162 Rock House Rd DAVIE COUNTY HEALTH DEPARTMENT ��/-2/�'l'�
- " -`"` Environmentai Health Section
, ' P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028 �
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 9900006$8 Tax PIN/EH#: 5$40-83-5495
Billed To: Joshua Hendrix Subdivision Info:
Reference Name: Josh Hendrix Location/Address: Rock House Road-27028
Proposed Facility: Residence Property Size: 4.454 Acres
ATC Number:,�,3�
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the constcuction 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 REVOCATTON IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER S�'STEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type_��_ #People�_ #Bedrooms_ d� #Baths�
Dishwasher: � Garbage Disposal: O Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/ShiR #Seats Industrial Waste: 0
Lot Size Type Water Supply r�{/G�/ Design Wastewater Flow(GPD)����� Site: New�Repair❑
System Specifications: Tank Size,�Q/Z GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft. /O��
Other: �S ��� U�.w� .
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- AP OVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINiSHED GRADE. ****NOTICE: Contact a repr ta 've o e Davie County Health Deparhnent for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m. 1:3 .m. n the ay of installation. Telephone#is(336)751-87G0.****
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Environmental Health S ecialist's Si ature: �C� ►' ' , Date: � ��!
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DCHD OS/99(Revised)
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� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksvitle,NC 27028
(336)751-8760
Account #: 990000688 Tax PIN/EH#: 5840-83-5495
Bilied To: Joshua Hendrix Subdivision Info:
Reference Name: Josh Hendrix Location/Address: Rock House Road-27028
Proposed Facility: Residence � Property Size: 4.454 Acres
ATC Number. �/.3�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 I VALID FOR A PERIOD OF FIVE YEARS.
, ��y�
Environmental Health Specialist s Signature: � i � Date: �L�j>���
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CERTIFICATE OF COMPLETION
**NOTE**The issuance ofthis Certificate ofCompletion 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 period of time.
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Septic System Installed By: ����
Environmental Health Specialist's Signature: . Date:
DCHD OS/99(Revised)
AWA110N/IMPROVEMENT PERMIT dc ATC `'�'�'--
� ` rP: � • �t ' i unty Health Department � � � � � � � ..
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,_.. , 1 ,, .. , - En menta/Hea/tfi Serdor�
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.:� '1� ` B �8/210 Hospital Street t�,2 4
�=-� � JUL 2 0 �' �.iie, Hc z�oze � �
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� �Lt�/J/17 (336)751-8760 ENV!pAVMENTAC Hfq1T
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at,tIl�ORT 8E PROCE3S� ���� I�Y,Ea � �tEQUIRED I
2NFORMATION I3 PROVIDED. Aefer to the INFORM�TIOI� 81DE+.'L�^�3�1 f�a� is����ttations.
i. �� rA �e Hiiion ��ashua �-�e�r,c��fZ.v1c conr.aat reraon �bS� �'1 P.X�C�.11�–�—
Maiiinq 1lddress �� O� (J O 5 Hamo pt►one —
City/8tate/Zip`��YYtYV�O'N�. � .�. �- 1 b l� Business phone "��ri,"'t`7 1 `t
Z. Name on Pes�it/1►TC it Oi!lerent thm Al�we
ltailing l�ddress City/8tate/Zip
�. �rpliaation sor: ite Evaluation U Improvemeat Pesmit/ATC C1�oth '
a. system to sarv�ca: 0 Housn �Mobile �ame 0 Busiaess 0 Industry 0 other
e. If Itesidence: f People _�_ # Bedroans oy i Bathrooms �
/� DishnasAer O Oatbaye Diaposal �1 NashinQ Nachine O Baa�t/PlumbinQ 0 Basement/No plumbing
6. i! Bnsiness/Indnstry/OtAer: 8pecily type f Peopie � Sinhs _
i Caaemodes i 8hoxers * Vrinals f Natex Coolers
ITi �i'OOD3ERVICB: � 3eats 8stia�ated Nater Usage �qalloas per day) � .
7. �ps of water svpplp: 0 Cont�ty/City [�itell 0 Co�uunity
��
s. Do you Anticipate additfon�or e:panaiona of t6e facllity th�s ayatem ia intended to�erve! 0 Yes No
If yea,w6at type? ` �
*•*IMPiORTAN7''•"CLIE�iTS�i!'i��'T C011lPLETETHE ttEQUIRED PROPBRTY INFORMATION REQUESTLD
BELOW. Either a PLAT or SI 1 E PI.AN AlUST BESUB�IIITTED by the cilent �rit6lTilS APPLICATION.
Property�finee�s�nm+�� `T c_._t ������/� '�VRiTE AIRECfIONS(trom Mock:vflle)to PROPERTY:
Tmi Oit�ce PIN: � �S�d- 8 3 -s�q`� �5'�=�� �s��t /,��i;e,v 2q�_
Property Addresa: Rnad Npme �Qc�G�i-o c,(5�f�cQ• � � ' `UclC ����c,pe �G�,
City/Zip �� lOc��S�i�IIP,N���� '���l�rr12 ��tJ ��/�
� r �P�'rWPs
lf in�Subdiviaion providc fnformatlon,as�ollow�: � s�� � �' � ,
Name: .
Section: Block: Lot: Date Pruperty Fi�gged ��'���s/� ���e�
This i�to certifp that ihe intormation provided is con�ect to tbe best of my kaowiedga I underatand t6at�ny permit(a)
issued bereafter are subject to auspen�ioo or rewocation,If the aite pisns or iatended uae c6ange,or if t6e 3at'ormation �
submltted in this appltcatioa i�falaitied or changed I,olso,anderstand tliat I am re�ottsible for o!1 cbarges�itcurred from
tbis appJlcation. t,6er+eby,give con�ent to t6e Aathorized Repre�entative of t6e Davie County Healtb Department
to enter apon above described property located in Davie County and owned b�
to conduct all testing procedurea as necasAry to ddermine the�ite aitabilih.
DATE 1��� SIGNATORE_� c�cly,s�
THIS AREA MAY B�USLD FOR DRAWING YOUR SIT4 PI.AN�Iaclude all of t6e tollowing: E�atln.g and prnposed
property lina and dimenaions, riructures, aetb�ka, aad�eptic locationa).
Account No. CCJ�
Revised DCHD(07/98) invoice No. ���
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C. F. SEATS ' OEEO NORTH
�.i3.a6 PG. 3t5 – '
_ CASPER SAiN
0.8. S9�':PG.44S
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N 00� S3� 48�� _E —� ( 789.20 TOTAL ) _ EIP +.
444. 20 NI.�_ ___---�,��_�_.__---
345.00 — �—
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MAiRY G, SMITH I ; TAKEN FROM THE MARY G. SMITH •
��. 114 PG. 552 � PROPERTY OB.114 PG. 552 ��
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AREA= 5.450 , ACRES � ;� AREA= 4.454 ACRES W ° I � �ErvEva FOSTER
. � - D.B.92 PG.t28
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_ _ _ _ `_ _ EASEMENT .RECORDED I N PLAT &C. 4 PG. 23 3 VARIOUS _DEEDS �
.— —� — — ' EX I ST ING ROAD TO SR 1639 --.. — — — .— � , .
: ( TOTAL 387,84) , --- — — — .
', 3t 5.44 72.40 i NIP _ _:-__ 350.00 - _— — � 1 : . � L EG
. -t— !i 00"56� 25 E (892.03 rOTAL ) EIP
, . 1 S T O N E � � � . I E IP_EX�ST'
� ,. W . - NIP = NEW
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, ,._.. DAVIE COUNTY HEALTH DEPARTMENT
��� � ' Environmental Health Section
Soi]/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000688 Tax PIN/EH#: 5840-83-5495
Billed To: Joshua Hendrix Subdivision Info:
Reference Name: Josh Hendrix Location/Address: Rock House Road-27028
Proposed Facility: Residence Property Size: 4.454 Acres Date Evaluated: �;/^�
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Water Supply: On-Site Well [� Community Public
Evaluation By: Auger Boring R,/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca sition
Slo %
HORIZON I DEPTH
Texture ou
Consistence
Structure
Mineralo
HORIZON II DEPTH �• ���
Texture rou
Consistence /
Structure L
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: �l�
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-Silry 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
MineraloQv
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
DCHD OS/99(Revised)
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