222 Springhill Dr DAVIE COUNTY HEALTH DEPARTMENT n��-2��p_
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A ' -- r' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000860 Tax PIN/EH#: 5745-37-3926
Billed To: Gregory Minor Subdivision Info:
Reference Name: Gregory Minor Location/Address: Spring Hill Drive-27014
Proposed Facility: Residence Property Size: 150 X 125
ATC Number: 2257
**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 Tf�INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People f #Bedrooms � #Baths_ �Z
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementJNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size /_S�X/�S� Type Water Supply�_ Design Wastewater Flow(GPD)�3Z Site: New�Repair�
�
System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width���Rock Depth� Linear Ft�G`v
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 u BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 830 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: �1��i�/
DCHD OS/99(Revised)
t _ � P .� .
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r.o.Bog s4snio x�p�t��sr��t
Mocksville,NC 27028
(336)751-8760
AccouM #: 990000860 Tax PIN/EH#: 5745-87-3926
Bilied To: Gregory Minor Subdivision Info:
Reference Name: Gregory Minor Location/Address: Spring Hiil Drive-27014
Proposed Facility: Residence Property Size: 150 X 125
ATC Number: 2257
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLTST 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 R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �l � Date: �l��4 '"�%
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.
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Septic System Installed By: �. �
Environmental Health Specialist's Signature: Date: 3
DCHD OS/99(Revised)
APPUCATION FOR SITE EVALUATION/IMPROVEMEM PEHMR&ATC O � � � 0 d [�
. • ._ , � Oavle County Hesith Oepartment
Environmenis/Hea/th Se+cdon
�.o. Bo: 848/210 8ospital Strset NOV ( p 1999
. Mocl�avills, NC 27028 � •
(336)781-8760 �
• ENVIROAN�MENTAL NEALTH
***?D�ORTANT�'�* T�I$ ]�PM.ICATI0T1 G71pN01' S� PROC688�D UNL�88 ALI+ T�
t�iS�01t�91T=ON t8 PRGV=DED. ttiler to th� IN8'O1tMATION 80I►L�T2li for isistruations. '
i, �. tio b. asu.d o ' ' 0 2 co�t.ot r.=.o� __G2� 2�/ I�� ; �+02
K.sis� �... L c ao.. �oa� �v4 =�,l,S�-9 5�f y
" ��r/at.�t..�asp ���,�Q n T_.� � �fs o 2 5 swsa... ��. _ 7(��(- 9 07- �'a 6�
4. Maa. on p.z�i.t/J►rc it aslr.s�.nb lbaa ]►bo..
Nsilieiq 71d�dr��• CitY/etat,�/iiP .
a. �►ppiiaatioa gor: �t.� E�ralnatioa 0 Zmprov�msat p�rmit/Ils'C �Both
�. sY.t.. to s.rvsa.� Gl�ious� O Mobile 8om� 0 8usin�sa O tadustsy 0 Oth�=
a. _� ttesidu�a�: t psopio �_ � Badrooms �_ � Sathrooms
�Di�hxaab�s �iasbaq� Di�potal O�aihis�q ltaohia� 0 sas�at/pluabinQ 0 Daa�n!/�to plm�biaq
6. i! swia���/Zndu�tsy/Oth�rs Bp�ai�Y t7tP� � �opl� + 81nka
� com.oa.. � ehow.r. i vriaal� i 1�,at�r cool.z.
ta a'OOD8ERV=C3: � S�ats =atimat�d Nat�r tJaaq� to�l� r� �r1
�. T�rp. cr nat.r .upplp: e�co,�ty/raty o xal a commuaity
e. Do you�nHcipate sddiHona or eipansione of the faeWty this ayatem Is intended to�erveT 0 Yea p,A16
If yea,w6st type?
. ***IMPORTAN7w**CLIENTS Ml/ST GbMPLETETHE REQUIRED PROPERTY INFORMATION REQUEStED
BELOR+. Etther s PI.AT or S1TE PI.AN Mi/ST BES(18bIITTED by We elient tvtth THIS APPI.ICATION.
Property Dimenslons: I�U K_� Z S R+RI'TE DIRECfION3(iram Mockaville)to PROPERTY:
T�i 081ce PIN: # `7'?4�� _'�7 �- �9� 6 O � O , a� rf�I
Property Address: Road Name �PfiLiN(r N:�� (Zi�e o ( � `
t � ' ' �
� City/Zip�o�lPenne�. NC �'1�(4
If ln�Subdtviaion provtde intormsdon,aa follmve: :
Name: �
r=
Secdons Block:� Loh � DAte ProPerty'Fl��ait ��/G-q q
T6is is to certify t6at t6e informaHon provided is correct to the best of my knawledga I anderabnd thet�ny permit(e)
iasned hereaRer sre anbjat to easpeneton or revocation,if t6e eite plans or inhnded ae�c6enee,or if the iniormaHon
aabmltted in this spplicaHon W faleifled or ch�n�ed. I,also,anderstand tA�at I ani rGsponslble jor all charg�t lncamd jrone
tbls appilcadox. I,6ereby,giva eouaent to t6e Aathorhed Repneenbtfv�of t6e Davie Coanty H W Dep�rtment
to enter npon above deacribed prnperty lacated in Davie Coanty aad awned by '7v u[- lal.. :n�f�
to coadact ali tesHng procedura na neceas�ry to deternilue the�ite�aihbW
DATE I 1- �'D�^ q�l SIGNATURE
THIS AREA MAY BE U3ED FOR DRAWQiG YOUR S1TL PLAN(Inclnde�il ot t6e follo�vring: F�isting snd proposed
property linea snd dimenelons, etractarea, eetbacka, and eeptle IocsHons�
Site Revbtt Charge
Date(a):
Client NoHBa�Hon Date:
� EHS:
Acconnt Na ��O v
Revi�ed DCHD(07/99) ;, Involce Na ���
. —
"I. C. RAY CATES certlty that on__ Jlll Y 2 , 19��, I surveyed the property shown on thfs plat;
that the property line� and location ot all structures are accucately shown hereon; that no structure located on thls property
encroaches on any adJacent street or property, and that no structure on adiecent property enc�����Mt��e premises
.� RO •,
surveyed." AUGUST �$. 1995 (inter�or IOi lines) .�� �N Ca' ( '�
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PROPERTY OF �, `; . .
PATRICK MORRISON
PARCC� 3 DAVIE COUNTY TAX MAP M-5- 10 B
LOT NO. 2g ihru 40 MAP OF REVISED MAP OF C�GCW000 DEVBLOCK NO. B
DEEO DOOK 169 PAGE 668 JERUSALEM TOWNSHIP,
PLAT BOOK � PACiE 3U DA V I E COUNTY, N. C.
sCAL[: 1 INCH= 50 FtlT
. __ .._ 3065-B-29
. � � .. - DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
Soi]JSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Accounf #: 990000860 Tax PIN/EH#: 5745-37-3926
Billed To: Gregory Minor Subdivision Infa
Reference Name: Gregory Minor Location/Address: Spring Hill Drive-27014
Proposed Facility: Residence Property.Size: 150X 125 Date Evaluated: /1��7/��
Water Supply: On-Site Well Community Public �/
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 - 2 3 4 5 6 7
Landsca osition
Slo e% .L `
HORIZON I DEPTH '
Texture rou '
Consistence
Structure
Mineralo
HORIZON II DEPTH . (� '' 6 �
Texture rou L
Consistence � i
Structure �C f
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 L �
SITE CLASSIFICATION: � EVALUATION BY: �l�
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
Mois
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
tructure
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
DC�ID OS/99(Revised)
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