853 Redland Rd DAVIE COUNTY HEALTH DEPARTMENT �J� �, � �v ?
Environmental Health Section �
• ' � � P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001648 Tax PIN/EH#: 5862-26-0978
Billed To: Terry Smith Subdivision Info:
Reference Name: Location/Address: Rediand Road-27006
Proposed Facility: Residence Property Size: see map
ATC Number: 2785
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AIJTHORIZATION 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
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR Tf�INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People_� #Bedrooms � #Baths �1�
Dishwasher� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply C +� Design Wastewater Flow(GPD) i�� Site: Ney� Repair❑
, ,� �
System Specifications: Tank Size�('�GAL. Pump Tank GAL. Trench Width� Rock Depth�� Linear Ft.c��6
Other:
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 Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:3 p . n the day of installation. Telephone#is(336)751-87G0.****
/
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Environmental Health Specialist's Signature: , � Date: �''���,(�f
DCHD OS/99(Revised)
�-�(
' ' � � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001648 Tax PIN/EH#: 5862-26-0978
Billed To: Terry Smith Subdivision Info:
Reference Name: Location/Address: Redland Road-27006
Proposed Facility: Residence Property Size: see map
ATC Number: 2785
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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA C NSTR C IS V F A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � Date: -����/
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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 tee that the system will function satisfactorily for any
given period oftime. � 6�
�D
$0
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k
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Septic System Installed By:
Environmental Health SpecialisYs Signature: Date: 7"'���`'�J �
DCHD OS/99(Revised)
J
. �� � ���-` . .-_�
• - ~ � a �y� � �
. • • �' `�- � .._ � � �
`�,� APPUCATfO(V FUR SffE EVALUATION/IMPROVfMEM PERMIT&ATC � �
Oavie County Hea{th Depa�tment • � 2 ' �
�j Envi�nmenta/Kea/tfr Sedion
`� P.O. Box 848/210 Hospital 3treet
Mocksville, NC 27028 ENV4RONMENTAL HEAITH
(336)751-8760 DAVIE COUNTY
***II�ORTANI'*** TFiIS APPI�ZCATION CANNOT HE PROCE3SED VNLESS ALL THE REQUIRED
INE'OR2�TION IS PROVIDED. Refer to the INE'ORMATION HUI,LETIN for instructions.
1, xsmo to bo sillod l� . � contaat Porson /�
lSailinq 7►ddraei � Q Homo Fhoao��l1 ��/
City/Stat.o/ZZB H��l(XnC� 11lG �7���i Husinoss ?hono,
j-r
2. Nam� on P�rmitl�C if Dilt�rant thus 7►bovo
Hailinq 1►cldr�a• City/$tatoJLiP �� ,
3. Appiication For: �31te Enaluation Impron�nt Permit/ATC � Both
�. syst.� to sa�s�.: 0 House �Mobile Home ❑ Busineas ❑ Indust=y C! Other
�a. It Residence: t People �_ � Bedrooms .� � Bathrooms �,�,,,,
�Mshwashar i] Garbaqo Dispo�al �Nashin9 Hachina U Haaomant/Plumbiaq O Hseomant/No PlumbinQ
6. Zt Husino�sllndustty/Othar: 8pocily type f Paoplo t Sinks
� Co�das � Shoxors � Urissals � ifator Coolors
IF FOOD3ERVICE: � 3eata 8atimated Water Usage tQauon. �r amY)
7. �pe ot .rater supply: �COunty/City ❑ i�Tell 0 Community
e. Do you anticipate addiHons or e�pansions of the facility this system is intended to serve? O Yes `�No
If yes,what type?
***IMPORTAN7'�**CLIENTS MUSTCOMPLETETNE REQUIRED PROPERTY INFORMATION REQUFSTED
BELUW. Eit6er s�T or SITE PLAN MUST BESUBMITTED by t6c client with THIS APPLICATION,
-___�—
Property Dimenstons: WRITE DlRECTIONS(from Mocksville)to PROPERTY:
Ta:om�e nv: # ��[�� -� t� a G 7� /SS �A 5'� P d f��//�,ctd �'d �
PropertyAddress: RoadName���QY1� � �-•t�� O<tJ` (��c� li4�c� �C��
City/Zip�'dlll`�"IJLE N�. /YJrf p_ 5 l9rf/` �e�`j
If tn a Subdlvtston provide infocmaHon,as follmrs:
Name: 1
Section: Block: Lot: Date Property Flagged: �� � �
This is to certify that the informallon provided is correct to the best of my knowledge. I understand thAt any permtt(s)
issued 6ereaner are subJect to suspension or revocatioa,i[the�ite plans or iatended use change,or if the information
submitted in thts appticaHon is Calsttied or changed I,also,understand thal 1 arn responslble jor a[l charges tncurred jrom
t61s appllcatlon. 1,bereby,glve conseat to the Authorized Representative of the Davte Co�nty Health Department
to enter upoa above described property located in Davie County and owned by
to conduct aU testing procedures as necessary to determtne t6e site suitability.
L l�'� � � f SIGNATURE x r
DATE �
THIS AREA MAY BE USED FOR DRAWING YOUR.SITE PLAN(Include at f t6e following: E�.iting and proposed
property Ilnes and dtmensions, structures, setbacks, and septic locations).
Site Revisit C6arge
Date(s):
Ctient Notiiication Date:
EHS:
Ac¢ouat No.
1 � � �
Revised DCHD(07/94) ' Invoice No. -�—. 5 � 3�3 �
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, . , f . ` . . DAVIE COiJNTY HEALTH DEPARTMENT
. � • " Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 890001648 Tax PIN/EH#: 5862-26-0978
Billed To: Terry Smith Subdivision Info:
Reference Name: Location/Address: Redland Road-270p6
Proposed Facility: Residence ' Property Size: see map Date Evaluated: :��2��/�l
Water Supply: On-Site Well Community Public t�
Evaluation By: Auger Boring b/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca sition ' ZL
Slo %
HORIZON I DEPTH �' '-
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH " � �
Texture rou
Consistence
Structure i
Mineralo ;
HORIZON III DEPTH �
Texture rou '
Consistence
Structure .
Mineralo � �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS ` .
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE '�
SITE CLASSIFICATION: ►n� EVALUATION BY: n YcY /
LONG-TERM ACCEPTANCE RATE: ' _ OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
exture
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
ois
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
Mineralo�v
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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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/270 Hospital Street
Courier #09-40-Ofi
Mocksville� NC 27028
_ ....,. ..;
,Phone #: (336)757-8760 ' -
Mazch 28, 2001
Terry P. Smith
725 Redland Road
Mocksville,NC 27028 _
Re: Site Evaluation/Redland Road
Tax Office Pin: #5862-26-0978
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on Mazch
27, 2001. Based upon the information provided on the Application for Site Evaluation �
and after an evalua.tion was completed on the site,the site was found to be provisionally
suitable for the installation of an on-site sewage system
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this offce.
Sincerely,
/1,4�����• ._
Robert B. Hall, Jr.,RS.
Environmental Health Specialist
RH/di
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