167 Sand Clay Ln • DAVIE COUNTY HEALTH DEPARTMENT �'L � �� � � ���0
� _ �, Environmental Health Section
' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001231 Tax PIN/EH#: 5719-92-8797
Billed To: FoRest Bryant Subdivision Info:
Reference Name: Forrest Bryant Location/Address: Sand Clay Road-2702$
Proposed Facility: Residence Property Size: 1.00 Acre
**NOT�*��iib�lmpro4ement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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 STTE PLANS OR THE INTENDED USE CIiANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �1rJ M {�n�.� #People � #Bedrooms � #Baths Z
Dishwasher: � Garbage Disposal: ❑ Washing Machine: u Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � �+(��� Type Water Supply 1�6t�'T�Design Wastewater Flow(GPD)�� Site: New� Repair❑
/
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth I 2 � Linear Ft.��
ocher: . 2�.��1�2-��ilT►c�1 �OX�--S_ �iJsj�- l�t rJGs C(�o.C,. r,�,�cS ,
Required Site Modifications/Conditions: �'fqL.L,b� Cor��Tt�I�Q. �C� ��� o� �. �LT� (o oF� �,Q(�r'��
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 u BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.o�the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature:
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DCHD OS/99(Revised) � �� �-��� (p�
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` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section .
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760 .
Account #: 990001231 Tax PIN/EH#: 5719-92-8797
Billed To: Forrest Bryant Subdivision info:
Reference Name: Forrest Bryant Location/Address: Sand Clay Road-27028
Proposed Facility: Residence Property Size: 'I.00 Acre
ATC Number: 2474
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 WASTEW C RU ION S VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa e: Date: �
� 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 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:_���/n
7—
DCHD OS/99(Revised)
. . ;�t�, • '
'� APPLICATION FOR SffE EVALUATION/IMPROVEMEM PERM A� � � Q � �
Davie County Health Department
� � � Envii»nmenta/Hea/[fiSecGion
P.O. Box 848/210 Hospital Street � � 2 2���
Mocksville, NC 27028
(336)751-8760 �►�RONMENTAL HEALTH
` DAVIE COUNTY
***Ii�ORTANT*** THI3 APPLICATION CAIaTOT EE PROCESSED UNLL�SS ALL THE REQUIRED
INFORI�ATION IS PROVIDED. Refer to the INFORt�►TION BULLETIN for instructions.
l. Name to ba Hilled ����� � �N� Contact Person �1�1�� Ica2,.1,4n/�
Mailinq Addraas 4 2.v-�c°��'-►�,�- � �x t7 b Home Phone �(o � ��3'7 �»Z'�Zg
City/Stata/ZIP Q n�N.on�S d Z. �"��-�Bu�ineas Phone 7 S� ! �o�3 cVT ���
2. Nama on Permit/]►TC i! Dilferasit than Abova
Mailinq 7Wdrosa City/State/Eip
3. Appiication For: '�.'3ite Enaluation �X Improvement Permit/ATC �oth
a. sysr.em to so�ce: ❑ House Q Mobile Home ❑ Business ❑ Industry ❑ Other
s. If Residence: # People � # Bedrooms ..,�_ # Bathrooms Z-.
�Dishxasher ❑ Garbaqe Diapoaal �Washing Machine ❑ Bssement/Plumb9aq ❑ Basemant/No Plwmbinq
6. If Businase/Industry/Othar: Specify typa � People # Sinka
� Co�odes # Shoxera # Urinals � L�ater Coolera
IF FOODSERVICE: # Seats Lstimated Water Usage (qallona �= aay�
�. Zme of water suppiy: �Couaty/City ❑ Well ❑ Communi�ty
e. Do you anticipate additions or e=pansions of the facility this system is intended to serve? ❑Yes ,�No
If yes,wLat type?
***IMPORTANTk*'�CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PI.AT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
�rupercy�tmensions: °��0 K ��� � Z Zg�4 ��� WRITE DIRECTIONS(from Mocksville)to PROPERTY:
�Taz Office PIN: # �� ��� �2 -- $ � �� co� � ps�- e,T /�o c�3 v���e.
Property address: Ro3d�Na3 eD �An�� C lav Ln� CroSS �' �v Zn�c�. �-�
. c;ry�z;p (►��,�ksu,l l e ��o yt' -� �Z,v�,�- 3l�� s��� S�w��la�(,ti
If in a Subdivision provide informallon,as follows: �o '� Zn.c� S��.,o �u�.ll�fe�a(.
Name: oT 7urn,�N< q;� 5 t�[.Aac�}- Iw� WDd�S ,
Section: Blcek: Lot: Date Property Flagged: � ^lZ'�
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspeasion or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understand that I am responslble jor all cha�ges incurred from
� this applicatlo�. I,hereby,give consent to the Authorized Representative of t6e Davie County Aealt6 Department
to enter upon above described property located in Davie County and owned by .,T.T S m�� �it.
to conduct all testing procedures as necessary to determine the site suitability.
DATE l0 ' c.e��6 SIGNATURE�-d-�r.� (�3 ��—
�� .
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLA.N(Include all of the following: Eaisting and proposed
property lines aad dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
, �:
+ Client Notification Date:
" � EHS:
r
� ? Account No. ���
Revised DCHD(07/99) L � Invoice No. ���
7a �
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. . ., . . . . . . . ..: :;
MARY E. �EAFORD .
D.B. 66 PG. 460 "
87 199
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A
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EXISTING 30� EASEMENT DESC1f�"CION SEE D.B� 66 A � w
�, /�j �7� PG. 460 3 O a':
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a�° NORTH--+-461.48 TOTAL � �� ��
�{ 174.35 . 287.13
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Fy DAVIE COUNTY HEALTH DEPARTMENT
. . :
' Environmentai Heaith Secfion
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001231 Tax PIN/EH#: 5719-92-8797
Biiled To: Forrest Bryant Subdivision Info:
Reference Name: Forrest Bryarrt Location/Address: Sand Clay Road-2702 �
�
Proposed Facility: Residence Property Size: 1.00 Acre Date Evaluated:
Water Supply: � On-Site Well / Community Public
Evaluation By: Auger Boring �`� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca sidon �
Slo %
HORIZON I DEPTH p - ,p �(,
Texture rou G'L
Consistence Gr-�
� -- structure
� � Mineralo �,' ;
C
1 HORIZON II DEPTH --'LO �
Texture rou �
Consistence F;
Structure
Mineralo 1 � 1 ` t: '
HORIZON III DEPTH t —�{
Texture rou G� � G �
Consistence
• Structure
Mineralo ' ' �
HORIZON IV DEPTH Z� f . -f'
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
• RESTRICTIVE HORIZON •
SAPROLITE
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE 3 ,
SITE CLASSIFICATION: EVALUATION BY: V '
LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-$houlder L-Linear 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-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
t t r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineralo�v
' 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
� DC�ID OS/99(Revised)
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