194 Redland Rd r.;;,---_..��.,� DAVIE COUNTY HEALTH DEPARTMENT
, • Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(33G)751-8760
Account #: 990002706 Tax PIN/EH#: 5861-48-6550
Billed To: Jeff Hayes Subdivision Info:
Reference Name: D��}1vt�►� s• ��H�U� Location/Address: off Redland Drive-27006
Proposed Facility Residence Property Size: 175 x 245
ATC Number: 3987
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 Treatm t and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW S S VA FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: ate: � '��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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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Environmental Health Specialist's Signa Date: ��
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
; ` � . � • Environmental Health Section
. •�'� ss' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)7S1-87(0 ��� ;���
�ti
IMPROVEMENT/OPERATION PERMIT
Account #: 990002706 Tax PIN/EH#: 5861-48-6550
Billed To: Jeff Hayes 9,,,, Subdivision Info:
Reference Name: �r�yr�,S.�l"a�/�if1, CB�Zy-o7) Location/Address: off Redland Drive-27006
Proposed Facility Residence Property Size: 175 x 245 /�� �,.al��(��7
�Un
ATC Number: 3987
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction ofa 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 LS SUBJECT TO REVOCATION IF SITE PLANS OR T�IE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �0��� #People #Bedrooms � #Baths Z
Dishwasher: � Garbage Disposai:❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Q�AC-Qi. Type Water Supply��Design Wastewater Flow(GPD)�� Site: New�Repair❑
System Specifications: Tank Size �'�OC)GAL. Pump Tank GAL. Trench Width��� Rock Depth 12�� Linear Ft. ��
och�:' 3 '`���T�i�T�� ��.s
Required Site Modifications/Conditions: ��� �`FFF �pc'kS�. ��'� �� p�F �E7� l—t�J�.
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW
FINISEIED GRADE. ****NOTIC :. Contact a representative ofthe Davie County Health Dep ent 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. Telepho e#is(336)751-87G0.****
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Environmental Health Specialist's S�, ature: '7D� � , " � Z '� JS"�
DCHD OS/99(Revised) ��
• �
� ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
� _ (33�751-8760/Fax(336)751-8786
Application For: 0 Site Evaluation/Improvement Permit �Authorization To Construct(ATC) � Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/1Vlodification of Existing System or Facility
***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed��o(�,� �TG�.iI r�}/�� Contact Person �r.Qrj;�y�� �'TC�,�/"� i�',._,
Billing Address�;�"� �'j-j-{ �.� ����,t � l ��f-`� r Home Phone �(�,� '�/��j�7
City/State/ZIP�6-���� � �f� ')v L �����Business Phone
Name on PermidATC if Di r nt than Above ° C'J �� r'1 I`
Mailing Address � City/State/Zip „
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pemut is valid for 0 m nths with site plan,no expiration with complete plat.)
Owner's Name �� Phone Number 7-�,"�9'���
Owner's Address �c/1 '�' City/State/Zip��(;� y�. a�j�('��
Property Address n City
Lot Size �� Tax PIN#S��=C{�Q'�-�Q
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the sife? ❑Yes �10
Does the site contain jurisdictional wetlands? � ❑Yes Cd'�10
Are there any easements or right-of-ways on the site? OYes f6No
Is the site subject to approval by another public agency? �Yes C�No
Will wastewater 6ther than domestic sewage be generated? ❑Yes �No
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms� Garden Tub/Whirlpool ❑Yes No
Basement: ❑ es No Basement Plumbing: ❑Yes No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested:. �Conventional f�'Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:j�County/City Water �New Well OExisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�No
If yes,what Type? i
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pemut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I de tand that I am res onsible for the proper idenrification and labeling of property lines and corners and locating and flagging
r s aki g the house/facil loc ' n,propo ed well location and the location of any other amenities.
"�' - ' Site Revisit Charge
Pro rty owner's or owner's legal repr' entative signature - .
. -�/ Date(s):
•' ' � Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# �L1—
Revised 11/06 Invoice#
FEB. 4. 2005 1:47PM CBT TRIAD� 998 4492 N0. 1356 P. 2 � ,
L ' ^ , • � . �/ � • s� � •
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• At'PLICATION POti SITE[VALtJAT10N/iMP1i0YCh1FM�N171hI1T S�ATC
• • . Davte County tteatth Dopartment •
� ,EnYirnnmen[a/Nea/thsection.
r.o. noa s�o/zio xo�nitiai srs�et
� Mockavil.le� xC 27028 �
(336)751-4760 � .
, trsSFlPOItTRA1T*ts TIIIS 1►PPLSCtITZON CANNOT� PROCL''SSJLD 4NLLSS N+L TIII: I2�4�kL•'D ~_••�I
INFotusATzoN Zs rxovzn�D. aoEor to tha 2NFOItrraTZott DULLLrIir for �inatructiono:__ .�
� • l. N� co be Dillud�¢�t_� S Or. `u'�����nCacC PCr�oa �_ QC�C Hc�Y�$ r �-
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Hatlsn7 ndarca� f Z7 �/1�QC�' 1�V A� l�u r� _� __ uoma rLonc ._ ...... ...
� � ' City/+"tate/ZSP � 0.�� ��/��0�6 �uD�c9a 7Luua '39_9-4�`�--- ,._._
S. Nawo oa Paraii.C/71IC i.�Li1tCtW6 than Abevc � ._..._.._... • .
ga311n9 wdarcas � � City/s ce/z1p ----._...�.._ � � - � - � . �
��!...111��,,,,...►� �-� Z �
�, appli.cation For: �Sitc Lwaluatioa J�apzovc�ent Penait/l�TC O n�c��
1 �� {. .
�. Syet�n to Stswice��liou�e C1 2Zo�ile Home ❑ Dusiae9� ❑ Induatsy � OClicr _„�
a
S. TYpe ay�tem rngueatcd�Coaventlonal. ❑ eameaeloaal mdifled Q iunbvu�lvc � ,
i. Z! aeniclencee t PQODle � Eeclroom� � ' o Duthroom:: ..Z..__.
�altvlahet QCazb3gn OLyoasl �OAing NSebino �SaocnenclPlwebiny OW:mnnnL/Ho ilwd�in� �
7. if Dualaass/Sndn�Ccy/Otllns� �u1I7 Crpe B Ycoplc 1 SinG: .
i Comwdeo 4 Shoreze � osiaale 0�aecr ceelorn�___,
, IF FOOD3ERVIC�s 4 saate �stimatnd Fiater Uaage (�allona pnr c'wy) �' '
e. zyt�c ot wacar aupply��Cou�ity�City 0 Wb21 ❑ community .
�. no you .aciciyuo �aasetoan or exgansions o[ti�c faeililr Uils syslem is iulcudcd lo scrrc?❑a'cs ��u
Ifycs,�vhatty�pc? • - • •
'"!A!1'O �•CLlENTSdif�C7'COMNIIT,ETF1 RL•'QU!/UiDNll01'L•'!Yl'YINFOIN•L\h'lONltLQUIiSPI'sll
I3BI.0 . LTlcbcr a PLnT or SITL J'L.r�f+ •SU IC17LD br thc cGcnt��ilk TkIIS Al'Pl,lC��T{OTV.
3'roperfyUimcnsiuur. �nsxa�� x��sxa4s lYltlTi;DIItECI'10�lS(fYunihlncl:srilic)ful'1tUPlilt'fl':
Taz O�ce PiCt: OS��4�-�S-�es"`S(� l54_ E0.5� '� ��s'T O r1
PropertyAddrrss: RoadNuac_(f���l0�t�� 1.)�iV'e. _�c�XG.n� I�naGl. �IC� �nnf�
cicy/z�P�c�v, .�C, al�0b �R-�v� .
ICin a Subdivisionprovidci�formaUon,as[uiloirs:
Nawc: - '
See(ion: D1ocL-: Lot: Datc homc eorncrs IIapbeei: /0
� TL'u ts to eerGfy that the infarmatiou proridcd is carrcct lo Wc 6rst of mr kaotixlutgc.1 wtJcnland lHal anp�tcn„i!(s)
issucd Gercaf�cr ara sabjcct to suspeusion or tevoea4on,if t!u stte plans or intenJed use cl�ange,pr iI Ilie tuforaiuliud
subtui(ted in tl�is appllCaiiou ts falsili¢A or cLatycd j,clto,.Wu(erstaudlJtall uni trxporisiGlc�ora!!drarga inctrrr�•�l frnm ""'
• rbis��pplicr7TG,fr. I�lcrcbp,gisccauscuttolhcAufkortu;clRcprescutatirrotctrc�avicCamq•IIcnitl )cp�rliiic t
(o ciuer upon aboti•e dcseribcd property luexlcd iu DavIe Coun�r and otiy�ccd br E,s �.eJj�
to cunduc�111 IesGng pr cGd res ns necessary tu dclermine the si[e suitab;litr. �-
brl'rL � 6 sIGNATUItE �
TIi1SAR�AMAY�USLDTOitDItAWINGYOU.RSITEPLAN(Iud callo[thoLuAo�r;ug: LsLcliugnuJprnposcd
. preperty Iincs an�I dimeusioiu, struetures,scWacks,aud septie loeations).
,
' . , Sitc ltevisit Chargc
` Dalc{s):
� , • � ClicutNolificaUouDutc: .
� I�IIS: - . ..
Sign givcp ' • A.ccount No.��. '�J'.'
. .Rnvian t Tnan rnc�m
�n.J � �G � z
. .
.
DAVIE COUNTY HEALTH DEPARTMENT .
� - ., . .
. - � , - Environmentcal Health Section ' -
� : � " '� Soi�/Site Evaluation �
_ ; ,
APPLICANT INFORMATION . -� - PROPERTY INFORMATION
Account #: 990002706 � - Tax PIN/EH#: 5861-48-6550 � '
Billed To: Jeff;Hayes � Subdivision Info: -
.. Reference Name: Location/Address: off Redland Drive-2700
�.,.: Proposed Facility: Residence Property Size: 175 x 245 Date Evaluated: �
: ' ���i. � . , . .. � . ' � .
� � '.�i.�,,� � - , . . . . . . . .
Water Supply: On-Site Well Community ' Public .
�
Evaluation By: Auger Boring � � Pit Cut : • � .
' -. FAC"TORS 1 2 3 4 5 6 7
Landsca osition � � ' .
Slo % '
HORIZON I DEPTH p— ' —�2 p—�t?
Texture rou G�
Consistence �S
Structure
Mineralo •
HORIZON II DEP'TH .-C.1-O ') - � � -
Texture ou -
Consistence ;S '
Structure S ,� ,
Mineralo ' +'• ,
HORIZON III DEPT'H .� ': .
Texture rou
'Consistence �S "- �
Structure -. S ._ ..-;-,.« • .
� Mineralo ! . . .
HORIZON IV DEPTH
Texture rou -
Consistence ; �
Structure � . • •
Mineralo -
SOIL WETNESS -
RESTRICTIVE HORIZON ` '_
SAPROLITE .
CLASSIFICATION ' �
LONG-TERM ACCEPTANCE RATE � --a
STI'E CLASSIFICATION: _ EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: D° � 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 ,
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-Slighdy 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
Mineralo�v
1:1,2:1,Mixed
ote
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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