187 Shore Ln . - . DAVIE COUNTY HEALTH DEPARTMENT � I�--a,b ���
� Environmental Health Section �
• � P.O.Boa 848/210 Hospital Street
� Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001467 Tax PIN/EH#: 5803-39-4724
Billed To: Danny Shore Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27055
Proposed Facility: Residence Property Size: 2.064 acres
i4TC Nurr�ber: 2626
**NUTE** T'his Improvement/Operation 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 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 PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People_�� #Bedrooms V #Baths�_
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: � BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��C Type Water Supply� Design Wastewater Flow(GPD)_<'� Site: New�Repair❑�
,, ��;' 2
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width;��i Rock Deptn� Linear Ft.�'
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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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Environmental Health Specialist's Signature: Date:,���8'!�� L/
DCHD OS/99(Revised)
• a /J d�
• DAVIE COUNTY HEALTH DEPARTMENT �
� Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001467 Tax PIN/EH#: 580�39-4724
Biiled To: Danny Shore Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27055
Proposed Facility: Residence Property Size: 2.064 acres
ATC Number: 2626
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED 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 Signahue: „��� Date: /6 ��"�
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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 uarantee that the system will function satisfactorily for any
given period of time.
/��X� �,a y���,,��
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S tic S tem Installed B : �
eP YS Y �
Environmental Health Specialist's Signature: ��,� Date: s %3(��(��
DCHD OS/99(Revised)
- ` � ' �� `� a,�en-� ���� ��o�- 3�- ��a� p � �o a
,nl �fAPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC �
Davie County Heaith Department QCj
� 1'CJ Environmenia/Kea/th Section 2`5 Z��� �
P.O. Box 848/210 Hospital Street
� Mocksnille, NC 27028 ����ONMENTAL HEq
(336)751-8760 �A�IECOUNTY �
***Il�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALI, THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORt�TION BU7�LETIN for instructions.
1. Name to be Billed n �� r � Contact Peraon 1 �
Mailing Addresa � �f[."'( �r VV i ��,Some Phone riTJ(fJJ �/Y0� l �W 7
��, City/State/ZZP � , IY Business Phone O / � / �
1 ��i n �T ta
. Name on Permit/ATC f Dilferent than Above �'�
� �-
G�' n
Mailinq Addresa City/State/Zip
�CQ�,�S�G.� /o�3 u�a°
3. Application For: �Site Evaluation ' �Improvement Permit/ATC ❑ Both
a. sy�et� to se�ioe: l[�iouse ❑ Mobile Home � Business � Industry ❑ Other
s. If Residence: t People � � Bedrooms � i Bathrooms �
�ishxasher 17 Garbage Diaposal [1/�7ashing Mschine O Bssement/Pluaibing ❑ Basement/No Plumbing
6. I£ Hueineea/Industry/Other: Speci£y type i People M Sinks
# Co�des � Shoxera � Urinals * Water Coolera
IF E'OODSERVICE: # Seats Estimated Water Usage (gallona �r aay)
�. Ty�e of water supply: � County/City �Well � ❑ Community
e. Do you anticipate additioas or eapansions of the facility this system is intended to serve? 0 Yes '�o
If yes,what typc?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTGD
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wit6 THIS APPLICATION.
Property Dimensions: ��v� T �� WRITE DIRECTIONS(trom Mocksville)to PROPERTY:
� i�
Tax O�ce PIN: # 58b3 -39- �f�'a� tOC�� � fi0 U ��� G�'1C-�-�
Property Address: Road Name , '�• 'C�• �� J tI2 m� 1 e ��'S� �'`�j
c;��z�p �la��n����I�Nc.. _� �'cr�ew a.�-� on I��f—
If in a Subdivision provide information,as follows: Z��`� �t' r� , �-1 �• 'C� •
Name:
Section: Block: Lot: Date Property Flagged: D
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 suspension or revocatioa,if the site plans or intended use change,or if the information
submitted ia this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from
!h!s app/ication. I,hereby,give coasent to the Aut6orized Representative of the Duvie County Health Departmcot
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suit i
DATE IO `7 � SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
� Date(s):
�e..w� �
Client Notification Date:
,C,�jL`L_cL.e.'''�'� EHS: ,
lJ
Account No. ��o� "
�Ivl���,�a 1 ��`J�-.
Revised DCHD(07/99) nvoice No. �
!N✓.� �r.S L�f-.e / �1-7/o 0
�
��- l�z 3
' ' � � - ' � DAVIE COUNTY HEALTH DEPARTMENT
' • Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
-' Account #: �9Q001467 Tax PIN/EH#: 5803-39-4724 •
Billed To:��anny Shore Subdivision Info:
Reference Name: Location/Address: Liberty Church Road-27055
Proposed Facility: Re�E� Property Size: 2.064 acres Date Evaluated: _ /�j d� f�a
'Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �� Pit Cut L� �
FACTORS 1 2, 3 4 5 6 7
Landsca e osition 1L L
Slo e% �
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH � �'
Texture rou
Consistence �
Structure �
Mineralo
HORIZON III DEPTH
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: � �S 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-Tenace 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
Moist _
CONSISTENCE
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-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-Subangular blocky PL-Platy PR-Prismatic '
Mineraloav
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
DCHD OS/99(Revised)
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` . .: .. D��IE;��UIV'1'Y��I.T�I I}}���Tbi�NT._.._._ . ._... �_ . �., _:..,.;
� ' ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street �
Courier #09-40-06
Mocksviile, NC 27028
Phone #: (336)751-8760
October 27, 2000
Danny L. Shore
2669 Liberty Church Road
Yadkinville,N. C. 27055
Re: Site Evaluation/Liberty Church Road
Tax Office PIN: #5803-39-4724
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
October 26,2000. Based upon the information provided on the Application for Site
Evalurrtion and after an evaluation was completed on the site,the site was found to be
provisiori�lly 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,
��'�`����• .
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s)