304 Yadkin Valley Rd , DAVIE COUNTY HEALTH DEPARTMENT �/2� ����
Environmental Health Section
• ' P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000757 Tax PIN/EH#: 5872-38-3072
Billed To: Kellogg Construction Company Subdivision Info:
Reference Name: David Hanes Location/Address: Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 5.000 Acres
ATC Nurr�ber: 2434
**NOTE** T'h�s Improvement/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:�Washing Machine: 4� Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size � L° Type Water Supply�� Design Wastewater Flow(GPD) �� Site: New d Repair❑
�� �� /
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth�` 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.****
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Environmental Health Specialist's Signature: �` ' Date:� . ,3�2���
DCHD OS/99(Revised)
t , �-,
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. ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
r.o.Bog sasnio x�p�r��s��t
Mocksville,NC 27028
(33G)751-8760
Account #: 990000757 Tax PIN/EH#: 5872-38-3072
Billed To: Kellogg Construction Company Subdivision Info:
Reference Name: David Hanes Location/Address: Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 5.000 Acres
ATC Number: 2434
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSiJED 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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA ONSTRUCTION IS VALID FO ERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: r Date:1) '�� i✓v
P�� CERTIFICATE OF COMPLETION
0
**NOTE** The issuance oft Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in ompliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"bu sh�ll_i�NO WAY be taken as a guarantee that the system will function satisfactorily for any
given per'od of time. ds
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Septic System Installed By: � ��i SXJ �
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Environmental Health SpecialisYs Signature: �' /kG''�"t Date: (O�— �
DCHD OS/99(Revised)
, APPUCATION FOR SffE EVALUATION/IMPROVEMEM PERMfT&ATC � � � Q �V �
' Davie County Heaith Department �
Environmenta/Hea/th Secbion
P.O. Box 84B/210 Hoapital 3treet � � 2 200Q
. Mockaville, NC 27028 �
(336)751-8760 Ef�VIRO;�t,1EP�TAI HEALTH
D,aVIE COU�lTY
***Ib�ORTANT*** THIS APPLICATION CANNOT 8E PROG'ZSSED UNLE33 ALL THE REQIIIRED
INFORt�ATION I3 PROVZDED. Refer to the INFORt�TION BULLETIN for instructions.
1. Nam� to b� Bill�d{�I,��1,c�c�pN�HANES GowS�'1lva'�loA (�l.C. Coataot ?�rson �►qvlb �"�14NLfS
�i� �... p:u. `f3ox 2�.Ss�n � s�. �� 3�/ �� t ► cv
City/St�t�/ZIp �DVANG6r . /J. C. 2.7i 00` Businoss Phoru C( 't E 'S�e�t �
2. Nam� on ?�rmit/ATC i! Dilf�rust thas► Abovo
MailiaQ l►ddr�ss CiLy/Stat�/Zip
3. Appiication For: �ite Eva�luation ❑ Improvemsnt Permit/ATC � Both
a. syr..m to s•�io.: �iouse ❑ Mobile Home ❑ Business 0 Industxy ❑ Other
s. If ltesidence: � People # Bedrooms �_ # Bathrooms '�� ��T�R�
B�Diahxaah�r fYGarbaq� Diaposal W�aahiaq Machina ❑ Bas�nt/?lumbinQ ❑ 8as�nt/No Blumbinq
6. If Susis�ss/Industsy/Othor: Sp�oify typ� i P�opl� i Sinks
� Commod�s # Showor� # Urinals • Nat�r Cool�rs
IF H'OOD3ERVICE: # Sents Eatimated �Pater Usage (Qa�.�ons p�r day) '
7. Type of Nater aupply: B�County/City ❑ Well O Commuaity
e. Do you aaticipate additions or ezpansions of the facility this system is intended to serve? 0 Yes f�1�lo
If yes,what type? '
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BEIAW. EiWer a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: SE� R T +�.►,. ���qU��'J, WRITE DIREGTIONS(from Mocksville)to PROPERT'Y:
2.� r�Q L
TazOH'icePIN: # C � dnt)COOOt10 �NO C wi�+�' f�� r'►ec.�tf�i�lt,
PropertyAddress: RoadName 3��� YAoK�+� V4LIc� (�wc� G-x�k �t� Hw�Yd4 l.c��C A�' T pw= Rp^+P
� City/Zip �ovAwc.G��t•c. 2�aob 1'�� ��o n,�l RiSI+ aN y/�Gk���/yllcy IReec�
If in a Subdivision provlde information,as follows: _ �rsc f3�t,.�s.�+ s{4'�aa -�'l 2N,� t�ai u�cw`� oN��
Name: CSe� �ha;�8ox da l.cf� wi�ti 3a�
SecNon: Blcek: Lot: Date Property Ftagged: �� ►?� �-eav �
Th�s is to certify that the information�provided is correct to the best of my knowledge. I nnderstand that any permit(s)
issued hereafter are subject to saspension or revocation,�f the site pians or intended ase chaage,or i1f the information
snbmitted in this applicaHon Is falsIfied or changed. I,also,understand that I ane responstble jor al[charges 3ncurred from
thls applicat�on. I,hereby,give consent to the Aathorized Representative of the Davie County Health Department
to enter npon above described property located in Davie Coanty and owned by 3��N,�s Q e eso�
to conduct all testing procedares as necessary to determine the site suitability.
DATE S!2'i-� 2 o e o SIGNATIJRE �wJ �• �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PI.AN(Include all of the following: F.risting and proposed
property lines and dimensions, stractures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notlficarion Date:
EHS•
Account Na �
Revised DCHD(07/99) Invoice Na ����
DAVIE COUNTY HEALTH DEPARTMENT
. Environmental Health Section
P. O. Box 665
Mocksvllle, N.C. 27028
� SOIL/SITE EVALUATION
Name i��{��.� � �i��— Date � � ��3 ��
Address S �'Cc�°` Lot Size � �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S.. S S
�~� PS`� P� PS PS
�'tt'� U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) �---P� ��PS� PS PS
C '�-� � U 'U
3) Soil Structure (12-36 in.) � --gg�� S S
Clayey Soils C�P ��P'� PS PS
lT'' �1 U U�
4) Soil Depth (inches) S S
p `y.L.J PS PS
< �J—' u U .
5) Soil Drainage: internal . � S. S
pg ' �TY PS PS
� U�—� U U
External S � S S
. PS PS PS
� U U U
6) Restrictive Horizons _��
7) Ava(lable Space S S S
C lT' PS PS
� U U
8) Other (Specif��) S S S S
' ..PS PS PS
U U
9) Site Classitication � '
U—UNSUITABLE S—SU P ovisiona Suitable
Recommendations/Comments: v - �v\ - ^
Described by �_-4^-��-�� '��y�- Title ��� '� Date � ��-� ^$U
SITE DIAGRAM
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, , . . DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME ` � Cok'� DATE EVALUATED__�1 r,Z� ��
PROPOSED FACILITY PROPERTY SIZE S �e
SUBDIVISION ROAD NAME X.4C�'• l/-' �i�
� !
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% a
HORIZON I DEPTH ` ' ',y ��
Texture rou (`
Consistence
Structure
Mineralo
HORIZON II DEPTH r� �� '�'�i�r
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: OJ EVALUATION BY: � G I
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Lineaz 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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineralogX
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-gaUday/ft2
DCHD(01-90)
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