435 Sain Rd , , , DAVIE COUNTY HEALTH DEPARTMENT � ���� �
'" - Environmental Health Section
. ` P.O.Boz 848/210 Hospital Street � „�
' , Mceksville,NC 27028 �
' • (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001553 Tax PIN/EH#: 5749-65-3971
Billed To: Liane Smith Subdivision Info:
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: Residence Property Size: 10 acres
**NOT�:*'�'Tfii s�mprov�t/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type T�' #People�_ #Bedrooms �J #Baths�.S�
Dishwasher� Garbage Disposal: ❑ Washing Machin� Basement w/Plumbing: ❑ Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size aAC Type Water Supply�� Design Wastewater Flow(GPD) ��� Site: New� Repair❑
.
System Specifications: Tank Size�l�GAL. Pump Tank GAL. Trench Width���Rock Depth. 2 � Linear Ft.c��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFF U N FILTER RISER(S)IF 6 u BELOW
FINISHED GRADE. ****NOTICE: Contact a`representativ ofthe Davie ty ealth Depariment for final inspection ofthis
system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to • e day of' st 11 ion. Telephone#is(336)751-8760.****
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Environmental Health SpecialisYs Signature: �' Y� Date: �'��7��✓
DCHD OS/99(Revised) �
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• � . �
, DAVIE COUNTY HEALTH DEPARTMENT
' . Environmental Health Section
' ' � P.O.Boa 848l210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001553 Tax PIN/EH#: 5749-65-3971
Billed To: Liane Smith Subdivision Info:
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: Residence Property Size: 10 acres
ATC Number. 2685
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: (.Y�� Date: �':.����
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the syst d 'bed on ImprovementlOperation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130 , ectio .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee t at e em will function satisfactorily for any
given period of time. a /
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Septic System Installed By: ��(/
Environmental Health Specialist's Signature: -__�/���/y�� Date: /� Z Z '!��
1 Ol� C�.41-�-�R.o�. �C„�-`y W S>:ut...�'rt� C�.ss2- �i�w�.�,�L S t btt'� "i�� �'TtL�1►L t.S
S�r -�- �fi►tott 70 �—r �4LL �P-e.,ti- ao� P�Jm4 o�f
DCHD OS/49�tevised)
� �� )� n M
- AP('L1CA770N fUlt SI fE EVAlUA7lON/i81PIiUVEhQCNi't3Lltt�9i 1�&R►1 C a � � � u " �
� Davie County Heaith Department -
• • Environmenia/Hea/tfi Section uY�2�� �
� P.O. Box 848/210 Hospital Stree� �A
`( Mocksville, NC 27028
Q �`� (336)751-8760 ENVIRDAVIEECOUNTY�LjH ;
\
***IMPORTANT*** THIS APPLICATION C�NNOT BE PROCESSED UNLESS �I,I, THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFOR2�TION BULLETIN for instructions.
1. Name to be Billed Li Qn� U 1��an o ��I'Y!I � Contact Person _ L�Q,nPi O/— (�G�'�h
Mailing Address �o[ G M c�I am rDck /C� Home Phone �3 3'� 7 J��'SJ�Jr� ,
���S���Zzp ,�.ack.,vi I le N�' a�a�8 $us�e9a Phone /33�) 9 yo 5a4� � q^� �
2. Name on Yermit/ATC if DiPferent than Above ��a���� sG�� I
2iailing rdcireas City/State/Zip
3. Application For: ❑ Site Evaluation � Improvement Permit/ATC Q" Both
a. syatem to sezv3ca: �House ❑ Mobile Home ❑.Business ❑ Industry O Other
5. If Residence: # People � � Bedrooms �_ R Bathrooms 2• �
� �e
[IYDishxasher � Garbaqe Diaposal LY Washing Mechine U Basement/Plumbing U Danament/210 Plumbinq
6. If Bueineas/Znduatry/Other: Specify typo # Pooplo Q SinkD
# Commodes R Shoxers 0 Usinals # Wator Coolera
IF FOODSER�)ICE: # Seats Estimated Water Usage (gallons por aay�
�. �pe of water supply: ❑ County/City �Well ❑ Community
e. Do you anticipate additions or capansions of tLc facility this system is intcnded to scrvc? �Ycs 0 No
If ycs,what type? ��-�-s�- � — � S -ti�s `�.���.t�
***IMPORTANT***CLIENTS MUSTCOMPLETETIiE REQUIRED PROP�RTY INrORMATION It�QUi'sS'I'CD
BELO�Y. Eithec a PLAT or SITE PLAN MUST BESUBMI7TED by tiu clicnt with THIS APPLICATIO]V.
Pcoperty Dimcnsions: �D CtCrLS l-0� 340-►YO�I�.l.�y[tIT�DIRGCTIONS(from Mocluvilic)lo!'ItOI'Lsli'1'1':
Tax o�r��r�r: # 5'7 y�p�� -3�� I -�ram 15� E �-urn r�h�-
Property Address: Road Name �Q111 �0 Q� �11� c�llJ n �0 Q 0. . I`�S �
c;ty�z;p Mo c ks��t�c Nc a7oag �hG �-�h I�aus� on. I�e�-�- aGr�
If ia a Subdivision providc inCormation,as follows: �j�Y��(t�,-t-0(t� ��Q.CP� � �'�'$ `�1G
�
Namc: ol��reen -�a.rm hous� � �
Section: Block: Lot: Date Property Flaggcd:
This is to ccrtify that the information providcd is correct to the best of my knowledge. I understand thut any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intendcd use cLange,or if tLc inforinatiun
submittcd ia�this application is falsificd or changcd I,also,understand that I am resporrsible jor a!1 charges incurred jro�ri
thls applicatioa. I,hcreby,givc consent to the Authorizcd Rcpresentativc of thc Davie County II alth Dcpartment
to entcr upon abovc describcd property tocatcd ia Davic Couniy and oyvned by �$CQ,1� �Qj h
to conduct alt testing procedures as necessary to determiue tLe site suitability.
. o 0
DATE I SIGNATURC
THIS AREA MAY BE USED FOR DRA.WING YOUR SITE PLAN(Include all of the following: �aisting and proposed
propetty lines and dimensions, structures, setbacks, and septic locations).
� Sitc Revisit C6argc
��►�T'� �'-� "� �-
.
� . Datc(s):
Q n. S � l��-
� �' Client Notilication Datc:
EHS• •'
� e-�.�� 0�.1,�-R-� .
� �J� ��,� .� Account No. � " �
, .�r-�---7-,�� •
Rcviscd DCHD(07/99) �, ��-�- Invoice.No. ,v��o(, �
1 9 ��
. � . �-�-
�"' � DAVIE COUNTY HEALTH DEPART'MENT
. , �-
Environmental Health Section
� Soil/Site Evaluation
��APPLICANI'INFORMATION PROPERTY INFORMATION
Account #: 990001553 Tax PIN/EH#: 5749-65-3971
Billed To: Liane Smith Subdivision Info: ,
Reference Name: Location/Address: Sain Road-27028
Proposed Facility: Residence Property Size: 10 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 sition
Slo %
HORIZON I DEPTH
Texture ou
Consistence
Structure
Mineralo
HORIZON II DEPTH k G�/�-�c�
Texture rou
Consistence ./'
Structure iL. �C.
Mineralo `! -`'
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON N 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-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloav �
1:1,2:1,Mixed
otes
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
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