161 Vogler Rd DAVIE COUNTY HEALTH DEPARTMENT -� �i l
. Environmental Health Section ��. �--/� 6 / � /
• " • P.O.Boz 848/210 Hospital Street .
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001554 Tax PIN/EH#: 5880-67-4337
Billed To: Diana Ellis Subdivision Info:
Reference Name: Location/Address: Vagler Road-270U6
Proposed Facility: Residence Property Size: 1 acre
**NOTE�**Ttii b�mprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHOWZATION 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 1 #Bedrooms 2 #Baths �
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size N� Type Water Supply W L.� � �esign Wastewater Flow(GPD)� Site: New�Repair❑
r' �� �
System Specifications: Tank Size���iAL. Pump Tank GAL. Trench Widtl�'��� Rock Depth j2 Linear Ft. 30�
Other: '�L ��'- 'STP—����43�v �X�-� _ ItJ�Tl�l.l. C�*�c:.'S -i 'D.C. A�l��•
Required Site Modifications/Conditions: STi4�- �� ��"��(�Q ��`� ��f O� ���^�` 't� c� �
M �C..
IMPROVEMENT/OPERATTON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTTCE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:0 p .to 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.****
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Environmental Health SpecialisYs Signatu e: Date: _ � _
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DCHD OS/99(Revised)
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. � • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Bog 848/210 Hospital 5treet
Mceksville,NC 27028
(336)751-8760
Account #: 990001554 Tax PIN/EH#: 5880-67-4337
Billed To: Diana Etlis Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 2703
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This 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.1 00 Treatm and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW CTI VA D ERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur : ate:
CERTIFICATE OF COMPLETION
**NOTE** The 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 Treatrnent and
Disposal Systems,"bu�t��11 in NO WAY be taken as a guarantee that the system will function satisfactorily for any _
given period of ti ��� �� �
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Septic System Installed By: � t'C-��'`� 1 �
Environmental Health Specialist's Signahue• Date:
DCHD OS/99(Revised)
' ' 'P11(:ATION FUii SIfE CVALUAiION/1fl1T'II(�i/�,9FNT'�1Ttt��9i1-:��,liC � � � D L�
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Davie County Health Department
Environmenla/Hea/lfi Section ����
' � � P.O. Box 848/210 Hospital Stareet z/�����
' � ' Mocksville, NC 27028
r ��)fl EfvVIRO,�'�AE�lTAL HL�.°��TH
(336)751-8760 DAUIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORt�,TION BULLETIN for instructions.
l. Name to 2w IIilled /J Contact Peraon � /_"'�
C����
Mailing Address Home Phono ��
City/State/ZIP Husinoss Phone �
2. Name on Permit/ATC iP DiPferent than Above
Mailing Addresa City/State/Zip
3. Application For: ❑ Site Evaluation 0 Improvement Permit/ATC �d Both
/ \
a. sye� to sez,.i�e: ❑ House �Mobile Home � Business ❑ Industry CJ O�her
� s. If Residence: �i People � � Bedrooms � # Bathrooms �
O Diahxasher [J Gasbage Diaposal �Waahing Ma 'ne C] IIasemcuit/Plumbing O Duuoment/No Plumbing
6. Zf Duainess/Induatry/Other: Specify typa � Poople II Sinkn
� Commodes @ Shoxers # Urinals # Wator Coolera
-_.�.�
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per a,y)
�. Zype of water supply: 0 County/City �Well ❑ Community
e. Do you auticipatc additions or capansions of thc facility this system is intcndcd to scrvc? ❑Ycs i�o
If ycs,what typc?
***IMPORTANT***CLIENTS hiUSTCOMPLETCTIIE RLQUIR�D PROP�RTY INrOItMATION Ii�QUi:S'I'GD
BELOW. Either a PLAT or SITE PLAN MUST 13ESUBMI7TED by tlic clicnt witli THIS APPLICATION. .
Property Dimensions: �a�/'� ' WRITG DIRCCI'IONS(from Moc{csvilic)to I'ROf'l;R"1'1':
TaxOt]iccPIN: # ��$(�14���� �-7Q � G�i �a �1�
Property Address: Road Name� �� ��7 lJ� `� /7 /– ��� �
City/Zip��la nr_� ��.(y� G� 1'f?/ E'.S � ��QC��`�
� / � �,j ' f��
If iu a Subdivision providc information,as follows: G-.0��Cr� �.s ��� �� �/ /
�
Namc: ��rl�� ��� ��� r���j�CY.
Section: Block: Lot: Datc Property Flaggcd: � �
This is to certify that the information provided is correct to the best of my knowledge. I understand tl�ut Any peru�it(s)
issued hcreafter are subject to suspension or revocation,if the sitc plans or intended use c6augc,or if t6c informatiun
submitted in this application is falsified or changed. I,also,undersland that I am responsible for a!1 charges incrirred from
lhis application.-�I,hcreby,givc consent to the Authorizcd Represcntativc of thc Davie County Hcalt Dcpartiuent
to cntcr upon abovc dcscribed property locatcd in Uavic County and owncd by ..—�/�f'�Q/�j',Y1Ct/'�
ro conduct al tcsting� ocedures as ncccssary to determine tLe site suitability.
DATE r SIGNATUR� �I f,��� �C.. (��
THIS A MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc All of tLc following: �aisting and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Chargc
. Datc(s):
� Clicnt Notification Datc:
EHS: �
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Accaunt No. ` �� �
Revised DCHD(07/99) Invoice,No. �0 3'�
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. DAVIE COUNTY HEALTH DEPARTMENT
• •� �• • • � Environmental Health Section
. ,
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001554 Tax PIN/EH#: 5880-67-4337
Billed To: Diana Ellis Subdivision Info:
Reference Name: Location/Address: Vogler Road-2700
Proposed Facility: Residence Property Size: 1 acre Date Evaluated: � ,
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring J Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e% Co '� .`s2c
HORIZON I DEPTH O� C Z � ��- O- ��
Texture rou G G
Consistence `
Structure l� S
Mineralo �+'�f 1cS:.:O
HORIZON II DEPTH 2- Z - J V-
Texture rou C +
Consistence ; ' $ : S
Structure S < S �...31�
Mineralo � A/� -r�
HORIZON III DEPTH 2�- J - 1 -
Texture rou �
Consistence :S -� r �
Structure
Mineralo 1 ��
HORIZON IV DEPTH
Texture rou '
Consistence
Structure
Mineralo
SOIL WETNESS �
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE p. ,� O•35
SITE CLASSIFICATION: C S EVALUATION BY: � � �t(.�'�E I Q�
LONG-TERM ACCEPT�A�1��ATE: �'� OTHER(S)PRESENT:
,1 �ti
REMARKS: ��$I 1 �c,n L�t�l-v�t Q�-- s 1 L�C r�� ��-
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 �
, �
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-Subangulaz blocky PL-Platy PR-Prismac�c� Z o ��r-7
Mineraloev � � (� c� 3 � �-'�-�
1:1 2:1 Mixed � `�� Z�
Notes � � 3�,7
Horizon depth-In inches Z� Z��
Depth of fill-In inches ' �� �
Restrictive horizon-Thickness and inches from land su�''r`�
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-gal/day/ft2
DC�ID OS/99(Revised)
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