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1243 Ridge Rd � ' DAVIE COUNTY HEALTH DEPARTMENT � , • s , Environmental Health Section �c�_J_�a y/ ; • P.O.Boa 8 4 8/2 1 0 Haspi ta l S tree t r Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003148 Tax PIN/EH#: 5707-26-3189 Billed To: Paula Orrell Subdivision Info: Reference Name: Location/Address: 1243 Ridge Road-27028 Proposed Facility: Residence Property Size: 15 1/2 acres **NOTE�*Thm�er. 3750 �s mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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 Artide 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS PERMTT 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 ffi #People L/ #Bedrooms� #Baths� Dishwasher� Garbage Disposal: ❑ Washing Machinez� Basement w/Plumbing: 0 BasementJNo Plumbing:� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply L� Design Wastewater Flow(GPD) ��� Site: New�Repair❑ System Specifications: Tank Sizp/�Q�GAL. Pump Tank GAL. Trench Width���f Rock Depth��Linear Ft�OO! Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW F(NISHED 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 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.**** � � Environmental Health SpecialisYs Signature: Date: L � 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 #: 990003148 Tax PIN/EH#: 5707-26-3189 Billed To: Paula Orrell Subdivision Info: Reference Name: Location/Address: 1243 Ridge Road-27028 ATC Number: 3750 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 Otl'ice 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: GZ` Date: a 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. C�eK� ��� r- � � 1 S° ���c , Septic System Installed By: Environmental Health Specialist's Signature: /1/ � Date: G� � � 6 DCHD OS/99(Revised) . . ' , ',.t� _' � f J v, _ `-1�((/ •, . A!'!'LlCATION fOil SlTL•LVALUATION/lhii'JiUVChIfNC I'L•lG19IT a il'1 L ' Davie Counfy Health Department • Environi�lenta/Hea/t/1 Section � �, P.O. Box B�II/210 HoapiL•a1. S�rceL• �� r�„,� irock3ville, rTc 27020 � (336)751-II7G0 • ***ITSPORTANT*** TIiIS 1►PPLICATION CllNNOT D� PROC�SSLD U2dLL•'S5 ALL `1'lIL izLQuzi.Lv ��.-.�� .. . � INFOItMATION IS PROVID�D. Retor t;o L-ho INI'ORt3ATI0N DULL�TIri �or in�L•rucL-ion�t: • 1. Namc to be Dillcd u.lQ. DI 1 �I � ConLaeL I'ci::on 1_�-(�CX�_.. 2•lsiling Rddre�s I O�''1 -J �(_.I�Je Ifanc Plionc a ao 5g . . . � ' �--.._..._. City/Statc/ZIP rn�� ���� II'e-. N � a�oa� Du�ineJa lli�uc '1 �� ����� 2. Namo on Pcrmit/nTC iP DiLLcrent than l�bovc � ___,_........... . .. . Mailing nddreas City/SCaI•c�(i.i ^-•�.._...._..... .._..._ . 3. Application For: ❑ Site Evaluation �inprove nenL Pennil:/ATC ❑ 210 L-li a. sYtcc� co Service: �Housc ❑ 23oY�ile Home 0 Du�ine�� O Tndu.,txy ❑ ot;l�cx• __ ___..__._ � S. Typc sy�tem requcsted: ❑ Conventional ❑ convcntional uiodiEicd 0 ic�novaL•ivc G. TL Residence: if Peoplc T U Bedroom� � I! DaL-lirouinu �l( a' UDiahwaaher ❑Gsrbagc Diapo�al L'TWa�hing Diachino ODa�esnenL-/l�lwnbl.n� L'�Ua:.•emenC/i7o 1�luiubiii� 7. IL Dusinc3s/Industry /OCher: vcrity Cypc If Pcopin I} Sinl:� ..__..._.___ � Cozimodes Q Showcrn 1F Urinaln 1} WaCcr Coolur� IF FOODSERVIC�: �� Seata �stimated S4ater U:;agc (gallona per day) � _..____.__.____. e. Typo ot watcr aupply: Ll Coun�y/CiEy ❑ Wcll ❑ Conuuuni��r 9. no you anticipatc additiona or expaiisious of thc f:icility tliis s��sici�i is iiilciiQcd to scrvc?Cl �'u '�� Ifycs,titi•liat typc? • ' _. ***lAIPOIZ'li1�Y'l'`**CL1LnTSd1UST COAl1'LGTI:'fl1L; ltLQUl1tGU 1'lt01'l:lt'i'Y li�ll�Oltll�lA'1'1UN 1tLQ111:5'1'I�:ll^ '�•-I i3GLO1Y. �i(hcra PLAT orS1T�PLr�N�1IUSTITCSU11�1fl77'GD by thc clicnt �riUi'1'IItS�11'P1,1CA'I'IOIV. � � 1'►-up�rl)•llititctisiuus: � �I ��- a�'e S 11'IZI'1'1:ll11ZLCl'IUNS(l"ruiu tl�lucl;s�•illc) lu I'RUI'l:i�'1'1': i:�x orr,«rirr: r� 5�o�ac�31 S q f-I�w v �� A as+ l-�. (`� S —�-�-=--- Proper(y Address: Road Namc (a�3 � � �"D Rl C�(��. ��` • �'l.11r r� �...e-�t" • � , City/'Lip I�l�(�KS�JII�t. N�a�oa� On �iC�qe. Si-� � ��a rni ��eS l If iii a Subdivisioii providc iuformatio�i,as fullotivs: l71'1 �I U h�" ' Q�►"G� 'tCxl�e- n�a„��: � � � or� bo-f^h si des o-F c1 ri Je . Scctiou: Blocic: Lot: Datc l�onic corncrs Aabbcd: CJ— �p r O`� . L....1 . Tliis is lo ccrtify tvat tlic inforruztiou providcd is c rrcct to tlic bcst of iiiy lcuotiti•lcdbc. ,I Ull(IL`I'SIAIl(I III:II auy periuil(s) issucd licrcaftcr are subj'cct to suspcusion or rcvoc�l��,.it.tlie-s'r�plans or;,,c�„J�� US����:►„b�,�►•�r u��;��r�t•��►:►Iio,� submittcd in tliis applica[iou is falsi1icd or ciiaubcd. I,�Iso,«rr�lcrsla�l�1 lh�if!aiu rcaf�uusiLlc fui•u!!c/rcrr�es iirc«rrr�!f'run, tlrisup��licaliurr. I,licreb�•,bivc couscut to ttic Aulhorizcd Rcprescutativc of(lic 1):n�ic Co«uly llc:i!(li 1)cp:ir(iuwif (o cntcr upoc�abo�•c dcscribcd pruperl��lu�atcd iu llavic County aud otiti•ucd by ��1(�-f,Qh � Pa,�Drre.l � � tu cui�duct all tcstii�g procccluc•cs as ticccss:u•y lo�ctci•i►iii�c tlic si(c sui�ability� ' DA!'�; � — tQ � O�-I' SIGNA'fUI2L �' ���� TIiIS AREA 11'IAY 73�USi'sD TOR DRAWING YOUR SIT�PLr�.l�f(IucIudc aIl of llic follotivinb: Lxisliub.uiQ pr�pusccl property lincs autl dimctisious, structures, sctbacics, and scptic locatious). � � , Silc ltct�isil Clcu•�;c � o��. Datc(s): _ . • U ��SyS�- CliciilNolilicalioiillatc: � , S���a s h�.J �IIS: � ��� . �' � Sigci givcn_�`S ✓� � �, �u�� Accou�it No. � Z �� =�� / � � - 1 , ;� �, �flA, 8583 - 7439 �:�; �� ` � 735 (�,� P �.. s � �� �J � (3.56A) z.� � , 13Q,� , ����. � (y2q/ � ^� �h., _ � ( � �z' ,�� m a OOA) ��'. �,sl . - 3028 �5�2� � � 6912 ,�� �,S ��� . 1 � 78 �3 . 3.�67A ���� �' ' � n - 3s � 0688 �y � � �,�,.A) : ('��� sas `y�,'17 � ' '�'�s ,.. 31$ �(� _ ���, � J� V � � <,. : ^� , ' Y'I �V � �ti � � (15 34A) •� 3189 �3 - ` #; bti r�'> s ,zo >, � ..-- 1g� I � 12C � ; � , , . , � . , , , . .� , , ,�� .,_ ~ 1S[ Q " O\� y�-"` � 14.194A �/' ' �� 6288 g ^ � . � � � `` z. �t � 3C �./, , �` - - ----' I sry � 255 �Z��as . 9693 {.g 68.429A - C:I �, ' ��,�� .•:,. . ' . DAVIE COUNTY HEALTH DEPART'MENT • Environmental Health Section � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003148 Tax PIN/EH#: 5707-26-3189 Billed To: Paula Orrell Subdivision Infa Reference Name: Location/Address: 1243 Ridge Road-27028 Proposed Facility: Residence Property Size: 15 1/2 acres Date Evaluated: , Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 : Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou ' Consistence Swcture Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 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-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 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 DC�-ID OS/99(Revised) ��r.,.r. .... .. -t�,.. .��;-.... ,,.... �,«... ;......r Ar+ .av.. .. . . .. . � . . . . � ... . . ._,,.._... ` - ' _ .` . �O � ... �- � r , •; �,.` � , �`. DAVIE COUNTY HEALTH DEPARTMENT '��9� � � ag , ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION (,{�,,��'J ' .•NOTE:Issued in Compliance With Article II of G.S.Chapter 130a �� Sanitary Sewage Systems Permit NUmb9rd� Name .. �r�vf> ;;- , /� ��;,i'..,;,t• _. Date �'���� N� 7 8 6 5 a r�-�� Location �SL�.LG.���� ��/ / Y /� l �7 �r'//i7 I'C" !'. !" _t'.%'i�' �'. /�� ��� � Subdivision Name � Lot No. Sec. or Block No. Lot Size ���� .� House _ Mobile Home ..l�' _ Business __ Industry No. Bedrooms �_.No. Baths _�— No. in Family 2 _. Public,Assembly \ Other Garbage Disposal YES Q NO � Specifications for System: Auto Dish Washer YES � NO p �^� / --. /[/G''✓r/�.4� l�/ . Auto�Wash Ma^hine YES NO p rY 7ype Water Supply ., �1� -----=---- ad��.��" %� �� ,.;,:.. .. �...��:::.:_..... . ,..-:. _..."-..1 � .. 'This permit Void if sewage system described below is not installed within 5 years from date of issue.' This permit is subject to revocation if site plans or the intended use change , ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEETHIS PERMIT/LAYOUT BEFORE INSTAWNG T IS SYSTEM. �"" .�'�r�'�'vt j�i/. /�/C�//f /�r,•sz/ �v `jl,�, (� S"/r�J /,�/� - _______ ' , ._--„�..�--- �f J�/G•,/,%c yv. I� ,�� :1/�%f/!� �` _ '� � f � . _ . • ' : � � � � � ; � ��CG�DS ' ' ' �/��'� . ' ;� . . i' • . • ' Im rovements permit b _1 LLj P Y •Contact a representative of the Davie Counry Health Department for final fnspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day o(completion.Telephone Number:704-634-5985. Fina1 Installation Diagram: System Instalted by �:,� , L� I� U . � , , _ 6�` ` Certiticate of�Completion _���� _,_ Date ^7�����5� _ 'The signing oi this certificate shall indicate that the system described above has been installed in compliance with the standards set torth in the above regulation, but shall in NO way be taken as a guarantee that the system will function,.