr��i ient/Operation Permit 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). THLS
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: G� Garbage Disposal:❑ Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: 0
Commercial Specification: Faciliry Type #People #PeoplelShift #Seats Industrial Waste: �
Lot Size__�__��� Type Water Sup ly Design Wastewater Flow(GPD) Site: New� Repair❑
�04� ,, ��
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth,� Linear Ft.�
Other: � S(J .(S�L� �� .
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 Depariment for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m. ' stallation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: � �GG� � Date: ��`'�b 7�� �
DCHD OS/99(Revised)
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. ", ' k� APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERRrtIT&ATC D L� � � O " �
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Davie County Health Department
� � � Environmenta/Hea/lfi SecGion �II '��6 2000
� P.O. Box 848/210 Hospital Street
� �' Mocksville, NC 27028 ENVIRONMENTAL NEALTH
� L� (336)751-8760 DAVIE COUNTY
***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULI,ETIN for instructions.
1. Naatia to be Billed �n(+�. ����-F 1'}""� Contact Peraon �j/�
Mailinq Addresa 2U�-� L(1�-�(}(���w 1�(� ie� Home Phone �9a-53�
City/$tate/2IP ��}���/ � I (�: �/ �/� �' I�p1 Busi.neas Phona
t
2. Hnme on Permit/ATC if Dif£erent than Above (
Mailing Adtlresa �tJ`-�' ��)('���� �i City/State/Zip ' �
3. Application For: �Site Evaluation ❑ Improvement Permit/ATC �PDr 1 �oth
.
e. syet� to sesvice: ❑ House � Mobile Home ❑ Business � Industry ❑ Oth
s. if Residence: t People �_ i Bedrooms _'� # Bathrooms
[ iahxasher I:1 Garbage Diaposal ashing Machine U Basement/Plumbing fJ Hasement/No Plumbing
6. Z£ Hueinees/Industry/Other: Specify type � � People �i Sinks
/ CoaodAs / Shoxers # Urinals # Water Cooler�
IF FOODSERVICE: # Seats Estimated Water Usage (qallona per aay�
�. Type of water supply: ❑ County/City ❑ Well - ❑ Coatmunity
s. Do you anticipate additions or eapansions of tLe facility this system is intended to serve? ❑Ycs �
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN b1UST BESUBMI7TED by the clieat with THIS APPLI�CATION.
Property Dimensions: S�'� �1�.,� WRITE DIRECT'IONS(from Mocksvillc)to PROPERTI':
Tax Office PIN: # �$ � � (.� ��-�- l' �� C.�1 ��
Property Address: Read Name� � e r� �� � bY1 tJU(� �����
City/Zip �CK�V� � 1�� �N ��� ` O�� �(1 7 fe �i
��lo� � �s� �� i s o r��i )
If in a Subdivision provide information,as follows: r
Name: '
`� �� I g' o �
Section: Block: Lot: Date Property Flagged:
This is to certify that the information provided is correct to the best of my kaowledge. 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 applicatioa is falsilied or changed I,a/so,understand tha!I am responsible jor all cha�es incurred jrom
this npplication. 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. , .
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DATE � �— C� � C�l� SIGNATURE '�
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THIS AREA MAY BE USED TOR DRAWIl�IG YOUR SITE PLAN(Inciude all of the following: Eaistiag and proposed f
property lines and dimeasions, structures, setbacks, and septic locations). ..
Site Revisit Charge
- ' � Date(s):
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' � Client Notification Date:
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`""� ' " DAVIE COiJN'I'Y HEALTH DEPARTMENT
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� Environmentai Health Section
Soil/Site EvaluaHon
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: '990001488- ; Tax PIN/EH#: 5811-60-4824
Billed To: Anita t'roffitt _ Subdivision Info:
Reference Name: Location/Address: Ralph Ratledge Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: //�y�
Water Supply: On-Site Well V Community Public
Evaluation By: Auger Boring__L� Pit Cut �
FACTORS 1 2 3 4 5 6 7.
Landsca osition .L, �—
Slo % .'L
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH '�' 0�
Texture rou G
Consistence ✓ I
Structure / (
Mineralo �
HORIZON III DEPTH
Texture rou `
Consistence
Struct�re '
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 i
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
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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