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Au,�zizATioN�vo. ,�����DAVIE COUNTY HEALTH DEPARTMENT �� ����' �
�*; Environmental Health Section PROPERTY INFORMATION
� '• ,
�'et,�►�tee s �/ ,/ ,/ ' .';� � P.O.;Box 848� ,
-�"'"� l�ame: ` �.��i U *�/��/��'r.�fJ s ' , ,;:,., Mocksville,NG,27028 `Subdivision Name:
-` , "/''� � Phone# 336-751-8760 {
� .Directions to property:�t/ ' /j;,�1 f!� Section: Lor.
� /I AUTHORIZATION FOR ' �
` �G1lG�'/�'C�€'/F2�' �/'r/��'. : WASTEWATER � . - -
� Tax Office PIN:# -
SYSTEM CONSTRUCTION �����`
. �Road�Name: l"� ^� "��� Zip:
Y . , Y ,
**NOT'E**This Authorization foi Wastewater S stem Construction MUST BE ISSCJED b the Davie Counry Env'uonmeiltal Health Section prior
. to issuance of any Building�ecnvts.This For►n/Authorization Number should be presented to the Davie Counry Building Inspections '
: Office when applying for Building Permits: , ' ` � ` ' .
(ln compliance with Article l l of G.S;Chapter 130A;Wastewater Systems,Section:1900 Sewage Treatment and Disposal Systems)
�; " �***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� !'' �j� , "f ,..f'' ,�. IS VALID FOR A PERiOD,OF FIVE YEARS.' �
ENVIRONMENTAL HEALTH SPECIALIST � DATE ISSUED
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� � ?``� i�'�,; . � �.. + ..�I •�.:� .. .._ : .. . . , .
1 , ,�Q��71� DAVIE COUNTY HEALTH DEPARTMENT �� /� 7 - ��'' � r
��.��' ��- . TMPROVEMENT AND OPERATION PERMITS . PROPERTY INFORMATION
:;�e'rmi�tee's � , f; �
"`,��`�ame:`` '�'.!`�«� �! �. �r'�,'•/''', ..t;'..� ; Subdivision Name:
. .�.'. � .- . ` � . . . f, �. .:h�. . . . .
Directions to property:��-����.-}^"/" , -f �''�-' Section: Lot:
� f.-�- ; .V IlVIPROVEMENT .
� .....''%',�'-'�'f' ;r�. r ,f"�r`,� L` PERNIIT Tax Office PIN:# - -
. ' . . . . . , .. , . - . . '. �:- ..� . . )�.' .�! ,�•� . :rQ.,�'��'k :��K{�"'� ` . .
l
Road Name. r� ' Zip:
*,*NOTE**This Impmvement Pemut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An
ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtamed frc�m this Department prior to the ,
` construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
, .
�,r ***N01TCE***THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE
,��'�;_;� r"f,��;,,� ��:;��,,t,a�� `f�.� PLANS OR TI�INTENDED USE CHANGE.YOUR WASTEWATER
,;' �,,:'�
ENVIRONMENTAL HEALTH SPECIALIST DATE TSSUED SYSTEM CONTRACTOR MUST SEE TfII.S PERMTP BEFORE
' : INSTALLING TI-�SYSTEM. ::
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS�#BATHS_�#OCCUPANTS_�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICAT'ION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
; ��� , ` . -, ., . ,
//// . ,�/
, . � , � : .
LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) / � �NEW SITE � REPAIR SITE �
, SYSTEM SPECIFICATIONS: TANK SIZE��_GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEP'TH LINEAR FT.
OTHER �
„ REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENTPERMITLAYOU'f�'APPROVF� EFFLI.I�NT. FILTER* �RISER(S) IF fi" �I£�OW FINISH�cD GRRDE�
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FiNAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#I��/�}�'4�$�.
(33E'i)751-87641
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION OPERATION PERMIT BY: DATE: ,
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,'SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
t�� M .� Environmentai Health Section �� � v �7 U �
• P.O.Boa 848/210 Hospital Street
' ' ' Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001518 Tax PIN/EH#: 5830-98-3903
Billed To: David Andrews Subdivision Info:
Reference Name: Brian Andrews Location/Address: Angeil Rd:2702$
Proposed Facility: Residence Property Size: 150 acres
**NOT�*'��iibgmprov�UOperation 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 �N' #People_� #Bedrooms�� #Baths,,,,�
Dishwasher: � Garbage Disposal: � Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size C Type Water Supply �L!/ Design Wastewater Flow(GPD)� Site: New�Repair❑
System Specifications: Tank Size,/�GAL. Pump Tank GAL. Trench Width��Rock Depth L� Linear Ft.�'�
Other:
Required Site Modifications/Conditions: `
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED 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.****
�,Ve��
�u�,��,ce w��er �'
Environmental Health Specialist's Signature: Date: / —�/�-g� �
DCHD OS/99(Revised) .
t. �. �� � -/7-°/
ti
. � ' DAVIE COUNTY HEALTH DEPARTMENT
� " Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001518 Tax PIN/EH#: 583U-98-3903
Billed To: David Andrews Subdivision Info:
Reference Name: Brian Andrews Location/Address: Angel) Rd-27028
Proposed Facility: Residence Property Size: 150 acres
ATC Number: 2666
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). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:��� Date: l" ���
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this 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. /
p�ly�
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SU��Ac� � �y�
,����v�,�� �
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Septic System Installed By: � ��
Environmental Health Specialist's Signature: �,�%� � � Date: ���-J��
DCHD OS/99(Revised)
� . � . . . � . . . .. � . � .
. l.� •• . . ' . . � � . . � . . . �.1� � � \� � .
D .� �--.�
• ' � APPLIG4TION FOR SITE CVALUATION/1114PROVEh9ENT f�ER�7ii&A�C
� � D a v i e C o u n t y H e a i t h D e p a rt m e n t ��� 2 8 7���
Environmenta/Hea/[fi Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***I2�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI+ESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULI,ETIN for instructions.
1. Name to be Billed ��j1 V!G �7. ��d d�P+.L�s Contact Peraon '�y•�n.v G'Y' �/ /c�I �✓n�ss`/�wJ
Mailing Addresa �.3�"h� .�.�'. L'n�jU i�G /'*�� fiome Phone "�c3�j
✓ ,_ � V
City/Stata/ZZP [���� �/►C Z�Y✓S� Busineas Phone ��� � l
C �-SZ- - 757'!��/ na�:o A.vc.�..s
2. Name on Permit/ATC if Different than Above
Mailing Addresa City/State/Zip
3. Appiication For: ❑ Site Evaluation 0 Improvement Permit/ATC Both
a. syHt� to service: � House � Mobile Home 0 Business ❑ Industry ❑ O�he
s. If Residence: � People _�_ # Bedrooms � # Bathrooms 3
'Q�Diahxasher ❑ Garbage Diaposal �Washing Machine ❑ Basemant/Plumbing U Basc�ament/No Plumbing
6. If Husinesa/Induatry/Other: Speqify type # People $ Sinka
Y Commodea $ Shoxers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay�
�. Type of water suPPlY= ❑ County/City �Well 0 Community
e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Ycs �No
If yes,whut tyPe'
***IMPORTANT***CLIENTS MUSTCOMPLETETIiE REQUIRL'DPROPERTY INrORMATION RCQULS7'GD
BELOW. Either a PLAT or SITE PLAN MUST BESUB�ITTED by the client with THIS APPLICATION.
PropertyDimensions: � S O �Gr++ f WRIT�DIRECTIONS(from Mocksville)to PROPGR'I'Y:
FS'OOUJc�v�o/ //
Tax OfYice PIN: # Sb�d gcy3963 _}��c�. G o� Tu �,�s</�•l �F�' caA. l�-w.r// �!
i
Property Address: Road Name ��.c�/��i1�� ! ..� dCj ,,�, �Ur•�
' City/Zip /.Y.��GK�,.o.��',yT C
If in a Subdivision provide information,as follows:
,
Namc:
Sectioa: Block: Lot: Date Property Flagged: /Z-Z�+ -�v�J v
This is to certify that the information provided is correct to the best of my knowledge. I understand thut 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 applicaHou is falsified or changed 7,also,understand that I am responsible for a!1 charges incurred jroin
lhis application. I,hereby,give coasent to the Authorized Representutive of the Davie County Hcalth Department
to enter upon above described property located in Davie County and y ?.�,9v�c��. �.t�r.v7�f � �9n,��.�t�r/
to conduct all testing procedures as necessary to determine the s' suitability. '
DATE J 2� 2 �J �Z�(�c)v SICNAT �
THIS A.REA 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).
Sitc Revisit Chargc
. Date(s):
Client NotiGcatioa Date:
EHS•
Account No. ��
Reviscd DCHD(07/99) Invoice.No. � � ,
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`,� . � � , , DAVIE COUNTY IiEALTH DEPART'MENT
,, ,- "�. Environmental Health Section
' ' � ''� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
� Account #: 990001518 Tax PIN/EH#: 5830-98-3903
Billed To: David Andrews ' Subdivision Info:
Reference Name: � Location/Address .Angell Rd.-27028
Proposed Facility: Residence Property Size: 150 acres Date Evaluated: /--y��/
•��-
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition ,L
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH .� � t•
Texture rou
Consistence i
Structure / �J /C
Mineralo ,'(
HORIZON III DEPTH
` Texture rou
Consistence
Structure .
Mineralo �
HORIZON IV DEPTH
Texture ou
Consistence
S[ructure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON ,
SAPROLITE _
CLASSIFICATION '
LONG-TERM ACCEPTANCE RATE �
STI'E 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-Tenace 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
t ture
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky '
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(sui[able),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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