187 Ralton Eugene Trail , � R ' � . . ��" �
DAVIE COUNTY HEALTH DEPARTMENT
' � Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(33G)751-8760
Account #: 990001151 Tax PIN/EH#: 5863-83-7311
Biiled To: James Reeves Subdivision Info: j�,
Reference Name: James Reeves Location/Address: Ralton Eugene Drive-27006
Pro osed Facility: Residence Property Size: 281x330x295x
ATC Number. 3115
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 ONSTRUCTION IS VA A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � Date: �//'`�.�
� 3 �ed�od�c.s
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompl ' n shal indi te the system described on ImprovemendOperation Permit
has been installed in complian wit icl of . .Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall ir�� t n as a guarantee that the system will function satisfactorily for any �
given period of time. � �
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Septic System Installed By: ����
Environmental Health SpecialisYs Signature: � Date: �`"���
DCHD OS/99(Revised)
, DAVIE COUNTY HEALTH DEPARTMENT
y• ; � '� : Environmental Health Section
�i�- ��3 -��
� ` -' P.O.Boa 848/210 Hospital Street
' Mceksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT �, J��
/
Account #: 590001151 Tax PIN/EH#: 5863-83-7311
Bilied To: James Reeves Subdivision Info: �
Reference Name: James Reeves Location/Address: Raiton Eugene Drive-27006
Proposed Facility: Residence Property Size: 281x330x295x
ATC ly�rpber: 3115
**NOTE** is 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 1] 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 �j #People ( #Bedrooms � #Baths �C
Dishwasher:� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing;,� Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply ��i/ Design Wastewater Flow(GPD) c3C�� Site: New�Repair 0
�, .� /
System Specifications: Tank Size pD.GAL. Pump Tank GAL. Trench Width�6 Rock Depth� Linear Ft.�
ocn�: o� -� ��a��ovm
Required Site Modifications/Conditions:
INIPROVEMENT/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 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.****
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Environmental Health Specialist's Signature: Date:�l�'��
DCHD OS/99(Revised)
. DAVIE COUNTY HEALTH DEPARTMENT
, ., ' ', . Environmental Health Section
: • • P.O.Boa 848/210 Hospital Street � •
Mocksville,NC 27028
� (336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001151 Tax PIN/EH#: 5863-83-7311
Billed To: James Reeves Subdivision Info:
Reference Name: James Reeves Location/Address: Ralton Eugene Drive-27006
Proposed Facility: Residence Property Size: 281x330x295x
ATC Number. 3115
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION 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 PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People '�l #Bedrooms � #Baths_�
Dishwasher: � Garbage DisposalX� Washing Machine� Basement w/Plumbing:� BasementJNo Plumbing: ❑
Commercial Specification: Facility Type #People #PeopleJShift #Seats Industrial Waste:0
Lot Size Type Water Supply_�� Design Wastewater Flow(GPD) ,`��� Site: New l� Repair❑
r� ����
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��'�2ock Depth� Linear Ft.J�UU
Other:
Required Site Modifications/Conditions:
I1�IPROVEMENT/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. .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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Environmental Health Specialist's Signature: � Date:
DCHD OS/99(Revised)
Jan 29 02 09: 33a
davie co�nty envhealth 336 751 � ��d ,' `
_ \ � �''� _ L IV . �r'�i.. ,..I- '. '
� i�l _ � � -- ll
,-.� . � � � �1. �
. `v ,`�.{�"� � � APPUCATION FOR SITE EVALUAT7UN/1MPROVE6tEPfT PERMI7' &A
���n'�'� + -� Q� 1' Davie County Health Department �---, . 'fl:��
.,,1„ � � /� ��� Environmenb/HFa/th Section • '
��Al
� /ZJ. P.O. Bos 848/210 Hospital Street � 1. �
�IZ V�' Koc3cavi1la, NC 27028 � _ ��I��
�� (336)75I-8760
**+Zl�pRTANT�+* T}iIS APPLICATION Cl�2VN0T SE PROC.ESSED UL•ILE3S ALL THE REQUIRED
SNFOFt2A:�ION IS pROVIDED. Ra£er to tha INFORt�aTION BiJLi,ETIN :Cor instructions.
n .rJ1�L,m� to b� Bill�d �n-YY1 Q_� KP�P� �(<<; Cootstst Par�on __J�C./7 ��_<w.� -�-(', r' � . .
�✓ fv
� Hailinq .1�ddrr■a �(JOr �C[c�k�/1 �4-11<<! K-C:` � tloma Phono�.3_JG•� ���/ c�` +-<i�..)�%
/1 / �
��1{/f city/atam/Zzr A�-J J G�r1 r.P_. N C� ,�"�c�0 o Husino�s P2�on.�.. 3:tG.) ��`�- �j(o :��
V 2. Nemo on P�rmi!/A2C i! Di!!�=�rft t?�ar� ]Wev + n � -
, _,��r._ rv�C `S !�P(�.� S
� lla.ilin J1ddr��a �UC:F �/ � � - ' .
� � `�rczc��C;n Vr_t���, � City/st�s_Gro. /Z3p 1?C_��;_„p�c' �.?i��.< ) o
3. Appl3cation For: &(3ita Eveiluatioa 2mprovement��t/ATC f.l Soth
.�-
a. ey.c� ca e�r..s��: FiYHouae Ll Mobila tiome ❑ Business Ll Ir�dustzy fl Other
� 1 �
s. sf Roaidanca: / p¢opla ^7 � Bedrooma J r Bathrooms ��
� ll�ni�hr��t�or 1) C�rbsqo Dispossl U'Ms�hinq tlaoitilno F.i�Hanaa�at/Pl�smbing I I na�omanG/No Plaambinfl . . �
6. i= Husinos�/Zntius�sy/Oth�rs 8psaily typa I Pooplo � 91nke .� � � �
, � � Commodo■ � � BAorars '- . / Urinale �I Hetar Coolars
SF FOODSERVICE: # Settt9 Estimated Hater U9ago (��s11an. p.r dsy)
7. lype of water supply:' D County/City L'YWall ❑ Community
e. Do you aoHcipate additloaa or ezpansiona oI the faciltty this syatem is inteoded to scrvc? !]Ycs Il No
Ifyes,wh�t type? . ._�
�+*IAlPORTANTi**CLIEIYI'S bfUSTCOAfPLETETlIE REQUJRED PROPERTY INFORMATION REQUESTED
BELOW. Eil6er a PLAT or SITE PLAN MUST BESUBhIl7T£D by Ihc ciicnt with T1ilS APPLICATION.
i
Property Dimensions: �.��•4� x 3:�0•�%�.�� ,i $•a(o�'3,fO WRtTE DIRECTIONS(1'rom Mocksvillc)to PFiOPL'RTY:
5 � 1
Taz 0(Tice PIN: # � rc /�., u y�. - .Z y C7 LU� . -f-c..��r• k� �l�.J�� �5�� i �x:�-
Property Address: Road Name �Sc:.1����� �uy��e f,I- fvrn �e{�f -�,.�.�a��!s -�.�:�..>':i�r-lo r,���� e�xr,.f
City/Zip �/r�!/�L'j�c_� N�: ��c��a i voU �/c_��1 c �F..rn �r•�� v� Yc���C'�v� �w��c•r �'•t�
!f in a Subdivisfon provide iaformatioa,as follows: �,Yc7 �• I �.,,:(r� •tr �vr.-, �c{/- �,-, /�.i l f�•;, <<ya,.�
1�Iame: Dr:vt� Pro�Pr�v i's /uan .�ar/s o�� �FeFf J'•••f
Section: Block: Loh Date Pro a S pi�' edr.•L/C y��� - �O '
Pe�'�' Sg
This ia ro certify t6at the informatioa provided is correct to the best of my knowledge. I u:nderstnnd that any permit(s)
i�sued hereafter a�e sabject to s�upenaian or revocatioo�if t6e aite plaa�or iatended use cl�ange,or iC lhe ioformalioo
submitted iu lhis applicallon is faisified or changed !.aLro,t�rtderslaad tha!1 orn ruponslG/efar a!/charges incurred jrom
thls applicatlon_ i,hcreby,give consent to t4e Anthorizeti Representative oCthe Davic County fie:�i16 Dep�rin�cnl
!o enter upoo above dcscribed property locatcd In Uavlc Couoty and owacd by .Sf!..n �.�i-�<'_Y"
..._„a�::c:a�::rs:iug procedures as aecessary to determine the sile suitability.
aA� _1.�� / OJ sicrrwz-u�E_ ��-�c�n � �f'�z-��� :
THIS AREA MAY SE USED FOR DRAWING YOUR STTE PLAN(lnciude n11 of!he follow9ug: E�sting and proposed
property line�.stnd dimensiona. atructures. setbacka, and aeptic localions).
� Slte Revisit Charge
� ' �(� '�'D Date(a):
(_?�"� ' � (�Q��� Client iVotification Dafe:
�i �aa s���.
EiiS•
j� 9�— 73 ° � �. ��,��o � �--
�� c�-� r- �
Account No. � .
Revised DCHD(07/99) `� Invoicc No. ��
- ���
�[ / � •
�/ t�C.
. -� � ��— ��3 9 ,,. � -� �,o S
,
- � '' '� • � • DAVIE COUNTY HEALTH DEPARTMENT
. ; ,� � Environmentai Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001151 Tax PIN/EH#: 5863-83-7311
Bilied To: James Reeves Subdivision Info:
Reference Name: James Reeves Location/Address: Ralton Eugene Drive-27006
Proposed Facility: Residence Property Size: 281x330x295x Date Evaluated: �l���'Z---
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring �- Pit � Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L,
Slo %
HORIZON I DEPTH � - ��
Texture rou S' �
Consistence
Structure
Mineralo
HORIZON II DEPTH � �° ..3�r
Texture rou G
Consistence
Structure �lG
Mineralo `� ,'/
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEP'TH
Texture rou �
Consistence
Swcture
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE < ,
SITE CLASSIFICATION: ►�� ' EVALUATION BY: '�
C�
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-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
tructure �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloav
' 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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