166 Shelton Ln . , DAVIE COUNTY HEALTH DEPARTMENT �GC �- 3v_ �/
. • Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001452 Tax PIN/EH#: 5823-65-8326
Billed To: William Perkins Subdivision Info:
Reference Name: Jack Perkins Location/Address: Shelton Lan�27028
Proposed Facility: Residence Property Size: see map
ATC N�u�pb r: 2708
**NOTE** Thls�mprovemendOperation Permit 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 REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE TAIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type (' #People� #Bedrooms #Baths�_
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement wlPlumbing: 0 Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � ��� Type Water Supply /rt�<�l Design Wastewater Flow(GPD) Site: New❑ Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width,���Rock Depth� Linear Ft�
Other:
Required Site Modifications/Conditions: �
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTiCE: Cantact a representative ofthe Davie County Health Department 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.on the day of installation. Telephone#is(336)751-8760.****
O
Environmental Health Specialist's Signature: Date: �"oC�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 #: 990001452 Tax PIN/EH#: 5823-65-8326
Billed To: William Perkins Subdivision Info:
Reference Name: Jack Perkins Location/Address: Shelton Lane-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2708
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: G� 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.
1�a X��'� �.
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Septic System Installed By:
Environmental Health Specialist's Signature: -----����.i' Date:�"���� `�
DCHD OS/99(Revised)
s ��p�r��a� b n-� �-�`"� �. �^ � ^°� �` u�
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� �APPLIC,ATION FOR SITE EVALUATION/IMPIiOVEMCNT PEIiA'il�'&ATC
` �t � � Davie County Health Department OCr � �
^ � � Environmenia/Hea/ifi Section ��'+��
� �� P.O. Box 848/210 Hospital Street
� � Mocksnille, NC 27028
� � a 5���� (336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruc�ions.
1. Name to be Billed �U+/�/��f/ �`-� /� �+-/E'� 1�� Contact Peraon I/< <J Q/�s �
Mailing Addrese f CJ IC� ��({��%O✓t^ �/�n'C�y. Fiome Phone � ' 1 C' �7 r .3 �G�
City/State/ZZP �//�Cf�'SGi�/�i �'`�OC?�vZ �•Businesa Phone
2. Name on Permit/ATC if DiPferent than Above � t'i � �'�!�/�-/� S �S��� �
Mailing ]�,ddreas City/Sta /2i � J
3. Application For: Site Evaluation �.,Zmpx�o�em�t Permit/ATC � ❑ Both
� �
a. syat� to sesvice: ❑ House e ❑ Business � Industry �Other ��r`n
5. If Residence: � People � 8 Bedrooms /'� � � Bathrooms � y
II Diahxasher I�I Garbaqe Diaposal �Washing Machine ❑ Basement/Plumbing (7 IIasement/No Plumbing
6. If Bueinesa/Industzy/Other: specify type $ People It 3inks
# Coaodes i Shoxers $ Urinals � Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (qallona �r a�y)
7. �pe of water supply: ❑ County/City [�Well fJ Community �
/
a. Do you nnticipatc additions or eapansions of the facility tf�is system is intended to serve? ❑Ycs �o
�
f ycs,what typc?
� ***IMPORTANT''`**CLIENTS h1UST C0�11PLETETIiE REQUIRED PROPERTY INFORMATION IiGQUI;STLD
� BELO\V. Either a PLAT or SITE PLAN�tUST BESUBMITTED by tl�c clicnt with TEIIS APPLICATION.
Property Dimensions: ✓ e� � � �OC�A� WRITE DIItEGTIONS(from Mocksvilic)to 1'[t01'GIt7'Y':
Tuz Officc PIN: #�� a+ �- � s' S��J ��' - �c.� �/ %fl ,�'�� � %�---- 12� Jc--�.
Property Address: Road Nam�-��'f�►^� �—`�-r'1 � a /� �� /r .3 i�.. �r s �%�
c;cy�z�p S�P /��,� 1�---- ��-�--- �'J�-'�'�'�� �
lf in a Subdivision provide information,as fallows: � '�o �-����`'/.
Namc:
Section: Block: Lot: Date Property Flagged: 1� I� � � �
T6is is to certify that the information provided is correct to the best of my kno�vledge. I understand that any pern�it(s)
issucd hcrcaftcr are subjcct to suspension or revocation,if tt�c site plans or intendcd use cUangc,or if thc int'ormation
submitted ia this application is falsified or changed I,also,understand lhat I am re�roasible jor a!1 charges incurrer!jrnrri
Ihis application. I,hereby,give consent to the Authorized Representative of the Davie County I�eaitL Departsnent
to enter upon a6ove described property located in Davie County and owncd Uy ______
to conduct all tcsting procedures as necessary to detcrminc tlie site suitability.
DATE �C� '' J� ^ ��� SIGNATURE � ��_
TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inclu all of thc followinb: �aisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Rcvisit Chargc
Datc(s):
Clicnt Notification Datc:
EHS: • �
Account No. I ��
Rcvised DCHD(07/99) Invoicc No. � �
, , :., . , :.
� ��. , .
' ` - - _ DAVIE COUNTY HEALTH DEPARTMENT �
. Environmental Health Section sECTiorr LOT
� SoiUSite Evaluation
APPLICANT'S NAME �P��`�`� S DATE EVALUATED �a 1J ��
PROPOSED FACILITY ��r l� PROPERTY SIZE � ��G
SUBDIVISION ROAD NAME ��8�4�. �17"�
Water Supply: On-Site Well t� Community Public
Evaluation By: Auger Boring_;(�__ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �
Slo % �
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH '` �
Texture ou C
Consistence ..E`� �
Structure b K /I <<
Mineralo /
HORIZON III DEP'TH
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: - `'
LONG-TERM ACCEPTANCE TE: ' � OTHER(S)PRESENT:
REMARKS: �/ GV � C/°jj'JC���
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-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 ct re
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
N es
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(01•90)
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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksvilie, NC 27028
Phone #: (336)751-8760
October 26, 2000
William B.Perkins
166 Shelton Lane
Mocksville,NC 27028 '
Re: Site Evaluation/Site 1
Tax Office PIN: #5823-65-8326 � �
Deaz Client(s):
As requested, a representative from this offce visited the aforementioned site on
October 25, 2000. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site,the site was found to be
provisionally suitable for the installation of an on-site sewage system at your barn. ._
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
���r�t�o•�.rl�,�,• �
Robert B. Hall,Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s) •