1852 Underpass Rd (3) _ DAVIE COUNTY HEALTH DEPARTMENT � rf_�G_ �
; ` Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
" (336)7S]-8760
IMPROVEMENT/OPERATION PERMIT J,r p c�
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Account #: 989900011 Tax PIN/EH#: 5871-77-8297.Barn
Billed To: Carolina Building Systems Subdivision Info:
Reference Name: Christine Dean Location/Address: Underpass Road-27006
Proposed Facility: Bam Property Size: 15 Acres
**NOTE**'I'fii b�mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 #People #Bedrooms #Baths�
Dishwasher: ❑ Garbage Disposal: 0 Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��AU Type Water Supply�V�// Design Wastewater Flow(GPD) /,,�� Site: New� Repair�
System Specifications: Tank Size//Idi? GAL. Pump Tank GAL. Trench Width��Rock Depth�.Z Linear Ft. d�
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(33G)751-87G0.****
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Environmental Health Specialist's Signature: �� �//y Date: �'`i ;�„��-�7(�
DCHD OS/99(Revised)
1
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 9$9900011 Tax PIN/EH#: 5871-77-8297.Barn
Billed To: Carolina Building Systems Subdivision Info:
Reference Name: Christine Dean Location/Address: U�derpass Road,27006
Proposed Facility: Barn Property Size: 15 Acres
ATC Number: 2461
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
'�*NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 Treahnent and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: � �� Date: � ���
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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.
�1`�� I ���� L
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Septic System Installed By: �
Environmental Health Specialist's Signature: - I � Date: �J —/D rd� ✓
DCHD OS/99(Revised)
c .+.� M
� APPLICATION FOR SRE EVALUATION/IMPROVEMENT PERMIT I�I �"� � � a u �
' Davie County Health Department
Environmenta/Heal(fi Section � — $ 2���
P.O. Bou 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 ���DAVIE COUNTY H
***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
/�- _J /�/f r �
1. Name to be Silled (�6�c(//2Cry �/�(l�l�`Iji i Y�� Contact Peraon fF(�� , ���
Mailing Addresa �� �jpf� ��g? Some Phone
City/State/ZIP ����IL��i IV� L�jJ L`t'� Busineas Phone (�'f— �3�� (G�I
2. Name on Permit/ATC iP DilPerent than Above ��`����� J/!:�
r�iiing naa=ees 1$.r'�Z UN���ASS � city/stata/zip �flVA�1C�F /�C Z?��o
3. Appiication For: ❑ Site Evaluation ❑ Improvement Permit/ATC � Both
a, sYatsm to sez�ice: � House ❑ Mobile Home ❑ Business ❑ Industry � Other B�
5. If Residence: # People � Bedrooms # Bathrooms
❑ Dishwaaher ❑ Garbage Diaposal ❑ Washinq Machine fl Baaement/Plumbing CI Basement/No Plwnbing
6. IP Huaineaa/Induatry/Other: Specify type �� �`�r'F'�1.1 Y People �i Sinka �
� Commodes � • Shorera � # Urinala � Water Coolera
IF FOODSERVICE: # Sests Estimated Water Usaqe (qallona per day)
�. Type of water suppiy: ❑ County/City �Q Well ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is inteaded to serve? ❑Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eit6er a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �� �� WRITE DIRECfIONS(from Mceksville)to PROPERTY:
Taa O�ce PIN: . # .5�7 I- 77- 8Z 9 7 ��� �l�sr � gv� � C o �
Property Address: Road Name �/���<'/✓�tJS �d. V�Da��S � f�"� TL. lOU Y,I�S.
City/Zip /7�U�s-aCC ���'G� Ul`� 2l�at-fT .
If in a Subdivision provide informallon,as follows:
Name: rV f�
Section: Block: Lot: Date Property Flagged: � � �U'�
T6is is to certify that the information provided is correct to the best of my knowledge. I understand t6at 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 application is falsified or changed I,also,understand that I am responsible jor all charges incurred jrom
this appl�cation. 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 �Pl S!lN� ,I��1t,1
to conduct all testing procedures as necessary to determine the site suit•bili .
DATE��/Z�aU SIGNA � �
—�-
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Ezisting and proposeci
property lines and dimensions, structures, setbacks, and septic locatio s).
Site Revisit Charge
.
Date(s):
r�� _
( � � Client Notification Date:
; ._ j
l' _.,� EHS:
Account No. V j/
Revised DCHD(07/99) Invoice No. /��
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; " , �. � DAVIE COIINTY HEALTH DEPART'MENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900011 Tax PIN/EH#: 5871-77-8297.Barn
Billed To: Carolina Building Systems Subdivision Info:
Reference Name: Christine Dean Location/Address: Underpass Road-27006
Proposed Facility: Bam Property Size: 15 Acres Date Evaluated: �,���
Water Supply: On-Site Well Community Public ��
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e% ,,,.�
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH '� ` - `
Texture rou
Consistence (
Structure
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 ,, S/
SITE 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-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 plas[ic 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
Mineralo�v
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(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
Classifcation-S(suitable),PS(provisionally suitable),U(unsuitable)
r, LTAR-Long-term acceptance rate-gallday/ft2
�•DCi�15�05/99(Revised)
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