211 Ridenhour Rd DAVIE COUNTY HEALTH DEPARTMENT n� 3 J �-`� a 1
. ' Environmental Health Section ! � 1S
,
� - �- ' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001575 Tax PIN/EH#: 5754-95-5315
Billed To: Dennis Adams Subdivision Info:
Reference Name: Danny Ridenhour Location/Address Ridenhour Road-27028
Proposed Facility: Residence Property Size: apprx.7 acres
**N��*��tiis�ImprovemenbOperation 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 perrrtit(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� #Bedrooms l� #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 7AC Type Water Supply� Design Wastewater Flow(GPD)�� Site: New�Repair❑
System Specifications: Tank Size/'�GAL. Pump Tank GAL. Trench Width c'����Rock Depth��Linear Ft�/
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATTON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the 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 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
1"
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
Mceksville,NC 27028
Account #: 990001575 (336)751-876(l�ax PIN/EH#: 5754-95-5315
Billed To: Dennis Adams Subdivision Info:
Reference Name: Danny Ridenhour Location/Address: Ridenhour Road-27028
Proposed Facility: Residence Property Size: apprx. 7 acres
ATC Number: 2718
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 WASTEWATER CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: ��%�C Date: � �O �� �
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S Cha ter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee t ia system will function satisfactorily for any
given period of time.
�aa $�
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Septic System Installed By:S- 0 ��/1��/
Environmental Health SpecialisYs Signature: �1'�� Date: 'L�`�- /��U
DCHD OS/99(Revised) .
_..�.�.r..�.�.
1 - . p [� t� � � N1t�
� � • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A
Davie County Health Depa�tment �kd 1 3 2���
Environmenta/Hea/th Secbon
P.O. Box 848/210 Hospital Street
. Mocksnille, NC 27028
(336)751-8760 EI�MRONMEMAl HEALiH
DAVIECOUNiY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE.REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for ins�ructions.
1. Name to be Billed D���v�5 Adp m s Contact Peraon �N/�/�� ��q�
Mailinq Addrees ��7 "A�N�dw �—'Ti` • 8ome Phone / ]�����/
City/State/ZIP � Y��(�C� /y J,.�� 2� v�W Busineas Phone �/T�/ �� � �
2. Name on Permit/ATC i! Ditferent than Above �AN��/ �/L/ENY11���
Mailing Addresa o����%,G�/�//Ul(i�• �4l�� City/State/Zip //��G�,1LJ���C�Ne• p�/��0
3. Appiication For: Cr�Site Evaluation ❑ Improvement Permit/ATC �Both
a. syst� to seZ,►3�e: ❑ House f�'Mobile Home ❑ Business 0 Industry ❑ Other
s. if Residence: # People � � Bedrooms �_ � Bathrooms �-
❑ Dishxasher O Garbage Disposal Q�washing Machi.ne ❑ Hasement/Plumbing ❑ Basement/No Plumbing
6. If Buainesa/Induatry/Other: Specify type # People � Sinka
� Commodea � Showera # Urinals � Water Coolara
IF FOODSERVICE: # Seats Estimated Water Usage (gallona pe= a�y�
�. Type of water supply: ❑ Couaty/City " �Well ❑ Community
a. Do you anticipate additions or eapansions of tLe facility this system is intended to serve? ❑Yes B'No
If yes,w6at type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wit6 THIS APPLICATION.
Properiy Dimensions: A�U D. ? A�n�`S WR1TE DIRECTIONS(from Mocksville)to PROPERTY:
TaxOfficePIN: # S'�Sf�gS=S"3I5— Saa.9��, �DI �o �C���- o�.�
Property Address: Road Name o2r//��c��J��OLC,� /4�� �/���fiLr /1��Z �o ✓L'�y'/l7" O/'✓f 2i/���
City/Zip �O G/1 S t�j�/�j Ne.Z70i-S l�iC. .LL�'� a�l! /G,��X�i�/�L'L�UiC� �'
If in a Subdivision provide information,as follows:
Name: '
Section: Block: Lo�t: Date Property Flagged: � /�3 / a/
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 use change,or if the information
submitted in this applicatioa is falsified or changed. I,also,understand lhat I am responsible jor all charges incurred from
this application. I,hereby,give consent to the Authorized RepresentaHve of the Davie County Health Depar ment
to enter upon above described property located in Davie County and a»ved by .,; ,�
to conduct all testing procedures as necessary to determine the site suitability.
r
DATE Z�-' I� '' � I SIGNATURE y�+,�;�L�it,c� /,�L�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include alt of the fopowing: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
'�•-- Client Notification Date:
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Revised DCHD(07/99) � Invoice No. � �
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RISIN� STAR MISSIONARY BAPTIST )
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, . - DAVIE COUNTY HEALTH DEPART'MENT
� � • • ' Environmentai Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001575 Tax PIN/EH#: 5754-95-5315
Billed To: Dennis Adams Subdivision Info:
Reference Name: Danny Ridenhour Location/Address: Ridenhour Road-27028
Proposed Facility: Residence Property Size: apprx.7 acres Date Evaluated: �2'��✓
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring s� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca sition ,L_. �=
Slo %
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �� ' "
Texture ou
Consistence �r
Swcture G
Mineralo -� �
HORIZON III DEP"TH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTI-I
Texture ou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON �
SAPROLITE _
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE ,. t
SITE CLASSIFICATION: v-, EVALUATION BY: G`-���j
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
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
tru tur
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
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