402 Riverdale Rd � DAVIE COUNTY HEALTH DEPARTMENT ,� c�S� 4�°'
�. . �
.. . Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003643 Tax PIN/EH#: 5744-96-7617
Billed To: Paula Foster Subdivision Info:
Reference Name: Location/Address: Riverdale Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4105
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
�—
Environmental Health SpecialisYs Signature:�� ,,(� Date: � � � S
�
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 � arantee that the system will function satisfactorily for any
given period of time.
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3d!
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Environmental Health SpecialisYs Signature: Date: ��
DCHD OS/99(Revised)
, DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section -
' ��' P.O.Boa 848/210 Hospital Street
` - Mocksville,NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003643 Tax PIN/EH#: 5744-96-7617
Bilted To: Paula Foster Subdivision Info:
Reference Name: Location/Address: Riverdale Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4105
**NOTE**This Improvement/Operation 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
PERMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR TFIE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type /� ,C� #People�,� #Bedrooms�_ #Baths�_
,�
Dishwasher� Garbage Disposal: ❑ Washing Machine:-� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply � �. .Design Wastewater Flow(GPD)� Site: New� Repair❑
. / �
System Specifications: Tank Sizef�GAL. Pump�Tank^., GAL. Trench Width�� Rock Depth��Linear Ft��
Other:
txcapted Systems m�y�4$o b� u�,.
Required Site Modifications/Conditions:
IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G f°BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 .m.to 130 .m.on e da installation. Telephone#is(33G)751-87G0.****
!
Environmental Health Specialist's Signature: f'`"���� Date:^�//tb�
DCHD OS/99(Revised)
K : �
• ���� �, � R SITE EVALUATION/IM1t!'ROVEM1IFM PERti11T&ATC .
'� � avie County Health Department
nvironmenta/Hea/t/�Section
��'� aUN � 3 � .O. Box 848/210 Hospital Street
�� Mocksville, NC 27028
M�����,;,� (336)751-8760 '
�a ;��� �1t1t't
***It ORTANT** ��� S APPLICATION G'ANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFO IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Namn to be Dilled �� .�o,. ��5� � Contact Peraon -�'�-eti cAa '�C)cJ��
Mailing Addreas `t`a �i �1�f'Q C��'�, �� • Home Phone �����o ��
City/State/ZIP ������()l� �`P. � ll- - d.��a.a Buaineas Phone `'�'1��S '-� � �d �°�
2. Name on Pezmit/ATC if Different than Above
�� �
Mailing Address City/3tate/Zip
3. Applicat-ion For: ,,�Site Evaluation �Improvement Permit/ATC � �oth
4. System to service: ❑ House C�Mobile Homo � I3usiness ❑ Indu�stry ❑ Other
/ �
5. Typo n}•atem requeateds ❑ Conventional ❑ conventional modified ❑ innovative p ac�ep te d
6. =f �to�idence: # People �_ # Fiedrooms � #� IIathrooms �
�Diahwasher ❑Garbage Diaposal ,l�tashing Machino ❑IIasemant/Plumbiag ❑IIauement/No Plumbing
/ �
7. IE Businesa/Industry /Othor: verify typo # Peoplo S Sinka
# Commodoa # Showera # Urinals S Wal•ar Coolera
IF FOODSERVICE: � Seats Estimated Water Usage (gaiions por day)
8. Type of watar auppiy: ,F�l County/City ❑ Well ❑ Community
/
9. no you anticipate additions or cxpansions of tlic facility tliis s}'StClll 1S lAfC11(IC(I f0 SCPVC`: �YCS �No
`
If��cs,tirl►at typc?
***IAIPORTANT"`**CLIGNTS hlUST COhfPLETL•TlIE REQUIRED PROPGR7'Y INrORNIATIOIY REQUGSTGD
[iGi,ON. �tthcr a PLAT or SITG PLAN MUSTl3E SUB�tfl77'ED by thc clicnt �vitli TIIiS APPUCATiON.
Propert��Dintensiotts: ��r� \VRIT�D1R�CTIONS(from N1ocicsviUc)to P1tOPGKTI':`
Tax OfGcc PIIY: # o���y'�'�'��� `� � l ��D � `Tv��`� 1'C T (��l1�' 6 n
Property Address: Road Namc 1�C L V�-f�ca,\-Py �� SQ_t C�o�.�'e� �� . 1 M�`'�
c�ty�z;n T or�sc� 11 l� t-}�n o n 12 c G�n-� ��o�
If in a Subdivision providc information,as Collotivs: �� ) � � � b � �-� a� ��C�
_ �
Namc: �v � •
Scction: Block: Lot: Datc liome corncrs IIaggcd:� U S
Tliis is to ccriify tl�at tLc information providcd is corrcct to tl�c best of my kno�vlcdgc. I undcrstand iliat�ny perinit(s)
issucd licrcafter are subject to suspcnsiou or revocation,if the site plans or intended use cl�a�ige,or if the information
suUnutted ii� tliis applicatioi�is falsificcl or clianged. 1,a1so,rurderstairrt tlrat I a�n responsiGJe for nll cltrrrges i�rcrrrrerl jroui
tlris applicnliorr. I,hcreby,give conscnt to tlic Autl�orized Rcprescntativc of thc Davic County IIca1tL Dcpartment
to cnter upon aUove describcd property locatcd in Davic County and oivned by
to conduct all tcsting proccdw•cs as iicccssary to dctcrnui�c tlic sitc suitability�.
DAT� SIGNATURF. �t' Gi��
TFIIS AR�A MAY B�US�D rOR DRAWIIYG YOUR SITE PLAN(Includc all of ttic folloiviiig: Lxisting aud proposed
property lincs and dimcnsions, stractures, setbacks, and septic locations).
�rp ,.� �ac1�S�ill Q. Silc Rcvisit Cl�argc
C�Q� �Gb� . Datc(s):
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. . DAVIE COUNTY HEALTH DEPARTMENT
� � � Environmental Health Section
• . Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INEORMATION
Account #: 990003643 Tax PIN/EH#: 5744-96-7617
Billed To: Paula Foster Subdivision Info:
Reference Name: Location/Address: Riverdale Road-27028 �
Proposed Facility: Residence Property Size: 1 acre Date Evaluated: � ��S
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 ai s�
Texture rou
Consistence
Structure
Mineralo !,%
HORIZON II DEPTH g"�� ��v
Texture rou
Consistence
Structure / . � .
Mineralo '� I
HORIZON III DEP'TH
Texture ou
Consistence
Structure �
Mineralo j
HORIZON IV DEPTH �
Texture rou
Consistence
Structure '
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE _
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:T�`/
LONG-TERM ACCEPTANCE RATE: t: - - OTHER(S)PRESENT:
REMARKS: -
- _ LEGEND
T, n s aFe PositiQn
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�cturg
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
ON4I�+T�.N ,
` MQ1S�
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
a�YI'13.CY11C@ _
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK=Subangulaz blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed . . _ .
L�I.ates _ �
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable) �
Soil weMess-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classificatiori-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2 , DCHD OS/OS(Revised)
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