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z �•--!, 1 DAVIE COUNTY HEALTH DEPARTMENT
' � Environmental Health Section
_ P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760 �
Account #: 990003777 Tax PIN/EH#: 5778-05-4352
Billed To: Gerald Morse Subdivision Info:
Reference Name: Greg Parrish Location/Address: Sandy Lane-27006
ATC Number: 4435 •
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authoriza ion for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section rior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie Coun Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 1 A,Wastewater Systems,Section.1900 Sewage Trea t and Disposal Systems). THIS
AUTHORIZAT ON ASTEWA CONSTRU V ID FOR PERIOD OF FIVE YEARS.
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Environmental Health Spec lisY ' a Date: � �
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C E OF�COMPLETION
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**NOTE** The issuance fthis C 'fica f C io indicate the system described on Improvement/Operation Permit
has been in led in co ian 'th .S.Chapter 130A,Section.1900"Sewage Treatment and
� Disposal Syst s,"but sh in WA . guazantee that the system will function satisfactorily for any
given period i time. � �� � �
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Septic System Installed By: � � � �Z-
Environmental Health Specialist's Signa Date: 1 20 �l0
DCHD OS/99(Revised)
, DAVIE COUNTY HEALTH DEPARTMENT
� . Environmental Health Section
„ �.... ��
. P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028 '���
(336)751-87G0
. I I.
IMPROVEMENT/OPERATION PERMIT
Account #: 990003777 Tax PIN/EH#: 5778-05-4352
Billed To: Gerald Morse Subdivision Info:
Reference Name: Greg Parrish Location/Address: Sandy Lane-27006 •
Proposed Facility: Residence Property Size: 2. 1 acres
**NOTE�*"This�Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION FOR WASTEWAT'ER 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 PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �� #People � #Bedrooms � #Baths 3
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industtial Waste: ❑
Lot Size 2+�C�'� Type Water Supply ��►1,��Design Wastewater Flow(GPD)� Site: New�Repair❑
.' �
System Specifications: Tank Size�'��AL. Pump Tank GAL. Trench Width 3� Rock Depth� Linear Ft.�
ocn�: Q�C�d� 2��i�����'J�J ��Sl--u�ti, , `� 1�t�Sr��t� c.t►�,.J �:�5
Required Site Modifications/Conditions: ��%� �Q�L �,��'-lZ�, ��,' t3 ��� p� � U•�1�%S �-.
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW
FINISH ADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis '
• .m.to 9:3 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C)751-87G0.****
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Environmental Hea t Specialist's Signa e: Date: ��
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DCHD OS/99(Revised) '
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� APPLIC FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� D N] � Davie County Health Department
� � Envaronmental Healtli Section
p P.O. Box 848/210 Hospital Street
1 �UN 2 3 2�p6 = Mo�ksv�ne,Nc Z�o2s
M�j��� (336)751-8760/Fax (336)751-8786
Ap ica��� valuation/Improvement Pemut ❑ Authorization To Construct(ATC) ❑ Both
*IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION -
�
Name to be Billed �%'-e .�! � Contact Person .��
Billing Address c��o Home Phone � '�
City/State/ZIP lQ,��,�f /l/.L'.>� /v2- Business Phone �/.(,Z • /C/
� �/�,/ C 33
Name on PermitlATC if Different than Above ��,�•�G'�'/ /�O.✓b'� - �/�' 3 " �go�� '
Mailing Address City/State/Zip d G�(/i /✓�•� /
PROPERTY INFORMATION
NOTE: A survey�plat or site plan must accompany this application. �.p�V��
(Permit is valid for 60 onths with site plan,no expiration with comp ete plat.)
Street Address .�z„�� L� City �. Tax PIN#
Subdivision Name Section/Lot# Lot Size
Directions To Site: �v�C : •" �.� O '
��G��-' O•-, P -Y� ��. d�Lv/S � oF' ��f�- /.O��
Date House/Facility Corners Flagged
If the answer to any of the following questions is"yes",supporting documentation�m st be attached.
Are there any existing wastewater systems on the site? ❑Yes CC�P�o �
Does the site contain jurisdictional wetlands? OYes ❑� .
Are there any easements or right-of-ways on the site? ❑Yes Q��
Is the site subject to approval by another public agency? ❑Yes �
Will wastewater other than domestic sewage be generated? ❑Yes C}3�o
IF RESIDENCE FILL OUT THE BOX BELOW
#People 5 #Bedrooms #Bathrooms ,3 Garden Tub/Whirlpool es ❑No
_ _ Basement: OYes C� Basement Plumbing: ❑Yes ��
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: nventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: i7�ounty/City Water ❑ New Wel( OExisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? [�� B�10
If yes,what type? /6 / c� ,��J� ..
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pemut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurrec�
frons tlzis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspec ' s to dete 'ne compliance with applicable laws and rules on the above described property located in
Davie County a 8 o d by
�
Site Revisit Charge
ro r owner's r owner's legal representative signature
Date(s):
Da�`�!� � Client Notification Date:
EHS:
Sign given OYes ❑No Account# ��
Revised 2/06 Invoice#
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. � ' • . � � . /�� � . � , . "�'f (-!, _ y-s .
' � e � � , Af'l'LlCATtUIV FOR SI7E CVALUA7tON/IhiP[tOVCM1iCNT PLR�f17 - � � � 0 (�j
' , , DaVie County Health Department � v �
• � Environmenta!/Yealtl�Section
• P.0. Mocksvi llo NC P 2 026 treet �Cr ��9.?O45 ,
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(336)751-II760 E�R�NMpyr
Al
***IFSPORTIINT*** TIiIS APPLICATION CANNOT B� PROCESS�D UNL�SS AI,L THE RLQ
INFOR2•l1�TIObI IS PROVID�D. Refer to tha TPTFOFiDiATTON BULLETIN for i.nuEructionn.
l. ?7ame Lo bc Dilled �{'{�CL'I� IYIDP�2 Contact Peraon (�Q(Gt4c�l �OfS�..
ldailing Addrosn �(,a�(/ /C//'//��'/}��h ,►�� Iiomo Phone 3j(p��]�i�' �r� ��
City/Stata/ZIP GL/�/ps'�l�y/� �✓'Ua'�1� �� ,�7 f0 �- IIu�ino�a Phono ���" �3� � `,��5
2, ttamo on Permit/I�TC iL Differnnt than 1►bova
Mailiiig Addruas . City/State/Zip
3. Application For: G7�5i.tc �valuation ❑ Improvement I'ermiL-/ATC ��Both '�
4. S alem lo Snrvicc: • •�jy t�
y ljYIIouuQ ❑ 23obile Homo ❑ IIuBine3a 0 Tnduutry ❑ OL-her
5. Typa n�•ntem requo�tod: LW Conventional ❑ conventional modified ❑ innovaL•ivo pacCepted
6. Ii •Itosidenco: It People �_ 8 I3edrooms _� il IIaLhrooma oc ��-
UdDinlu,ra�hor ❑Carbac�o Dispo�al L�It9ashing 2dachino ❑Dasement/Plun�ing ❑Daaement/2to Plumbing
7. If Duaineaa/Induatry /othor: verify type # People 8 Sinkn
fl Commodoa 11 Showora fl Urinala p T•JaLor Coolora "
� ; IE' FOODSERVICE: �� Seatu �sEimated i4ater IIaagQ (gaiions per day)
� a. �o oE wator aupply: jLYC�ounty/City ❑ Well ❑ Commun'ity
9. Do �ou anticipata addiCion� or cxp:insions of tlic facility t]iis systcn�is iiitc�ided to scrvc? Cl 1'cs C�f'No
If pcs,ticliat typc?
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. ***IniPOItT'�IN7�**cLiLHTs hruST CO111PLCTIi TIIC ItL•QUIRED PROPCRTY 1N1�ORA�I�ITION RLQULS'TI:D
;R fS1;i.O1V, isithcr 1 PLAT or51Ti:PLAN dIU.STBESU11bfITTF.D by thc clicnt �vith'I'IIIS APPI,tCAT10N. �
1't'opert}'Diulcnsions: �a J I�Cr�'S � lYIi1TG DIRCCTIONS(frutn��lodcsvilic)to P1i01'LR't'1':'
.
. •r:�.ocr,z�i�ttv: �, f� �7 �7 g' �.5� - �/3 sZ (2c� -}-v -�'a�� I'���I,� -�Ur» 1���-
I'ropert}'Address: Road Namc�,� u f•1t�2 /Cv �lv� ��P���m�nf (�Q � 3�0 '° •
Ci(y/Zip�(/:tH2 02,�[�!��n ��Il/� SO.�y L/�hf Olt��� UD
�If iri a Subditi�isio�t provicic iiifoi•►nafioli,as lollo}vs: �t0 ��//6 �� d� l�-�� L.oncf'��
1va,nc: ��h-�✓ .�r�� o� �hr�-� �.�
Scclioii: Blocic: Lot: Datc Itomc coriicrs Aaggcd: JD�ZG�OS
�
'I'l�is is to ccrtily tl�at Uic iufortnatiou provicicd is corrcct to thc bcst of tuy l:no�vlcdgc. I uncIcrslaiid lhat ai�y permi((s)
issucd I�crcaftcr are subjcct (o suspcnsion or rcvocatiai,if thc sitc plans or intcndcd usc cliangc,or if llic informalion
submiltccl in tl�is applicaliou is f•�Isiticd or clia►�gcd. I,also,rurrlcrslrrlyd tlrr�t 1 nur respousiL(c fi�r n!!cicnrgcs incru•1•ed jrunr
tlris npf�licalion. I,I�crcby,givc conscnt to tlic Autl�orizccl Rcprescntativc of tl�c Davic Com�ty I�Ic�lth llcpartment
to cnlcr t�port abo��c dcscribcd pc•operty�locatcd in llavic Cowity ac�d o�ti�ncclby
to ca�duct all tcsting proccdures as�icccssary to cletcr►ninc tlic sitc suitabilit��. '
D�l'I'L � ��`�Z!� �Q� SIGNtIT'UIZI: T' ��(' _
TIIIS AI2LA 111AY BI;USI;D rOIt DI2A�VING YOUR St'T�PLAN(IiicIudc all of tl�c follotiring: L�isting aiid proposcd
property lincs and dimensions, structures, setbacks, and septic locations). � .
/ ,�� � ' ���,�� Sitc I2cvisit Cl�argc '
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0��`��' �
� �� ` �T'?� . . C� Clicnt Notificatiou Datc:
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�I-IS:
p � � 3 c�'`� ��r �, � �
Sign givcn � 'C, �� CW-�''�`�-r� �`� � �,�lccouiit No. � ���
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Revisccl llCII (05/03 Iuti•oicc No.
I 6.73A � F .
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• a - � ' DAVIE COUNTY HEALTH DEPARTMENT '
� Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003777 Tax PIN/EH#: 5778-05-4352
Billed To: Gerald Morse Subdivision Info:
Reference Name: Location/Address: Sandy Lane-27006
Proposed Facility: Residence Property Size: 2. 1 acres Date Evaluated: �1' ��'�
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring ►� Pit Cut
FACTORS � 1 2 � 3 4 ' S 6 7
Landsca e sition L
Slo % � �o •
HORIZON I DEPTH -�Z
Texture rou SU- SGL
Consistence - S�
Structure ��
Mineralo � ..
HORIZON II DEPTH - 2.
Texture mu
Consistence � � �
Structure � S �
Mineralo � S� . _
' HORIZON III DEPTH .
� Texture rou .} -� , -
Consistence � -r-SS 'SSS� �
Structure � . �3k
Mineralo .: 5�= �
HORIZON IV DEPTH
Texture rou �
Consistence
Structure •
Mineralo _ . _
SOIL WETNESS 3
RESTRICTIVE HORIZON .. '
SAPROLITE
CLASSIFICATION � pS
' LONG-TERM ACCEPTANCE RATE E�• Q.3� -
SITE CLASSIFICATION:_ P� � EVALUATION BY:� ��c���wv�i-'
� _ � �t,� �,�.;
LONG-TERM ACCEPTANCE RATE: d'3 ' OTHER(S)PRESENT:
REMARKS: �
. . � LEGEND
L�ndsca,Fe 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 �
Texturg .
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
N�u1St
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm _
� �
• . NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic _
�� '
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic '
MineraloQv _
1:1,2:1,Mixed _ :
rioi�s .
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 OS/OS(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 /Fax: (336)751-8786 •
October 25, 2005
Gerald Morse
4641 Kinnamon Road
Winston-Salem,NC 27103
Re: Site Evaluation-
2.1 Acre Tract/Sandy Ln.
Tax PIN#: 5778054352
Dear Client(s):
As requested, a representative from this office visited the above site October 24,
2005 to perform a site evaluation. Based on the information provided on the Application
for Site Evaluation and after the evaluation was completed,the site was found to be
provisionally suitable for the installation of an on-site sewage disposal system.
House location, size and other design criteria may necessitate the use of an
alternative or innovative system. System design will be determined at the time an
Improvement Permit/Authorization to Construct is applied for and issued.
Before a representative of this office will revisit the site to issue an Improvement
PermitlAuthorization to Construct,the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off.
If you have any questions, feel free to contact this office at 751-8760.
Sincerel �
Jeff G. Beaucham ,R.S.
Environmental Health Section
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