734 Ridge Rd �' . 't ' DAVIE COUNTY HEALTH DEPARTMENT .
. • Environmental Health Section
� P.O.Boa 848/210 Hospital Street
� Mocksville,NC 27028
(336)751-8760 �-^�. � �,
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Account #: 990003819 Tax PIN/EH#: 5707-61-7704 ,' _.
Billed To: Richard Allen Sub-division Info: ��� ��3
Reference Name: Location/Address: 734 Ridge Road-27028
Proposed Facility Residence Property Size: 1.048 acres
ATC Number: 4277
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLIED 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � Date: � f �
accepted Systems mav also be use
CERTIFICATE OF COMPLETION
2- II - 4' ;
**NOTE** ' suance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been m in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems," 1 in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period oftime. /�Gr I ��, �Git,�.�
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Septic System Installed By: `
Environmental Health Specialist's Signature: — e: "
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DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT �/ '�,C1�
. ��; "� • Environmental Health Section 2 �� �v �
P.O.Boz 848/210 Hospital Street �v``
� _ Mocksville,NC 27028 (��S� �"� �S
(336)751-8760 � v- pv l
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IMPROVEMENT OPERATION PERMIT �e� � ��
� pb� �,
Account #: 990003819 Tax PIN/EH#: 5707-61-7704
Billed To: Richard Allen ` Subdivision Infa
Reference Name: Location/Address: 734 Ridge Road-27028
Proposed Facility Residence Property Size: 1.048 acres
ATC Number: 4277
**NOTE**This ImprovemendOperation 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 PERMTT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People ! #Bedrooms � #Baths�
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 L-1� Design Wastewater Flow(GPD)��1�0!/ Site: New� Repair❑
System Specifications: Tank Siz����AL. p Tank GAL. Trench Widt �l�ock Depth��Linear Ft.��
Other: �/1�f'L /� � / �- � � � �
�
Required Site Modifications/Conditions: 6
s state in 15A NCAC 18A.1
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EF�L� ��. �t�.�YS �2�'S gF� ELOW
FiNISHED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. r 1:00 .m.to 1:30 .m.on the da of installation. Telephone#is(33G)751-87G0.****
�
' �
Environmental Health Specialist's Signature: Date: �
DCHD OS/99(Revised)
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' • � E1PPLfCA71UN FOR SI7C CVALUA710N/!h(I'ItOVL•h1FM PE•R�ti11T&ATC
, Davie County Health Department
• EnvironmentalHealth Section
P.O. Box 848/210 Hospital Street �
MoCks��.iio, ��c 27028 �• .
(336)751-0760 ��
***IFlPORTANT*** TIiIS APPI,ICATION CANNOT IJE PROCESSED UNL�SS ALL TFI� RL•`QUIRED
INFOR2•il►TION IS PROVID�D. Refer to tho IN�'OR2dA�I0N BULLETIN Eor inutxuctiona.
1. Name Lo bc Dilled R ����.���. � e /L. Contact Pcr�on �f�� q y— �
7dailing Addro�a �. Ilomo Phono '" I��.3�v.�
C n
City/Statu/ZIP �l � (� Au�ino3a Phono � '
2. Namn on Permit/ATC ii Diffcront than 7lbova�/�C%j�y'� ���./''j
Mailinc� Addroa3 _� /�'(.� Q City/Stata/Zip
3. Application For: Sitc �valuation 0 Improvemen� Permit/ATC �Doth
9. syacem co sorvice: O IIouucs �2�obile Homcs ❑ Duuine3u ❑ Induatry � Other
S. Typo n}•atem roquc�tod: ❑ Conventional ❑ convantional modified ❑ innovaL•ivo pacCepted
6. If• Rn�idenca: p People �_ � Bectroom� � U DaL•2iroo�na �
LrlDi�liwa�hcr ❑Carba�o Disposal CJWashing 2dachino, ❑IIasement/Plun�ing ❑IIaaement/17o Plumbing
7. IE Duoineaa/induatry /Otlior: verify type � � Peop1Q f� Sinka
� Cosnmodoa U Showora tF Urinala p t•7aL•or Coolora
IF I'OODS�RVICE: 4E Seata Estimatcd Water Uaage (c�allona per day)
II. 2ypo of rrator aupply:�Coun�y/Ci.ty L� Wel1 � Community
9. Do fou anticipatn adclitions or cxpansioi�s of tlic facility tI�is s}�stc�ii is ii�tcndcd to sci•vc? Ll 1'cs �o �
If��cs,titi•hat typc?
**''I�iIPOItTitNT"**CLII:NTS AlUST COAIPLET�TII� RL•QUIXED PROPCRTl'INI�ORIYIA'I70N RLQULSTI:U
Itl;LO1Y. Isitltcr�PI,AT or SlTC PLAV r11U.ST BESU1J1lfI77'ED b,y tl�c clicnt ivitl�TII1S APPI,ICATJON.
l� Y � � � `
1'ro �cr(}�lliii�citsioris: \VItIT�DI1tECfIO1�S(from 11�Iodcsvillc)tu P1tOPIsIt7'1':'
•r:�r orr,��PIN: fE S".'7 fl`7 co l � 'Z 0�- � `� U�s� f1 r�a� �P_ D�r�
� �-�,�i"!
I'ropci•ly Adc1i•ess: Road Namc 7�' y��`4���f �I��C`' ' f�
T'
c;cyiz,I� ���5 �r���e, ��7� `�t � �)t _" d�S
If iri a Stibdi��isiolc provicic i»forniatio�i,as fallo�vs: `
Namc: �'"7`_�
Scc(iot�: I31oc1:: Lot: Datc Iiomc corncrs llaggcd: 1� � �
'1'his is to cci-tify tliat tIic iufoi•iiiatio�i pi•ovidcd is coi•rcct to tlic best of ii�y I.no�vledgc. I uncicrsl�t�d tIi:it any perinil(s)
issttcd licrcaftcr are subjcci to suspcnsion or rcvoca�ion,if tl�c sitc plans or intendcd usc cl�augc,or if tlic informalion
subu�it(cd in lBis applic;►liou is falsificd or changcd. I,also,turdcrslu�rrl tlirrt I anr respa�siLlcfnr nl!chnr��es irrcrrr•rc�l jr��uc
!lris npplicnfiu�r. I,hcrcb}�,bi�•c consent to tlic Au�borizcd Rcprescntatiti�c of tl�c Da��ic Cow�ty IIcaltli Dcpartu�cnt
to critcr t�po�i abovc dcscribcd property�locatcd in llavic Cou�it}'and oti�•r�cdby
to conduct all tcsling proccdures as��cccssar}'l0 cICICCIl]IIIC I�IC S1lC Slli�llilLl}�.
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Dit'I'I; SIGNr11'URL =
TIIIS AItLA 117AY BL USI:D rOR DIUIIVING YOUR SITI;PLAN(Licludc all of tlic folloti��ing: L�isling znd proposcd
property lines and Jimeusious, siructures, setbacics, and septic locations). � ,
� Sitc IZcvisit Cliargc '
� . Datc(s): '
Clicut Notific�tiou Datc:
�I�IS:
Sign bivcn '• wAccounl No. � �l t
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, , �' . DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section
+ � � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003819 Tax PIN/EH#: 5707-61-7704 �
Billed To: Richard Ailen Subdivision Info:
Reference Name: Location/Address: 734 Ridge Road-2702 ) ---�
Proposed Facility: Residence Property Size: .1.048 acres Date Evaluated: / 1%! �
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring_� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition
Slo %
HORIZON I DEPTH /. �l
Texture rou �
Consistence y �
Structure /' /
Mineralo ' l�/
HORIZON II DEPTH `� - � -
Texture rou
Consistence ,�
Structure / /
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: � EVALUATION BY:�c
�i
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND �
T, n s ape 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
T�xtutg �
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
CONSIST�.N . .
1l�lst
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� 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
Mineralogv
1:1,2:1,Mixed
lY4t�S
Horizon depih-In inches
Depth of fi11-In inches � :
Restrictive horizon-Thiclrness 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/OS(Revised)
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