144 Sand Clay Ln DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
•� . P.O.Boa 848/210 Hospital Street
' � � . Mocksville,NC 27028
� (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001731 Tax PIN/EH#: 5729-02-2592
Billed To: LaH►rence Cranflll Subdivision Info:
Reference Name: Location/Address: Sand Clay Lane-27028
Proposed Facility: Residence Property Size: see map
�1TC N b�r: 2840
**N TE** �iis mprovement/Operation Pertmit 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 REVOCATTON 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: � BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste: ❑
Lot Size Type Water Supply� Design Wastewater Flow(GPD) `l � Site: New�Repair❑
System Specifications: Tank Size,��GAL. Pump Tank GAL. Trench Widtl��� Rock Depth� Linear Ft.�
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- ROVED E � T FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a r entative of avie e�artment for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.t 1:30 p. .on ation. Telep one#is(336)751-8760.****
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Environmental Health Specialist's Signature: �� Date: � 1.�'��
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 #: 990001731 Tax PIN/EH#: 5729-02-2592
Billed To: Lawrence Cran�ll Subdivision Info:
Reference Name: Location/Address: Sand Clay Lane-27028
- Proposed Facility: Residence Property Size: see map
ATC Number: 2840
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 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 WASTEW R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: ��` Date: s �s- a�
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion 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 tak � a tee that the system will function satisfactorily for any
given period of time. � ��
5 ��
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Septic System Installed By: ��
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Environmental Health Specialist's Signature• Date:
DCHD OS199(Revised)
� ' �pS l�t��z
p _ � C� OMC�
' APP ON FON SITE EVALUATION/IRIPROVE]VtEM�PE1tMlT&ATC �
M�, Q 2001 Davie County Health Department
Envirrvnmenta/Healtfi Section
� J P.O. Box 848/210 Hospital Street
EDMRONMENT/�!HEAL1}r
� Mocksville, NC 27028
UAVIECOUNTY (336)751-8760
***Il�ORTANT*** THIS APPI,ICATION CANNOT BE PROCESSED UNLESS AI,I, THE REQUIRED
INFORI�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Nama to be IIilled ' y' � Contact Person
Mailinq ,Addreas �� I(a �V(0`��/InI � • Home Phone - "z!, .
City/State/ZIP � � � Buainesa Phone
2. Name on Permit/ATC Z Diiferent than AY>ove
Mailing Add=eas J(��.Q �5 �p� City/State/Zip
3. Appiication For: ite Evaluation Improvement Permit�ATC �Both
4. Syatem to seL,.i�a: [s�ouse ❑ Mobile Home O Business ❑ Industry O Other
s. If Residence: � People �� � Bedxooms � # Bathrooms �
l�D�hwasher U Garbaqe Diaposal ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbinq
6. If Bueinesa/Industxy/Other: Specify type � People # Sinka
� Coarmodes # Shoxers � Urinala # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (qallons per a8y)
7. Type oP water supply: County/City ❑ Well ❑ Community
s. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Ycs �]-�'�
If ycs,what typc?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRLD PROPERTY INFORMATION REQUESTGD
BELOW. Eit6er a PLAT or SITE PLAN MUST BESUBMITTED by the clicnt with THIS APPLICATION.
Property Dimensions:. .�� /�',�� �VR1TE DIRECTIONS(from Mocicsville)to PROPGRT'Y:
Tux Oftice P1N: # �`7a79 -OZ �aJ`9Z �n7/,(� 7U I"�/�C(0/1_( �G�l�(���- �5�/t.C2.'l[� 0�1 K.�T
` �Property Address: Road Name < (1 ���. (�
� ��ty,�,p m�n��,(I�. � �- Z7DZ8 � � �� �.
If in a Subdivision provide information,as follows: ,,�(.��'lphl �.t .(�, ���..Ln�/1a(i.(J14U ��..�.Q ..
,
Numc:
Sectioa: Block: Lot: Date Property Flagged: � �� � �
This is to certify that the information provided is correct to the best of my knotivledge. I wnderstand that any permit(s)
issued herCafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed I,also,undersland that I am respotrsible jor al!charges incarred jronr
this applicalion. I,hereby,givc consent to the Authorized Representative of the Davie County Hcalth Department
to enter upon above described property located in Davie County and owned by
to conduct aIl testing procedures as necessary to determine the site suitability.
DATE �'�—�� SIGNATURE �{..I:
;:'I'HIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the follo ' g: Eaisting and proposed
��property lines and dimensions, structures, setbacks, and septic locations).
� �� Site Revisit Charge
�
Date(s):
��
(�� Client Notification Datc:
\} '
EHS: • .
��a ��/
��� ��� '� Account No. ��
� ✓
Revised DCHD(07/99) I,✓� �� _ Invoice No. �� ,
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/�-��� va-�. �
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�' DAVIE COUNTY HEALTH DEPARTMENT
. . � . � u Environmental Health Section
� . , � Soil/Site Evaluadon
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001731 Tax PIN/EH#: 5729-02-2592
Billed To: Lawrence Cranfilf Subdivision Info:
Reference Name: Location/Address: Sand Clay Lane-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: _S%Y-d�
Water Supply: On-Site Well Community Public ✓
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �L �--
Slo %
HORIZON I DEPTH
Texture rou
Consistence '
Structure
Mineralo
HORIZON II DEPTH 6 '' .�G "'
Texture ou
Consistence � /
Structure 6/� S /
Mineralo . �"
HORIZON III DEPTT-I
Texture rou
Consistence
S Wcture
Mineralo •
HORIZON IV DEPTH
Texture ou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON • .
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ♦ ,
SITE CLASSIFICATION: b� EVALUATION BY: �
LONG-TERM ACCEPTANCE RATE: OTNER(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
Teacture
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
Mois
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
tru t re
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
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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