1391 Yadkin Valley Rd , DAVIE COUNTY HEALTH DEPARTMENT ���i 9�
� � � _ + Environmental Health Section � g
. P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028
� (336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 99000069d Tax PIN/EH#: 5863-34-9588
Billed To: Thelma Wiiliams Subdivision Info:
Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 2 Acres
ATC Number: 2133
**NOTE** lfiis Improvement/Operation 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
PERNIIT LS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ��¢�jn�' #People� #Bedrooms� #Baths Z
Dishwasher: �" Garbage Disposal: ❑ Washing Machine: n Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �'�''`�� Type Water Suppl�� Design Wastewater Flow(GPD)��� Site: New�Repair❑
�i i� �
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth�.� Linear Ft.�?lG✓
Other:
Required Site Modifications/Conditions:
iMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G "BELOW
F'INISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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)751-87G0.****
Environmental Health Specialist's Signature: Date: ' —
DCHD OS/99(Revised)
' . ,
' - � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
' P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990000694 Tax PIN/EH#: 5863-34-9588
Billed To: Thelma Williams Subdivision Info:
Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 2 Acres
ATC Number: 2133
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number shouid be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � Date: ��
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate ofCompletion 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.
F�
����� Q
� �
Septic System Installed By: �--lti
Environmental Health Specialist's Signature: 5(�• � � Date: ���i�?//��
DCHD OS/99(Revised)
, . APPUCATION FOR SRE EVALUATION/IMPROVEMENT PERMff&ATC � � � � � � �
� � �+ � ,_ „ � Davie County Health Department
Envirvnmenta/Hea/th Se�c[ion
�e�,�� p.o. $oX 848/210 Hospital 3tzeet � 2 6 Iggg
Mocksville, NC 27028
�. • � � (336)751-8760
Et1VIRON�.I�ENTA�NEALTH
***II�ORTANT*** THI$ APPLICATION CANNOT B�E PROCLrSSED UNLE33 ALL THE D �
IZTH'OR1�1Ti0N I3 PROVIDED. Refer to the INFORt�ATION BULLETIN for instructioas.
1. Nam� to b� Bill�d /rf�L�J/� LJ • �if//��/YIS Contact ?�rsoa �����r-1.�����/?sfs
Mailinq 11ddr�s• .�% � �� 8� phoa� �3�r- ,��d ���
.. City/Stat�/SIP /T�� �TO ll����i,-. -. ����!) 8win�u Phosu
2. 1�Iam� oa p�rmit/l1TC i! Difl�ruit than Abow��LJJ f� cJ� G!/!//%/�ms
Maiiiaq I►ddr�es .D•�DX�� City/Stat�/Lip P�.�// ��DG(//� 1/!o 'Ci' �/(/��
3, a►ppiication ror: I�31te Enaluation �improvemeat Permit/ATC �j Both
a. sy.r..m to s.�i�.: ❑ Housa �Mobile Homa ❑ Buaiaesa ❑ =ndustry ❑ Other
s. If Reaidence: # Peopie ,� � Bedrooms ,�_ # Bathrooms �_
�Dishxash�r O Garbaq� Di�posal �1PashinQ Machin� ❑ Bas�t/plumbinQ O Sa��nt/No plumbiaq
6. I! Husinoss/Industsy/Oth�r: Sp�aify typ� � p�opl� i Sis�ks
� Commod�s # Show�r� i Urinals i 1Pat�r Cool�rs
IF P'OOD3ERVICE: # SerltB Estimated Water US�igA (qaliona p�r day)
7. Type of Kater supply: ;L�( Cotu�ty/City O �Pell O Co�ity
e. Do you anticipate additions or eapansions of the facilIty this system is intended to serve? ❑Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INF�3RMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MIIST BE SUBMITTED by the cHent with TH1S APPLICATION.
� i � /�
Property Dimensions: o��g��X 3(�a o�'GG�7C''�e�W RITE DIREGTIONS(from Mocksville)to PROPERTY:
�p
Taz Otiice PIN: # � O�3—��f��� �� `��E�'r� gt�//� / � ��E/j�,
/'34/ / �
Property Address: Road Na�e / � ��a �i i1�<�o �'F1�y� ��✓ F�io�. ��f�C'�-y 1S
t� li
� City/Zip � �OT o�r�.�F� _:�,s� �s v�u �,�ss�d�.��[��-'n-�•-
If in a Subdivision provlde information,as follows: Of��iP l�F�/1►a n/c� ,C l✓� o� �Lc.�-ni�4 L�)p L/�2
� o �R� �'�- i3 yi y�l�F���,w��E y ��1.
Name: � ' �d,��d'�_'S',p�.t� 1Gf�,,,.,:tis.� �t/.
Sectlon: Block: Lot: Date Property Flagged: � �(o�-�/�
SzrYv���,�� 7 z Z� 99
This is to certify that the information provided is correct to the best t►f my kn ledge. I understand that any permit(s)
issued 6ereafter ure subject to suspenslon or revocaHon,if t6e aite plans or intended ase change,or if t6e information
sabmltted i�t6is applicaHon is falslfied��r changed. I,also,understand that I am responslble for all charges Incuned jrom
thts applrcadon. I,hereby,giv�s consent to th�Aathorized RepresentaHve of the Davie Connty Health Department
to enter upon abcNe described p�roperty located'►�Davie Coaaty and awned by
to condnct all tecting procednres as necessary to determIne the site snitabWty.
DA.TE /- � (D —,�/ SIGNATURE � I
'�"HIS A�.EA:�IAY BE�JSED FOR DRAWING YOUR SITE PI.�,N(Include all of the following: E�sting and proposed
proper:y Ilnes and djmensions, structures, setbacks, nnd sepNc locations).
Site Revlsit Chsrge
o���d� Dat�cg�:
�� �tie'� � Client h�uttficanon Date:
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, ,' �., °° � DAVIE COUNTY HEALTH DEPARTMENT
� r Environmental Health Section
, � ' Soil/Site Evaluation
APPLYCANT INFORMATION PROPERTY INFORMATION
Account #: 99000U694 Tax PIN/EH#: 5863-34-9588
Billed To: Thelma Williams Subdivision Info:
Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: ���(��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring a� 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 �� 'i
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 �
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 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
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-gal/day/ft2
DC�ID OS/99(Revised)
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