151 Sourwood Ln (2) ��,�,,�.� �'/�1��-"
. DAVIE COUNTY HEALTH DEPARTMENT
� . �. '� Environmental Heaith Section �� 'f�— / �--- '' S
. , , P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
� (33G)751-87G0
Account #: 990003670 Tax PIN/EH#: 5861-69-1796
Billed To: Harry Williams Subdivision Info:
Reference Name: Location/Address: 151 Sourwood Lane-27006
Proposed Facility Garage Property Size: see map
ATC Number: 4142
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLTST BE ISSLJED 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 CONSTRU TIO IS VALID FOR A PERIOD OF FIVE YEARS. .
Environmental Health Specialist's Signature: < Date:
CERTIITCATE 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.
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Septic System Installed By: / �/� �
Environmental Health Specialist's Signature: %���// Date: U �
DCHD OS/99(Revised)
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Bog 848/210 Hospital Street
., �' � ' � Mocksville,NC 27028
. �"' ' (336)7S1-87(►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003670 Tax PIN/EH#: 5861-69-1796
Billed To: Harry Williams Subdivision Info:
Reference Name: Location/Address: 151 Sourwood Lane-27006
Proposed Faciliry Garage Property Size: see map
ATC Number: 4142
**NOTE**This Improvement/Operation 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). THLS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CON'IRACTOR MUST SEE TfiIS PERMTT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type t #People #Bedrooms ,�j�� #Baths�
Dishwasher: � Garbage Disposal: ❑ Washing Machine: ❑ Basement wlPlumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply�_ Design Wastewater Flow(GPD) � � Site: New� Repair❑
System Specifications: Tank Size,/�'Q�GAL. Pump Tank GAL. Trench Width� Rock Depth�lLinear Ft.10�
Other: As stated In I5A NCAC 18A;1969(5)
sy3i�m3-rrray-ai�aa��s
Required Site Modifications/Conditions:
IA'IPROVEl�9ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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)751-87G0.****
_-
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Y
Environmental Health SpecialisYs Signature: � Date: �''�y`6S
DCHD OS/99(Revised) ���
Vv 'l�a` � � �
•.,� � , A ION FOR SITE EVALUATION/IM1tI'ROVEMEfVT PERM1IIT&ATC ,
� / Davie County Health Department �
��jL j � � Environmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
��u� Mocksville, NC 27028
�NVlRO�� (336)751-8760 �
***IbtPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Namo to be Billed . Contact Peraon'�,m p
Mailing Addresa �'V i3/ Iiome Phone ,��(A-��1��-f-�����1
-7 r /� ��
. City/State/ZIP �i` /� ��_�. c�/��'j� Buaineas Phone _�j.:LF'" �%�- C✓�_��
2. Name on Permit/ATC if DifPerent than Abovo f�,/�!. (�_.��'7�E�
Mailing Addresa City/State/Zip
3. Application For: �ite Evaluation �Improvement Permit/ATC �IIoth
4. systeia to service: ❑ House 0 Mobile Homo ❑ 33usiness ❑ Industry 0'OtherC,tj��,,,r�
/�`-7�_
" 5. Type uyatem requested: `t� Conventional ❑ convantional modified ❑ innovaCiva pacCepted
6. If itesidenca: � People # Bedrooms # IIathrooms
❑Diahwasher ❑(3arbage Disposal ❑Washing Machino ❑Basement/Pluaibing ❑IIasemant/No Plumbing
7. If Businesa/Induatry /Othcrs verify type Q�/�''��E # People �k Sinks �
�
# Commodos �_ # Showera �� � Urinals �_ S WaL•or Coolera �
IF FOODSERVICE: #� Seata Estimated Water Usage (galioas par aay)
8. Type of water auppiy: L7'County/City ❑ Well � Community
9. Do you anticipate additions or expansions of thc facility tl�is systcm is intciidcd to scrvc? Cl Ycs 1�'!VO
,�If 3'CS�11'�11t tynC�
***11�TPORTi1NT't**CL[CNTS MUST COh1PLETE TII� REQUIItED PROPGRTY INrORMATION REQUGSTL:D
BGLO�V. Githcr a PLAT or SITC PLAN 1LfUST BE SUBl�f17TED by the clicnt �viNi TIIIS APPLICATION. � ,,y�"�;' �
• N<,
`� 1�;
Property Dimensions: '��a ,�3 x 5�J I�I��(�dy�.�VRITE DIRGCTIONS(from NIocl:sviUc)to PROPCRTY:`
T�aorr,��riN: �j`�Y>C�l(s�� C7� � 1�S-�t,�v-c� C�e_m�,-,�n� =
, �.�
Property Address: Road Namc���, Xy a��tcl4o� rZ')e ���� 0(1 �ur�.c.;uoc� L2.'l� `� .
- .. �i�,
c�ty�z;n . Y'''
.��u-�.��e , �7b�'4� � �r���-:.
-:�,�
If in a Subdivision providc information,as follows: �
. Namc: .
�',
Section: Blocic:: .' Lot: Date l�ome corners IIagged: � � �
, Y
.. .'��
�
Ttiis is to certify tl�at tl�c information provided is correct to the best of rny knowledge. I understand tliat any permit(s)
issucd Iicrcaftcr are subject to susP�nsion or rcvocation,if thc sitc plans or intcndcd usc cliangc,or if thc i�iformation
submitted in tliis applicatiou is falsiCed or cl�anged. I,also,triidersta�id tkat I anr respousiGle jor a11 clrarges i�rcrrrred jrau
t/�is npplicatio�r. I,licreby,givc conscnt�to tlic Autl�orizcd Represci�tativc of tlic Davic County IIcallli Departmcnt
to enter upon above dcscribcd p►•operty located in Davic Cou�ity and otivned by
to conduct all testing procedures as neccssary to detcrminc the sitc suitability. �
r-
DATE / `�7— U� SIGNATUIt� �!�/� ,����v
THIS AR�A MAY B�US�D rOR DRAVVING YOUR SI'fE PLAN(Includc all of tlic follo�ving: Lxisting 1nd proposcd
property lines and dimensioiis, structures, setbacks, and septic locations). �
- Sitc Rcvisit Cl�argc
. Datc(s):
� ' Clicnt Notification Datc:
�I-IS:
Sign given . '• Account No. c=�lU �� �
• �—/,�3 0
Reviscd DCHD(OS/03 Lrvoicc No. �
• ' � i
` � DAVIE COUNTY HEALTH DEPARTMENT
,. ` � � � � Environmental Health Section
' �� - � " Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003670 Tax PIN/EH#: 5861-69-1796
Billed To: Harry Williams Subdivision Info:
Reference Name: Location/Address: 151 Sourwood Lane-J�'7006
Proposed Facility: Garage Property Size: see map Date Evaluated: �/.C��116
Water Supply: On-Site Well V Community Public '
Evaluation By: Auger Boring Pit_�� Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition
Slo % � .
HORIZON I DEPTH �- i/
Texture rou
Consistence � f'�- .
Structure r .
Mineralo �/ � ,- /
HORIZON II DEPTH yK f4
Texture rou
Consistence r /
Structure ,�
Mineralo
HORIZON III DEPTH
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:�/�j'�/
� LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS:
LEGEND �
I, n s ne Position � , '
R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace FP-F1ood plain H-Head slope �
� . . 1 . : . .. . . . . .
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
1l�ist
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 YP-Very plastic
a�i'11�i1I'g _
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloev -
1:1,2:1,Mixed
LYQteS
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(suifable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gallday/ft2 , DCHD OS/OS(Revised)
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