269 Ratledge Rd . , • � . _ . �r`--"-
. • . - - DAVIE COUNTY HEALTH DEPARTMENT
' ' -� Environmental Health Section
. . .. ,';� � r.o.Bog sasnio x�p�r�i st��t
Mocksville,NC 27028
(336)751-8760
Account #: 990002406 Tax PIN/EH#: 5727-30-3260
Billed To: David McCullar Subdivision Info:
Reference Name: Location/Address: Ratledge Road-27028
Pro osed Facilit : Residence Pro e Size: see ma
ATC Number: 3249
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 CONSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �� Date: �`' � �—�Z
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate o�Sifin�s indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article 11 of G. . apter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in W as a gu tee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: � N- � �"� "` � >1
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Environmental Health Specialist's Signature: �; Date: ! �
DCHD OS/99(Revised)
. ' '`- � DAVIE COUNTY HEALTH DEPARTMENT
.
• ��- ' - - Environmental Health Section
_ . � , � . P.O.Boa 848/210 Hospital Street ��// p �/v
Mocksville,NC 27028 �--'
±��""'--� (336)7S]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002406 Tax PIN/EH#: 5727-30-3260
Billed To: David McCullar Subdivision Info:
Reference Name: Location/Address: Ratledge Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3249
**NOTE** Th�s Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION 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 STTE 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 Type #People #People/Shift #Seats Industrial Waste: �
Lot Size C Type Water Supply //t�e// Design Wastewater Flow(GPD) 3Gd Site: New IGI Repair❑
System Specifications: Tank Size%0� GAL. Pump Tank GAL. Trench Width� Rock Depth /.� /Linear Ft.��
Other: p� '��/,�� �4G��� �,,r
Required Site Modifications/Conditions:
INIPROVEh9ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW
FINISt1ED GRADE. ****NOTICE: Cot esentative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.0 1:0 to 1: m.on the day of installation. Telephone#is(33G)751-87G0.****
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Environmental Health Specialist's Signature: Date: �—.�2?�'`� "
DCHD OS/99(Revised)
. . . � . � . � .:R
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_,�•K ` APPLICATIQN FOR SITE EVALUATIUN/IMI'ROVEMENi PERR9iT&�TC �
,� . .,�,,� Davie County Health Department - AUG - 9 2���_
Environinenfa/Hea/th Section �
. � P.O. Box 848/210 Hospital Street ENVIRO�N�EfdTAL HE��TH
- Mocksville, NC 27028 DAVIE COL1R?Y '
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROGESSED UNLESS ALL THE REQUIRED
,
INFORI�TION IS PROVIDED. Refer to the INFO�TION BULLETIN for instructions.
� L Cu���f
1. Name to be Billed ��J��/� �J1 ('� C, C l� I I �Ar Contact Person IJ AV�V f' C�n� M
���Ag �ess � t�a Cr�s �en t' Dr. �ome Phone 33�- �I��� �3 �3
City/State/zIP /•I�L r\S�I;ll e , ��. r„-1�1�c�g Business Phone 33 6 �3���;7 �3 l C1�dN,
2. Name on Permit/ATC i£ Different than Above �G�f
• Mailing Address �(�w� ( , City/State/Zip
3. Application For: l�!'Site Evaluation ❑ Improvement Permi�/ATC ❑ Both
/ �
a. system to sezvice: 0'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People ��"_ � Bedrooms 3 # Bathrooms �_
F� Dish�rasher L9'Garbaqe Disposal �Washing Machine �Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
�k commodes # Showers # Urinals # Water Coolers
�
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. �pe of water supply: ❑ County/City CI Well ❑ Community
a. Do you anticipate additions or eapansions of the facility this system is intended to scrvc? ❑Yes �No
If yes,what type?
***IMPORTAN711r**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMA'TION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the client with THIS APPLICATION.
a 4
Property Dimensions: 3 v�•gU,x 51,• a� ' WRIT�DIRECT'IONS(from Mocksville)to PROPERTY:
Tax Oftice PI1�1: # �� � �`J d r J 2 �� 1 j
Property Address: Road�N(a c� �t �2�1 ��. (�-� W11 l t �0 R ��t
c�ty�z�p Mo�Ysv�I�e / ����� Rd . T�,r� R►til•fi . Pc��r��., i 5
lf in a Subdivision providc information,as follows: � � I f t I t . 1+�C
—�
Name: �� � ��.,.��,���,t'1 �
Section: Block: Lot: Date Property Flagged: �_�To�.�f D��
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 us:.change,or if the information
submitted in this application is falsified or changed. I,a/so,understand tl:at I am responsible for all cl:arges incurred from
lhis application. I,hereby,give consent to the Authorized Representative of the Davie County Hcalth Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determinc the site suitabili .
DATE C�� � �lo�D� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: �xisting und proposed
property ling�,and dimensions, structures, setbacks, and septic locations).
�� _ Site Revisit Charge
Ca~�"�- �`r Datc(s):
� �2a-- �
S��� �- �r Clie�nt Notification Date:
��r�'�.,� �-��.e_._/y -1�
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' �� D�„� � �"���`,� Accoant No. 7 �
Revised DCHD(07/99) � � �-u� V J]--� Invoice No. �' �� � �
-t�
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� C• A• PILCHER � HAROLD P. CAMPBELL I SHA.RRI�b4.Ap�� 71 LE� �1 Q'� �
D.B. 81, PC. 499 I D.B. 145, PC. 8 5 7 � � � �� �, ,
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. � ��ev:.���� . . S 85'U'33' S 85•41'33' E —a �- ��,`
. E —� ''`" 186.20 S BS'e2'S7• E � ����%
189.82 ,
(ilE) � . ... .,�.. 113.68 .�,.!ia:
JERRY L. SHORE �;�
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D.B. 105, PC. 571
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�;� LINDA C. SHORE
y D.B. 140, PC. 70>
� I. GRADY L. TUiTERaM, CERTIF7 1Hni UHGEF'
MY OIRECTION AND '>UPERVISION, TH�°. Ma�
VA$ DRAWN FROM AN ACTU �IELL �i�F�[�
MADE BY f�,�\J,1TTERO SURVEYI G CO PaNr.
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� c336) 751 -561r.
C�� �• YORX
D.B. 95, PC. 96 I
PLAT pF SURVEY FOR�
� CINDY G. McCULLAh
REVISIONS SULE� � _ �OO� MPqOVED BY� DR�VN BY� JGSHUA
�� LTUTTERi�W
pA7E, JAN-25-20G2 �RE HVE�R4T-WBt
BEING 4.000 AC. TAkEN FRO�d THE JOHN W. GREEN PROPEPf�
SOO SO O LOO zOO 3OO � ID.B. 158, PG. 180) LYING W THE MOCkSVILLE TOWNSHIP
DAVIF fOUNTY. NpRTH CAROLINA
��,k P;� 5��7�s��
SCALE IN FEET °R""1N0 ""��''
TAX MAP RFF.�. r — z P '� °�q
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. � � • - DAVIE COUNTY HEALTH DEPARTMENT
� ��%� : ` • Environmental Health Section
_�}_ Soil/Site EvaluaHon
APPL.ICAi�iT INFORMATION PROPERTY INFORMATION
Account #: 990002406 Tax PIN/EH#: 5727-30-3260
Billed To: David McCullar Subdivision Info:
Reference Name: Location/Address: Ratledge Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: $�:�D "�07
Water Supply: On-Site Well � Community Public �
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition L
Slo %
HORIZON I DEPTH �• -�
Texture rou S' �'
Consistence
Structure
Mineralo
HORIZON II DEPTH � '� "
� Texture rou
Consistence E'�-
Structure ' -
Mineralo �
HORIZON III DEP'TH �
Texture rou
Consistence
Structure
Mineralo •
HORIZON N DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � EVALUATION BY: -
LONG-TERM ACCEPTA E RATE: '' � OTHER( )PR SENT:
REMARKS: (� '� V Ve�� ' � d y � �'�
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 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
truct re
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
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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. WASTEWATER SYSTEM APPROVAL FORM
County: ��/��'r�� Construction Authorization No.:
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I understand that the wastewater system to be installed pursuant to the above-referenced
Construction.Authorization is different from the system specified on the same document. I
approve of changing the system type to:
InfiltratorO chamber svstem, Innovative Approval IWWS-93-2-R3
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vOwner/Agent Date ;
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