310 Stage Coach Rd . , ��<���
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001049 Tax PIN/EH#: 5707-4&9578
Biiled To: Lawrence&Carta Smith Subdivision Info: '�3/Q c��q�e���
Reference Name: Lawrence 8�Carla Smith Location/Address: Stage Coach Road-27028
Proposed Facility: Residence Property Size: See Map
ATC Numbec 2376
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 WASTEWATER CO S N IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: Date: �� G'V
CERTIFICATE OF COMPLETION
**NOTE** T'he 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: C��r.l 1�. ��`��
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Environmental Health Specialist's Sign ture: D �
DCHD OS/99(Revised)
. DAVIE COUNTY HEALTH DEPARTMENT �/�"/'�/��G
� ' Environmental Health Section
� P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 890001049 Tax PIN/EH#: 5707-48-9578
Billed To: Lavvrence 8�Carla Smith Subdivision Info:
Reference Name: Lawrence 8�Carla Smith Location/Address: Stage Coach Road-27028
Proposed Facility: Residence Property Size: See Map
** �,TC�V,�rJb�r: 2376
N E is mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION 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 PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �1��` #People � #Bedrooms� #Baths Z
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size�`���ype Water Supply ���— Design Wastewater Flow(GPD) �OD Site: New� Repair❑
System Specifications: Tank Size ����'AL. Pump Tank GAL. Trench Width� Rock Depth �Zi� Linear Ft. ��O � _
och�r: 1 7�s:��c��,-�o.� -aow, I.�s,�.w ��.��5 9 �O.c. rn��J•
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Required Site Modifications/Conditions: ��,P �, �2e7�. c.,�7�(.,�, �GEP � �F I�Otfiir, �-T F,FS�-T�o-�
J� ��
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 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.****
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Environmental Health SpecialisYs Signa Date:
S'T��C�� G`�!�CN P�oA,�
DCHD OS/99(Revised)
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• TION FOR SfiTE EVALUATION/IMPROVEMENT PERMIT&ATC
� I 5 2000 Davie County Health Department
Enrrironmenta/Hea/1ri Secbion
P.O. Bos 848/210 Hospital Street
ENVIRONMENTAL HEALTH ��snille, NC 27028
• - DAVIE COUNTY (336)751-8760
***IMPORTANT*** TIiIS APPLICATION CANNOT HE PROCESSED UNLESS ALL TFIE REQIIIRED
INFORi�TION IS PROVIDED. Refer to the INFORMATION BULI,ETIN for instructions.
1. Name to be Silled �/;i//�if/'C � ��/� �in 7�h Contact Peraon ��� �}rn,'��
Mailinq Addrese �(��� �/,JrF' Hl'i i�Ci.e ri ,/'C �( Home Phone ��3 .�2-s�9a- �i-sr�
City/State/ZIP /'�//L�/C�S�L/�� �7��0 Sus9.neas Phone 3 3 C�`7��" a Y��
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2. Name on Permit/ATC if Different than Above
Mailinq llddreea City/State/Z3p
3. Application For: B�ite Evaluation ❑ Improvement Permit/ATC 1� Both�Itic� '
a. sl.st� to Service: �House ❑ Mobile Home ❑ Business � Industry ❑ Other
s. if Ftesidence: � People 3� � Bedrooms ^� t Bathrooms �
� Diahwasher ❑ Garbage Diaposal �Washing Machine �'Hasement/Plumbiag ❑ Basement/No Plumbing
6. If Huainesa/Induatzy/Other: Specify type � People # Sinka
� Co�odea � Shorers • Vrinals �i Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage ��ions �r a�y)
�. Type of water supply: ❑ County/City � Well ❑ Community
e. Do you anticipate addiHons or ezpansions of the facility this system is intended to serve? ❑Yes JXNo
If yes,what type?
, ***IMPORTAIVT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY 1NFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITIED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECfIONS(from Mocksville)to PROPERTY:
Taz O�ce PIN: # ���� •� �- q `.�'� � Trax �1ap �2LbOOC-b 2�•.02
•.�Propec�ty Address: Road Name .�7AC--E l�0AC1-► RhAI� l0� �o (��:c Aced�.�.,, �c�,� �a�;� .9c��.+���(
` , City/Zip 1�►C)C�CS�I l � �C'.J 1�2���� �a � ,�� [► cr � IQc.I. !I� �,l�� c.��I �`
_,. ._
� T . .
If in a Subdivision provide information,as follows: �� rn_r,�.f. A�n a,�.�« :s }�� .�;��� �,1 r;�� �
/� ,
Name: a.r1r o�"rocdr. �/i� �:)��[�s�i.���c��:� ,�<�.
Section: Blcek: Lot: Date Property Flagged: S—/$- 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 revocation,if the site plans or intended use chaage,or if the information
submitted in this application is falsified or c6anged I,a/so,understand that I am respons�blejor a/l charges incurred jrom
thls 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 owned by
to conduct all testing procedures as necessary to determine the site suitability. �
DATE � SIGNATtJRE
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):
L1eWI,1�:I� ' �U /'�
r'� Client Notification Date:
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y � '� '' � DAVIE COUNTY HEALTI�DEPART'MENT >
Environmental Health Section
Soil/Site Evaluation '
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001049 Tax PIN/EH#: 5707-48-9578
Billed To: Lawrence&Carla Smith Subdivision Info:
Reference Name: Lawrence 8�Carla Smith Location/Address Stage Coach Road- 7028
�Proposed Facility: Residence Property Size: See Map Date Evaluated: � G�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 , 2 3 4 5 6 7
Landsca e osition L
Slo e%
HORIZON I DEPTH ' Cv C� - O L-
Texture rou 5' L Gt�
Consistence �r $P �SS 5
Structure , C,(�
Mineralo ; � ';
HORIZON II DEPTH -22 ' - 2
Texture rou ',C • C. � S; '
Consistence . �(--; 5 ,`S
Structure
Mineralo I�
HORIZON III DEPTH "` _ - � - 2 _
Texture rou ; c� ; Gfi 5-;Gf :
- Consistence ' °'�•
r '� L`I
SiSUCtUIO . ` CJ �-i Lj
Mineralo \ ; � ; �
HORIZON IV DEPTH ;��
�_,
Texture rou . ..:.
;»
Consistence ' �. ��,''
Structure - ,}.;
Mineralo
��'
.SOIL WETNESS .
, RESTRICTIVE HORIZON ;, :
t�..
SAPROLITE � � �
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CLASSIFICATION . S
.�L,ONG-TERM ACCEPTANCE RATE �•'3S :3� �
,:..
,
SITE CLASSIFICATION: � , EVALUATION BY:���`''r ��%'-�"-�^^�' _'
�.'3s
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: �._T`� ��X:r'�2�, �.t7 C.��`( �'
_ LEGEND ,;� ..
� Landscaae Position r',
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
Structure
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
Notes ;, ..
t
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon'-Thickness and inches from land surface f'
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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