131 Walt Wilson Rd ., , � �
. , � DAVIE COUNTY HEALTH DEPARTMENT (r'°
• Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003955 Tax PIN/EH#: 5747-31-7887
Billed To: Justin Beauchamp Subdivision Info:
Reference Name: Andy Beauchamp Location/Address: 131 Walt Wilson Road-27028
Pro osed Facilit : Residence Pro ert Size: see lat
ATC Number: 4393
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED 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 WASTEWATER CONSTRUC.T.IOI*i V ID OR A PEWOD OF FIVE YEARS.
Environmental Health Specialist's Signature. Date:
�— � ��0
CERTTFICATE 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 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.
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Septic System Installed By: �1 Q'� �i�!/ C/��lh/�i%
Environmental Health Specialist's Signature: � �1�iL Date:
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' � � Environmental Health Section
' 4 P.O.Boz 848/210 Hospital Street
.:-
Mceksville,NC 27028
(336)75]-8760 t yl��
IMPROVEMENT OPERATION PERMI �I f
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Account #: 990003955 Tax PIN/EH#: 5747-31-7887
Billed To: Justin Beauchamp Subdivision Info:
Reference Name: Andy Beauchamp Location/Address: 131 Walt Wilson Road-27028
Proposed Facility: Residence Property Size: see plat
**NOTE�*This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AUTHORIZATION 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
Artide 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 CONTItACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type buSL _ #People Z #Bedrooms Z #Baths �—
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: 0 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size���Type Water Supply�'`��1— Design Wastewater Flow(GPD) 2� Site: NewP—f Repair❑
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System Specifications: Tank Size�U�GAL. Pump Tank GAL. Trench Width_� Rock Depth� � Linear Ft. l��
Other: � l��c1f�1�U Tl t�,r.l�X-. ��-�_�" '� � TZ►=�T 10�S`l STi�'"��
Required Site Modifications/Conditions: �f�1s'r"D1_I�_ (� C—���Q, � S �(— �r�-� �'Z7 �Qo rv�.
1�'IPROVEh1ENT/OPERATION PER1V11T 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 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33()751-87G0.****
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Environmental Health Specialist's Signature: at ��
DCHD OS/99(Revised)
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� � �APPLICATIO R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� �
�-�:- � � � ��� �] [� Davie County HealthDepartment
�, �� C�C� �
`, � �.. Environmental Health Section
��` P.O. Box 848/210 Hos ital Street
.�° 4 �',` APR 2 4 2006_ Mo�ks��iie, Nc i�o2s
`��� � (336)751-8760/Fax (336)751-8786
�IROhN�EJ�aL HEALIH
pplication F�Vi� mprovement Pernut ❑ Authorization To Construct(ATC) oth
***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMEITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
, Contact Person � P'�
Name to be Billed L -� �, 1��� , .�(� �,�,�� ; �,�
Billing Address � �c �'(F Home Phone 3� �- 9 j- � .>
City/State/ZIP • �� i� ' �� � ' � � � Business Phone ����.�5�/_S- �/6�/
�
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany this application.
(Pernut is valid for 60 months with site plan,no expiration with c mplete pl�at,.�
Street Address�j/ ��.�--���,�/y�n� �� City :� ,/�',��'��-6 � Tax PIN# ��%�j�j7��'`�
Subdivision Name Sectio t# _ Lot Size
Directions To Site: �/-.�... �' �; k �, ' j,('� �l
�
Date House/Facility Corners�'lagged ' 2s"�
If the answer to any of the following questions is"yes ,supporting documeri�ation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �13Qo
Does the site contain jurisdictional wetlands? ❑Yes �o
Are there any easements or right-of-ways on the site? ❑Yes [�3�0
Is the site subject to approval by another public agency? ❑Yes �o
Will wastewater other than domestic sewage be generated? ❑Yes I�o
IF RESIDENCE FILL OUT THE BOX BELOW
#People � #Bedrooms � #Bathrooms � Garden Tub/Whirlpool es �No
_ Basement: ❑Yes �o Basement Plumbing: ❑Yes fi�3�10
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
# Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
` � � oe
Type system requested: �onventional .B'Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water [B�New Well �Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [�Io
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes, or if
the information submitted in this application is falsified or changed. 1 understand tlzat I am responsible for all charges i�zcurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to eternune comp�iance with pplicable laws and rules on the above described property located in
Davie County and owned by c�-: -�-�� �tr�.� - c�t.,.
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P , erty er's or owner's al representative signature Site Revisit Charge
Date(s):
25 ��,� Client Notification Date:
D te EHS:
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Sign given tJYes ❑No Account#
Revised 2/06 Invoice# �[�(,�
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� . ' DAVIE COUNTY HEALTH DEPARTMENT
' , r ' Environmental Health Section �
.. •
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003955 Tax PIN/EH#: 5747-31-7887
Bilied To: Justin Beauchamp Subdivision Info:
Reference Name: Andy Beauchamp Location/Address: 131 Wait Wilson F� d 27028
Proposed Facility: Residence Property Size: see plat Date Evaluated: �� ��P
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Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FAC'TORS 1 2 3 4 5 6 7
Landsca e sition L
Slo e % 3
HORIZON I DEPTH p� �- -I 2 � - 1
Texture rou �,,., �-�— Gt_
Consistence � S '
Structure �;,� C=Q
Mineralo S.r'1L S ��t
HORIZON II DEPTH A C�� I � - O - 50
Texture rou
Consistence .- F� ' :S
Structure �
Mineralo �:''�, -�c �
HORIZON III DEPTH �;�o . .2
Texture rou L�# t r
Consistence ; r .
Structure S�
Mineralo � � �,
HORIZON IV DEPTH
Texture rou
Consistence �
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE ..
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE . O.2
SITE CLASSIFICATION:��'\ EVALUATION BY: C� �
LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT:
REMARKS: V � �\-3 �1 A`� F�%'LL�- h�w(j w'-S ,�iXZ ��J G►Sa �
LE END
i.andsca�e 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
CnN4iST .N . .
�IQiSt
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
13..'�.t
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
SYI11S�ilI'g
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
1Y4tgS
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
Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Revised)
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Davie County Health Department
Environmental Healtlz Section
P.O. Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
May 5, 2006
Justin Beauchamp
167 Walt Wilson Road
Mocksville,NC 27028
Re: 3.89 Acre Tract/Walt Wilson Road
Tax PIN# 5747317887
Dear Client(s): ,
As requested, a representative from this office visited the above site May 4, 2006 to
perform a site evaluation. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed, the site was found to be provisionally
suitable for the installation of an on-site sewage disposal system.
This Improvement Permit DOES NOT authorize the construction of a wastewater system.
. An Authorization To Construct a wastewater system must be obtained from this office prior to
the construction/installation of a wastewater system or the issuance of a building permit(in
compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement
Permit is subject to revocation if site plans or the intended use change.
Improvement Permit
System To Serve: 2. L.�� �`�1��-'= Wastewater Design Flow: ���
System Type: ❑Conventional e'Accepted �Innovative ❑Alternative ❑Other
System Location: ��aJfi�i�`511�3Jc-� Valid:�3"�ears ❑No Expiration
Site Modifications/Permit Conditions:
v e al [e p cialist D te
ps-i.p.letter 2/06