253 Singleton Rd - •. . • DAVIE COUNTY HEALTH DEPARTMENT "
� Environmental Health Section
P.O.Boa 848/Z10 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003329 Tax PIN/EH#: 5755-80-7673
Billed To: Terry Bates Subdivision Info:
Reference Name: Location/Address: Singleton Road-27028
Proposed Facility Residence Property Size: 300'x 600'
ATC Number: 3853
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). T'E�S
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �� /� Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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 guarantee that the system will function satisfactorily for any
given period of time.
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��Septic System Installed By: _�,� � ✓i
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Environmental Health Specialist's Signature: � l� Date: // /���
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DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
. ,� � Environmental Health Section d � 2 �D �
. ' P.O.Boz 848/210 Hospital Street � �
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003329 Tax PIN/EH#: 5755-80-7673
Billed To: Terry Bates Subdivision Info:
Reference Name: Location/Address: Singleton Road-27028
Proposed Facility Residence Property Size: 300'x 600'
ATC Number: 3853
**NOTE** This ImprovemendOperation 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 �f #Baths,� �
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply�i,/l Design Wastewater Flow(GPD)��� Site: Ne�Repair❑
,, ��
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���tock Depth� Linear F�SD�
Other:
Required Site Modifications/Conditions:
I1�IPROVEi19ENT/OPERATION PERMiT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISt1ED GRADE. ****NOTICE: Contact 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.****
�
Environmental Health SpecialisYs Signature: Date: � �
DCHD OS/99(Revised)
�' `�-,�.!".r�"�"...�""'' . . �. . . . .. . .. . .. . .� �- . .� �. � : . �. �.� � .. . .
� � � � CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
, Dc' l�1 .
Davie County Health Department
Environmenta/Hea/th Section
A�G 1 9 �" p.o. soX 848/210 Hospital streat
Mocksville, NC 27028
ROtyMENip1.lIEA1�
(336)751-8760
***I *** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
NFORMATION IS PROVIDED. Refer�to the INFORMATION BUI,LETIN for instructions.
t..
/' i. x�e to be Billed I���r({� '��'�{'S cont8ct Parson S�me vc P�pr�n�� '�t��eS .
Mailing Address _o�`� 3 S�tlq e�O 1.�} C`� Home Phona 3�6� ���--c����
City/3tate/ZIP m�C�(s�?i��� �L, c���cl� Buaineas Phone ��(�" � / j "'�a��
2. Name on Permit/ATC if Different than Above
Mailing Addreas City/State/Zip
, 3. Application For: � Site Evaluation ❑ Improvement Permit/ATC 0 Both
- 4. syatem to service: �3"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
`5. Type syatem requested: LI Conventional ❑ conventional modified ❑ innovative
6. 2f Residence: # People ,�_ # Bedrooms � # Bathrooms �_
L Dishwasher ❑Garbage Disposal �Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Susiness/Induatry /Other: verify type # People # Sinks
# Coa�odes # Showera # Urinala # Water Coolers
IF FOODSERVICE: # Sests Estimated Water IIsage (gallona per day)
8. Type of water aupplys 0 County/City 0 Well ❑ COmmutiity
9. ao Yon anticipate additiona or expansions of the facility this system is intended to serve? O Yes 0 No
If yes,what type?
***IMPORTANT'k**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY 1NFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
i
Property Dimensions: 3Q�� � � Da WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: � # �� J�� ���h / � �Dl So�l7Li �b Jc7� �O �
, dor
Property Address: Road Name ,��`/tJc� %�tJ� ►�� C�n�'',tIG(� S�c1�l y� C�i�t?�2✓J
��
City/Zip/�cC�C d��/% a���� /�� iPc.� �c112n1 �,P«- ;�O �v .
If in a Subdivision provide information,as follows: S�r��,�P�� l�n� �Lll�N k"���/��
Name: � r� /�vtl S� c9 itl ����{' /��20S S
�r�n r�-� r�o i�d.
Section: Block: Lot: Date home corners flagged: ��2 0:�o y
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 revocation,if the site plans or intended use change,or if the information
submitted in this application is falsi6ed or changed. I,also,understand tliat I am respoirsible for all cfiarges incrrrred from
tl:is application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and o�vned by '`� - S
to�conduct all testing procedures as necessary to determine the site suitability.
DATE B� I SIGNATURE �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include a 1 of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
• Date(s):
Client Notification Date:
: EHS:
Sign given �/ Account No. �� ��
Revised DCH (OS/03 Invoice No. _��s� i/
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- � ' „^ . , DAVIE COUNTY HEALTH DEPARTMENT
' ." - Environmental Health Section
~ Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003329 Tax PIN/EH#: 5755-80-7673
Billed To: Terry Bates Subdivision Info:
Reference Name: Location/Address: Singleton Road-270 8 �
Proposed Facility: Residence Property Size: 300'x 600' Date Evaluated: �
-/
Water Supply: On-Site Well Community Public ,
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo %
HORIZON I DEPTH !/ �"y
Texture rou L �� �
Consistence
Structure �
Mineralo
HORIZON II DEPTH '�
Texture rou
Consistence �
Structure
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 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 clay SIC-Silty clay C-Clay
CONSISTENCE
ois
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
truct re
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
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
DCHD OS/99(Revised)
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