105 Speer Rd , , DAVIE COUNTY HEALTH DEPARTMENT �/,�/—cz'�
. _ .
Environmental Health Section
� P.O.Boz 848/210 Hospltal Street
Mocksvllle,NC 27028
(336)751-8760 %�
IMPROVEMENT/OPERATION PERMIT
Account #: 989900204 Tax PIN/EH#: 5812-61-0113
Billed To: J. D. Crews Homebuilder Subdivision Info:
Reference Name: Jerry Crews Location/Address: Speer Road-27028
Proposed Facility: Residence Property Size: 0.784 Acre
**NOT�*��i�isgmprove8inent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTfHORIZATION 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). TIiIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR T��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: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #PeopleJShift #Seats Industrial Waste: ❑
Lot Size ✓�g Type Water Supply ('U Design Wastewater Flow(GPD)��� Site: NewJ� Repair❑
System Specifications: Tank Sizef�GAL. Pump Tank GAL. Trench Width���Rock Depth�7p_ Linear Ft.��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S),IF 6"BELOW
FINISNED 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.****
r
Environmental Health Specialist's Signature: Date: % !�7`�U
DCHD OS/99(Revised)
f �
' ` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900204 Tax PIN/EH#: 5812-61-0113
Bilied To: J. D. Crews Homebuilder Subdivision Info:
Reference Name: Jerry Crews Location/Address: Speer Road-27028
Proposed Facility: Residence Property Size: 0.784 Acre
ATC Number. 2388
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � � Date: �(�-��/-Pf I�
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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 guarantee that the system will function satisfactorily for any
given period of time.
�D�3��� �i
3
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Septic System Installed By: y!t ���'L��
.' 4 � �
Environmental Health Sp�ialist's Signature: �Gx%� Date: �" `7� 2
�
DCHD OS/99(Revised)
`. ` APPLlCAl1UN D�v e C u11�tyAH@81th Depef4itENT PEflM1I dc ATC 4 12 fi� � � M �
LK �U7 U
. ,�, . . Envfrenmerttal Xe�/th Se�ctfon
p.o. Bo: s48/zio xo�ta�. str�t M� 2 4 2000 "
Moakaviile, �C 27028
�336)751-8760
EPIVi N�tENTAI NEALTH
t**,II�pATa�NT*** THIS APBLICATIdN GMqOT 8S PROCEBSED ONLE3S ALI. '�tEQ�1YRSD
TNFOJt�ATION I9 PROVIDED. Rafer to the �1TION BOLLETIN i�or ing�rna�l.ona.
s. xame eo be s���ea �D CRe_�.c7S �}f�►�3u��deR3' oontaat �ereon �ERR�, C�t�1,J S
w►s.isnQ �� �f01 ��.mn R� R�_ ao■s �oc� '-��7 2.-7�I $
csty/stata/z=r �UGksV;11� ,UG aZ7oZ� Bussness ahone St�_ �/��/�y��rn-/�
Z. Itame on Pst�ib/111G it Ditlesesit than Aboroe
Naiiing I�ddsesa Ctty/8tate/Lip
3. !►pplication zor: U Site Evaluatioa 0 Imprav�ement Pe=mit/l�TC O�8o�h
a. systes to sesvice: ��ionae 0 ldobile Home 0 Snaiaess 0 Iadnstry � Other
a. it Reaidaace: ! Paople i Hedraa�aus � N Bathrooma �
1�Dishxaahes 0 Oa�tsaQn Disposal Y ttaahinq Naclsiu� 0 Sasement/p2nabinQ 0 Basement/1b 8lvmbiag
6. if 8nsiaess/inQustry/other: 8peaily type # p�aple � Sit�ks
t Caaemodes f 8tioxan � �rinals i Fatsr Coolera
I!' FOOOBERLtZCB: � Seats $stimated itater Usaq! iQalions psr aay)
7. � o� xatnr anpplp: 1� Co�usty/City U ifell 0 Co�tousiity
e. Do yoa�nttcip�tte:ddittoas or up�n�ons of the tacility t6is e�atem b inteaded to aerve! 0 Yei 9'1Vo �
It 3a.what type"
*"'IMPbRTA1VT"'CL[ENTS 111UST C�alPLE1E'TNB REQUIRED PROPBttTY INFORMA'T[ON REQU�STED
BELOW. Ettiter a PLAT or SITE PLAN MUST BE SUBMIITED b tfu clknt wlth 7WS APPl.ICATiON.
• �flY f��:.r�
Prupecty Dlmea�ioas: 100 X �9 X 1�l0 x io0 X�fa�c lo� Wltt'f�DQtECTIONS(ttom ModnWqe)to PROPERTY:
T�i Ottice PIN: a S 8 I z.-� ► -o I ► 3 �D1 nra,�-r�-�eF�' o,J �;��c��,
PrnperlyAddre�s: Road N�ne SPrx� P...�_ IQo�— ����pf.1 ELrt�oz�1Q _ L-�FT o�./
City/Zip I�oUtS J�l l c �t/G Z?oZd� ��r.�Q P..d _ � �O�D /rT -�R�-,L �l-
if ia a Subdjvldon provide informatioa,Aa totlorv� �10�
N�me:
�ection: Block: L�ot: Date Pnope.rt�'Ftagged. - ,�' Z`f—��
This is to certtfr tbr�t the tnformaiio�e prov�dtd W correct ta t�e best o�day kao�rledg� I anderabnd l6at uny permit(s)
iuue@ hereatter are snbject to a�,spesu�on or revocAtion,i(t6e:ite plaaa or latended use ebasge,or if the informsttoa
�b�jtted ia 16b sppikattoa is filsiBed or tluinged l,al.so,anderstand tbvt I a�n re.s�.ianstble for a!l cbatrgts tncurred fro»e
t�r�r appllcar�on. I,hse�e�rr�xe coaaeu!*o We�A�horiu.d Repressgtat�vt ot the Davie County Se�tllht Dtpartmtnt
to eoter apoo�6ove described pe�perty located in Davie Couaty and owoed b�•
to cond�ct a!!teriiug procedara sa necessary to determine the dte ent
DATE �'��`a a SIGNATURE
TBIS AREA 1NAY BE USED F'OR DRAWIr1G YOUR SI7'E PLAH([acinde aU+o�the tollo�irg: E�tin�snd propoaed
Property liaes and dlweostons, rirncturea, sdbscka, a�d septic[ocatlons).
5� Pt�c.� S��C'�Le� �
Accouut No. ���
Revlsed DCHD(07/98) ���Na _��r.L..0 �
DAVIE COUNTY HEALTH DEPARTMENT
Environmentai Health Section
Soil/Site Evaluation
APPLICANT INFORMATION � PROPERTY INFORMATION
Account #: 989900204 Tax PIN/EH#: 5812-61-0113
Billed To: J. D. Crews Homebuilder Subdivision Info:
Reference Name: Jerry Crews Location/Address: Speer Road-27028
Proposed Facility: Residence Property Size: 0.784 Acre Date Evaluated: ������
Water 5upply: On-Site Well Community Public v
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition ,L� L
Slo %
HORIZON I DEPTH
Texture rou
Consistence '
Structure
Mineralo
HORIZON II DEPTH � • '
Texture rou
Consistence � . _
Structure /L- � �/
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: � EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: r �' 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
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
t ctur
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineralo�
1:1,2:1,Mixed
ts
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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