1053 Ridge Rd .- ---�' _ .,
� !:_ . �
' DAVIE COUNTY HEALTH DEPARTMENT �
. Environmental Health Section - • �
P.O.Boa 848/210 Hospital Street
_— Mocksville,NC 27028
(336)751-8760
Account #: 990001139 ���y� n�y� ��i(l iafrs Tax PIN/EH#: 5707-54-1335 � �
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Billed To: StepherrCapuson Subdivision Info: (053 R�C�2.���
Reference Name: -Stephen�Capuson Location/Address: Ridge Road-27028
Proposed Facility: Residence Property Size: 27.75 Acres
ATC Number. 2550
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE*'� This Authorization for Wastewater System Construction MUST 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 WASTEW CO ON IS ALID FOR A PERIOD F FIVE YEARS. �
Environmental Health SpecialisYs Signatur Dat Oa
C �C�(�D17�5 �-�}��(�cf-� Itl �OC� = � ��bi fOc'.Iv�S
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 guarantee that the system will function satisfactorily for any
given peri�o�e. ,
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Septic Syste sta led By: �,
Environmental Health Specialist's Signature: � ate: �t
DCHD OS/99(Revised) �� ''
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`:f � . ,` DAVIE COUNTY HEALTH DEPARTMENT �`�-�3-• o
�``�'`i�. • Environmentai Health Section GG��- G's �S
� _ P.O.Boa 848/210 Hospital Street Z��
' ' . Mocksville;�NC 27028
' (336)751-8760
� IMPROVEMENT/OPERATION PERMIT
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� Account #: 990001139 �,�����(YY�r�� ��%�(11 c�,-r,S Tax PIN/EH#: 5707-541335
Billed To: Stephen-Gapuson °::;�f;s S�bdivision Info: �053 �Z��S���'�
Reference Name:-Stephen-Capuson Location/Address: Ridge Road-27028
Proposed Facility: Residence Property Size: 27.75 Acres
**N07'�*��iibgmprove�me ndOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION�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 ��ol��� #People `'I #Bedrooms� #Baths 3
Dishwasher: 4Q Gazbage Disposal:� Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � l'�S Type Water Supply��� Design Wastewater Flow(GPD)��_ Site: New� Repair❑ .
�
2� �r 1� �
System Specifications: Tank Size�GAL. Pump Tank�GAL. Trench Width c�.! Rock Depth� Linear Ft.�
o�h�: (� �1�'T�l�fto����
Required Site Modifications/Conditions: '���,(� �V l�� �O`p� �c�% �+%�t ��,
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6�BELOW
FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie County Health Departrnent 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 i allation. Telephone#is(336)751-8760.**�*
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DCHD OS/99(Revised)
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�', . B APPLICATION FOR SITE EVALUATION/IMPROVEMEM PERMIT& T
�}� •� Davie Coun ea t a
ty H I h Dep rtment ,� 200�
� /J�� � Environmenta/Hea/tfi Secbion
V' � ��� P.O. Bou 848/210 Hospital Street
� �� �/� Mocksnille, NC 27028 , � IRONh1ENTUNPf
� c (336)751-8760 - DAVIE CO
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***II�ORTANT�** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INEORMATION BULLETIN for instructions.
1. Name to be Billed u Contact Peraon '
Mailing Addreaa �//`�� /C� Cj �/�G�1 ' Home PhQ� /
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�o��,�������!l�G���$�ho e"�,�-s=7r17
2. Namo on Permit/ATC iP Different than Above --� �
Mail3nq llddress City/State/2ip �""`
3. Application For- ` : �:�e Evaluation �Improvement Permit/ATC Both
a. syatem to service�use ❑ Mo ile Home ❑ Business � Industry ❑ Other
s. =f Residence: � People � # Bedrooms � Bathrooms
� �_ �
�iehxasher ❑ Garbaqe Diapoaal $washing Machine �Sasement/Plumbing ❑ Basement/No Plumb3ng
��
Induatsy/Othor: Specify type � Peopla � Sinka
� Co�odea i Shoxera Y Urinals N Water Coolera
i
IF FOODSERVICE: # Seats Estimated Water Usage (gallona Per aay�
�. �pe of water aupply: ❑ Couaty/City �ell ^ ❑ Community
e. Do you anticipate additions or ezpansions of t�e facility this system;s intended to serve? O Yes �
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQU�E�TED
BELOW. Eit6er a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THiS APPLICATION.
Property Dimensions: °2� '����"S WRITE DIREC'fIONS(trom Mceksville)to PROPERTY:
Taa Office PIN: # i'���� ��� ��� H �PS��� �r�b L d 1
Property Add ress: Road Name�Q�fS �(LC�1 P { 1� • D P-�l,c)/�.rl �A cl�N 1`I C'f1G��E'l7l
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c�ty�z�p�l�cl �, /7G ..�?oot� � � _
W�F�- �°r�
If in a Subdivision provide information,as follows: ��-Ynn —�S�-�g�/ �)
Name: S��-�- C�-1 l 3�[ S--rf !�'�
Section: Block: Lot: Date Property Flagged: � ��G O
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the ia�formation
submitted in this application is falsified or changed. I,also,understand that I am responsib/e for al/charges incurred jrom
thls appllcatlon. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upc�n above described property located in Davie County and owned by
to conduct all testin proced es as necessary to determine the site suit$bility.
DATE � SIGNATURE
?�iJS AREA MAY BE USED FOR DRAWING YOUR STI'E PLAN(Include of t6e following: E�sting and proposed
property lines and dimensi • tructures, setbacks, and septic locations).
" � n � (� �( � Site Revisit Charge
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_ � Date(s):
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: . o PIP=PLACED IRON PIN ' I _ R�U�ERSO►� PROPERTY(D8.90 ?G.1
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�,", . ,• r,. • + DAVIE COUNTY HEALTH DEPARTMENT
� � � Environmental Health Section
- ' � + Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
% Account #: 990001139 Tax PIN/EH#: 5707-54-1335
Billed To: Stephen Capuson Subdivision Info: �.
Reference Name: Stephen Capuson LocatioNAddress: Ridge Road-2702
Proposed Facility: Residence Property Size: 27.75 Acres Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring V Pit - Cut '/
FACTORS 1 2 ' 4 5 6 7
Landsca osition �--
Slo % Z.o L
HORIZON I DEPTH � 10 - ?� O -12
Texture rou C �
Consistence � S J V `Y'S
Structure
Mineralo !'V�t P�+y�.7
HORIZON II DEPTH - 2�0 i 2- 20
Texture rou c�,
Consistence ' r$ S
Structure l� O�
Mineralo �+�xs D �.
HORIZON III DEPTH � - _p
Texture rou C.-t5
Consistence -:�
Structure Q 1�
Mineralo � ' i�: �
HORIZON N DEPTH -t G�
Texture ou %
Consistence �
Structure C�
Mineralo ,c
SOIL WETNESS '
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE t�-2
SITE CLASSIFICATION: P� �% � �tG�`�`'� EVALUATION BY: -��L� t�""'�
LONG-TERM ACCEPTANCE RATE: �'2 OTHER(S)PRESENT:
REMARKS: �� S1�QUA�� 1 J'�'�� �� ���"�"
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 day SIC-Silty clay C-Clay
CONSISTENCE ,
Moi
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
Structure
SC-Single grain ivI-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
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 sutface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCFID OS/99(Revised)
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