289 Seaford Rd DAVIE COUNTY HEALTH DEPARTMENT
-• � Environmental Health Section � (U J i �� (Ov--
• , , P.O.Boa 848/210 Hospital Street �
�-: `_�_-. • Mocksville,NC 27028 ' �'
(336)7S]-87(0 �� �
IMPROVEMENT/OPERATION PERMIT ��
o�.� � i`r`.,"•�
Account #: 990002077 Tax PIN/EH#: 5776-59-@�"s�Or"" ���`�"'
Billed To: Mildred Hoke Subdivision Info: l o�q� o -�
7
Reference Name: Location/Address: Sea ord Road-27006
Proposed Facility: Residence Property Size: 200x396
ATC Number: 3290 �
**NOTE** This ImprovemendOperation 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 THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People� #Bedrooms � #Baths�_
Dishwasher:� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply�_ Design Wastewater Flow(GPD) ��� Site: Ne�Repair❑
System Specifications: Tank Size1�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 CRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth 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.****
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7 (/� \ V �.� i�
Environmental Health Specialist s Signature: �! Date: f� � 7��
DCHD OS/99(Revised)
, • • �
• � DAVIE COUNTY HEALTH DEPARTMENT
• • ' ° Environmental Heaith Section
. � � P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028 ��''" r/ ,1
(336)751-8760 M"`�
� .
�, � � ��
Account #: 990002077 Tax PIN/EH#: 5776-59-E?3�' � � a.�m-�
Billed To: Mildred Hoke Subdivision Info:
Reference Name: Location/Address: Seaford Road-27006
Pro osed Facilit : Residence Pro ert Size: 200x396
ATC Number: 3290
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWA O STRUCTION IS VALID OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: GU> Date: /!�j —? �8 Z_
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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Septic System Installed By:
Environmental Health SpecialisYs Signature: Date:�'�1/"�3
DCHD OS/99(Revised)
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�,i � CATION FOR SITE EVALUATION/IMPROVEMENT PEIi1161T&AZC `
..� C,� � o . �
� U Davie County Health Department
Q Environmenta/Hea/th Section
�CC , 0 ZU01 P.O. Box 848/210 Hospital Street �
� Mocksville, NC 27028
��SA�NFALT� ' (336)751-8760
V1R�N;"1,.����y
*** ANT*** TIiIS APPLICATION CANNOT BE PROGESSED UNLESS ALI, THE REQUIRED
FORI�,TION IS PROVIDED. Refer to the INFORI�,TION �ULLETIN for instructions. '
i. x� to be sillefl ���J—�--�%�� � � /� �Contact Person L �/�/ 1��� .
Mailinq Addres� ' '�" � /iw v�"�� """� - " � �'`v Home Phone 33� 7 / (J —�0�O
City/State/2ZP Y,�/7f��_/� / �� ����" � Business Phone ��� � ��v �
2. Name on Permi.t/ATC if Different than Above � - �y�5 yz--
` O .
Mailing Address city/state/zip
3. Application For: �Site Evaluation ❑ Improvemen� Pex�(tit/ATC ��❑ Both
a, system to service: [�House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
/ 2
s. If Residence: � People � � Bedrooms J # Bathrooms Z
C ishaasher ❑ Garbage Disposal Y�'Washing Machine ❑ Basement/Plumbing U Basement/No Plumbing
6. If Business/Industry/Other: Specify type 9 People � Sinks
# Commodes # ShoWers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Esti.mated Water Usage �gaiions per day)
7. 7�pe of water supply: ❑ County/City Q�Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑Yes LTlvo
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQU/RED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN M(IST BESUBMI77'ED by the client wit6 THIS APPLICATION.
a � x 39� S9 � `
Property Dimensions: �a �V� � WRITE DIRECf1�NS(from Mocksville)to PROPERTI':
ft�PC�L 2 O, Z
axOfficePIN: # �� Ll�S?� 7a�✓/¢11/� L��/�1-�'jTCYV
Property Address: Road Name ��%����2l� i2o�'9!J TUl2/J /2/�'/S�� _�/� g d l �
c�ty�z;p �4�c/qn/��� N�a�o o G �i v�vi c�r..l, ��-�r o,J r���✓��-�,.�
lf in a Subdivision provide information,as follows: /� ����� �'�� D� `r�����
j'7 7 b =5 9 — c� 2 �' � �- � �20,�� o� L��i�'�T /��itv x 3 4r+i
Name:
� �o�9-oa'- UN �i�� /� ff�/
Section: Block: Lot: Date Property Flagged: e���1/7/�/
w i �l C�.
T6is 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 suspension or revocation,if the site plans or intended use change,or if tl�e information
submitted in this application is falsified or changed. I,also,understaud t/:at I am respo�tsible jor a!l c/iarges iircurrerl frone
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property locatcd in Davie County and owned by
tc ca�d:��t�i!testina prazedures Es necessar}�to cietermine the site suitability.
/ t
DAT�Q.(� � �C� I SIGNATURE ,
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of thc following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations). �
� Site Revisit Charge
�� � %� Date(s): �
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,'� Client Notification Datc:
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, • • DAVIE COUNTY HEALTH DEPARTMENT
� � � Environmental Healih Section
._ . ,. „ ,
Soi]/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002077 Tax PIN/EH#: 577fr59-0570
Billed To: Mildred Hoke Subdivision Info:
. Reference Name: Location/Address: Seaford Road-27006
Proposed Facility: Residence Property Size: 200x396 Date Evaluated: /� '�7��✓
Water Supply: On-Site Well v Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo %
HORIZON I DEPTH '� "
Texture rou �$'c L
Consistence
Structure -
Mineralo
HORIZON II DEPTH '` %
Texture rou
Consistence
Swcture /L_ l
Mineralo �' C
HORIZON III DEPT'H
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEP'TH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �=-� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: � OTHER(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
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 day 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
Structure
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
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
DC�ID OS/99(Revised)
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�ENVIRONMENTAI�HEALTH SECTION
P. O. Box 848/210 Nospital Street -
Courler #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760 �
December 18,2001
Mildred E. Hoke
- 27259 Hoover Rd,Apt. #26
Warren, Mi 48093
Re: Site Evaluation/Seaford Road �
� Tax Office Pin: # 5776-59-0570 �
Dear Client(s):
As requested, a representative from this offce visited the aforementioned site on ..
December 18,2001. 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
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, �
�a�'���/°��•
Robert B. Hall, Jr., RS.
Envu�onmental Health Specialist -
RH/di
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AUTHORIZATION':NO:.O 5 O 2 DAVIE CdUNTY HEALTH DEPARTMENT ,� �
� ,. � .
�e��a cj,� �o.,�« Environmental Hcalth Section :� PROPERTY INFORMAT.ION
�Per�iit�e�e's� � P.O.Box 848 - . "
...... _ _ . . : ,
�.Name:�.e�:�.a.�..�'-� o�.;_,..�.,�r Mocksville,NC 27028 Subdivision Name: �`-'�'�'-�'�F;e � �
� ' ;;,. - Phone#:704-634-8760 . '� i��
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'�Directions to property: - - 5 ���t– Section:
�' Lof: _._c�+�
AUTHORIZATION FOR•
�..` U...�..���,n!�. �, r*���,'�,�..�.�;�z� .WAST'EWATER Tax Office PIN:# ~4'�,�;�"'�-
--�---�— SYSTEM CONSTRUCTIOI�(
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� **NOTE**This Auihorization for Wastewater System Const►uction MLTST BE ISSUED by the Davie County Environmental Healtli Section prior
to issuance of any Building Pemuts.This Form/Authorization Number should be presented to the Davie County Building Inspections�
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). ''".
. Cb� � p',��.�� �� � C ,, �� ***NOTICE**�THIS AUTHORIZATION FOR WASTEWATER CONSTRUGTION
�co+��`� ` . C�� �I�I��. �b IS VALID FOR A PERIOD OF FIVE YEARS.
..: ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED "": . •
. . '*,.,
' , ,RFSIDENTIAI.SPECIFICATION:BUILDING TYPE.�#BEDROOMS �� #BATHS �' #�OCCUPAIVTS �'� GARBAGE DIS�OS., or No� ' "
' . - ,p� �
"COMMERCIAL SPECIFICATION: FACILITY TYPE ' #PEOPLE #PEOPLF/SH1bT #SEATS INDUSTRIAL AS Yes oc No
� r �
. . LOT S�IV -�0O ,'iYPE WATER SUPPLY u`� DESIGN WASTEWATER FLOW(GPD) J�v�. NEW STl'E �• REPAIR SITE ✓. ,;
'SYSTEM SPECIFiCATIONS: TANK S1ZE/D d� GAL. PUM TANK GAL. TRENCH WIDTH` 3 ' ROCK DEP'TH��LINEAR FT ��b?,
. �. , , ,
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. . . � � � . Q�]� , . . � � . . -. - � . . ' ' . ' .. . .. . . ' sa�
`` REQUIRED STTE MODIFj�ATICNS/CONDITIONS: ,
+rf . . � �',�- ,'i
'` IMPROVEMENT PERMTT LAYOUT a> "" ,`',
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• **CONTACT A REPRESENTATIVE OF THE DAVIE C H DEPARTNIE�T£.FOR FINAL INSPECTION OF THIS SYSTEM
. ' r G'I'VVEEN 8:30-9:30 A.M.OR 1:00-1:30 p.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760r :
OPERATTON PERMTf : :
SYSTEM INSTALLED BY:
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,'�; AUTfiORIZATION N0. ``` _ OPERATTON PERMTT BY: . . : :� ' ::'� ; ' , . `� DATEi
.. ;. � . . . _ ., ,. , . ,.
• "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS.BEEPi INSTALLED IN COMPLIANCE �''
W1T'H ARTICLE 11 OF G.S.CHAPTER 130A,SECfION.1900"SEWAGE TREATMENT AND DISPOSAL,SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A. j
' GUARANTEE THAT THE SYSTEM WII,L FUNCTION SATISFACTORII.Y FOR ANY GNEN PERIOD OF TIN1E. , .
DCHD OS/96(Reviud) ,... I
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