2228 Sheffield Rd :1 .�:�
DAVIE COUNTY HEALTH DEPARTMENT �a�
4 ' • Environmental Health Se�tion �� g'/V �
1 . ' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001610 Tax PIN/EH#: 4890-79-2790
Billed To: Rickey McClamrock Subdivision Info:
Reference Name: Location/Address: Sheffield Rd-27028
Proposed Facility: Residence Property Size: 4.46 acres
**NO'T�**This�mprovem�dOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building petmit(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 THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ��17�v #People� #Bedrooms � #Baths�
Dishwasher: �Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: �
Commercial Specification: Faciliry Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ``�•`�����Type Water Supply h�GLL Design Wastewater Flow(GPD)� Site: New�Repair 0
System Specifications: Tank Sizel�f7UIGAL. pump Tank GAL. Trench Widtt���� Rock Depth I�L�� Linear Ft--��
Other: � �ST�'R.x�T�.� ���—S �t�g'Tb.,(�t, ca a�,.rS ��O.c. n.��l�1 ,
Required Site Modifications/Conditions: ���- O� C.poJ"�c�e- - �5� c�� k�c�JS�. SU`��►-��-�
- !o` .u•�►��
IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
,system between 8:30 a.m.to :30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Enviro�al Health Specialist's Signature: Date: � � �
DCHD OS/99(Revised)
�J`` 3���/°/
� � DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
P.O.Boa 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001B10 Tax PIN/EH#: 4890-79-2790
Billed To: Rickey McClamrock Subdivision Info:
Reference Name: Location/Address: Sheffield Rd-27028
Proposed Facility: Residence Property Size: 4.46 acres
ATC Number. 2743
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 Sewa e Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW CTIO S VA D FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature• Date: � 0
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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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Environmental Health Specialist's Signature: Da . � �
DCHD OS/99(Revised)
.t-� �' (� M
� • APPLICATiON FOR SITE EVALUATION/I1�IPROVEM14ENT PEIiM1fli'&ATC � � " � � U �
� Davie County Health Department
Environmenta/Hea/tfi Section � — 2�
P.O. Box 848/210 Hospital Street
, Mocksnille, NC 27028
(336)751-8760 ENVIRONMENTAL HE�LTH
DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALI, THE REQUIRED
INFORt�TION IS PROVIDED. Refer to the INFORMATION BiJI�LETIN for instructions.
�
l. Nnme to be Hilled � � ��1-t20G!�_ Contact Person /l_���y G�� 4 4'r/rOG/�-
Mailinq Addresa �� � ,�v� .Q`F �1 C /�l p`C/� 8ome Phone �D� Sv� � �� �
City/State/ZIP ^�2Htnnri J�/ � Businesa Phone �s� S < 7 Z—
2. Name on Permit/ATC i£ Different than Above /U /7'
Mailing Addsess a City/State/Zip
3. Appiication For: [�Site Evaluation ❑ Improvement Permit ATC L�th
a. sYHt� to sesvice: tiYHouse ❑ Mobile Home ❑ Business O Industry 0 Other ��
s. If Residence: # People 1�j( � Bedrooms �_ A Bathrooms _�_
Dishvasher ❑ Garbage Disposai CYWashing Machine U Basement/Plumbing f�'�asement/No Plumbing
6. If Suainess/Industry/Other: Specify type �7 U /i1 .5 1P # People � B Sinka 2—
—�
# Commode� _� � Shoxers �_ � Urinals G �k Water Coolora �
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per any)
7. Type of water supply: ❑ County/City Q'�+Tell ❑ Community
e. Do you anticipate additions or eapansions of thc facility this system is intended to serve? ❑Ycs �(No
If ycs,what typc?
***IMPORTANT'°**CLIEIVTS MUSTCOMPLETETHE REQUIRBD PROPERTY INFORMATION REQUCS7'ED
BELOW. Either a PLAT or SITE PLAN�tUST I3ESUBMI7TED by the clicnt with THIS APPLICATION.
Property Dimensions: � 7• �� ��� WRITE DIRECTIONS(from Mocksville)to PfiOI'L;R7'Y:
Tux Ofiice PIN: # �g�v 7/`Z'oZ 7 �� �k9 fC �Y �✓�5� fo�ll h p`f �i,��a��
Property Address: Road Name S��i�� �C� „�J� � y��c 5 O j? /��^h t/"/�b�? ^
c;ryrL�p � � �3 y � �/ �c s� � a.z� o ��_�i�:P/�
If in a Subdivision provide information,as follows: L�G1'
Name:
Section: Block: Lot: Date Property Flagged: -3'a'��
This is to certify that the information provided is correct to tlie best of my knowledge. I understand thut any permit(s)
issucd herea!(er are subject to suspension or revocation,If thc site plans or intcndcd use cvange,or if the information
submitted in this application is falsified or changed I,also,understand that I am responsible for al1 charges incurred from
thls applicalion. I,hereby,give consent to the Authorized Representative of the Davie C unty Hcaltt� partmen
lo cnter upon above described property located in Davie County and owned by �
to conduct all testing procedures as necessary to determine the site suitability.
DATE � dZ -.-6ib�N�1T RE �
� '
; THIS.AREA MAY BE USED FOR D �G YO� �P clude a of the following: Eaistiag and proposed
property lines and dimensions, structu ,Qsetbacks, a septic 1 a ns). .
`3 ���, Site Revisit Charge
� �
, Q Datc(s):
� , Client Notification Date:
� � 30 �
EHS:
� �i� ��
�� _ 5� Account No. �P � �
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Revised DCHD(07/99) ��3 o p�Q� Invoice No. � � � �
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94 227 e�. 136 76 --� 179 .��
265 �
. (28.09A) .
� 3319 '
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LISTED IN
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F90000000309 '
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F�0000000303 I N D EX E D
(2.524A)
(4.41 A)
ON 4891 LIBERTY
`5331 � o � 2ss WESLEYAN
9876 �° � � � � CHURCH
1890A ' � M
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w_ � . r� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
� � � Soil/Site Evaluation -
APPLICANT INFORMATION PROPERTY INFORMATION
• Account #: 990001610 Tax PIN/EH#: a890-79-2790
� Billed To: Rickey McClamrock Subdivision Info:
Reference Name: Location/Address: Sheffield Rd:27028
Proposed Facility: Residence Property Size: 4.46 acres Date Evaluated: I ��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition � L
Slo % - 20
HORIZON I DEPTH c� -� b -CP O- �
Texture rou
Consistence �S r5 S
Structure G2 '(�
Mineralo : ) t: 1 (t 1
HORIZON II DEPTH -1 � ?� - 'L �
Texture rou
Consistence - G:S F•�
Structure � S g 1[
Mineralo I� �: 1 �
� HORIZON III DEPTH - 0 � 2 -Z c�
Texture rou +
Consistence 5 S$� � $S 9
Structure S3'� S
Mineralo ; I ; 1 ��I �
HORIZON IV DEPTH Z 5 -3 + _c..fZ
Texture rou ' S �
Consistence r
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON •
SAPROLITE �
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE O.`� �•4
SITE CLASSIFICATION: Q� EVALUATION BY: � ���
LONG-TERM ACCEPTANCE RATE: �'� OTHER(S)PRESENT:
REMARKS: �41�c�,.� �i..�C�..�s��� , �o�.� 'K l� Qa� N.�n�c� � .-�
LEGEND
Landscape Position i
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 �
Texture
i
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 i
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
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloev
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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