413 Will Boone Rd • • � DAVIE COUNTY HEALTH DEPARTMENT
. Environmental Health Section
P.O.Boa 848/210 Hospital Street
� Mocksville,NC 27028
(33G)751-87G0
Account #: 990003364 Tax PIN/EH#: 5746-99-2928
Billed To: Bernice Stanley Subdivision Info:
Reference Name: Location/Address: Will Boone Road-27028
Proposed Facility Residence Property Size: 3 acres
ATC Number: 4181
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). 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 CONSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: , Date: �
CERTIFICATE OF COMPLETION -�-;� S�g ( O�-� - )Jd �
**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 WA taken as a uarantee that the system will function satisfactorily for any
given period of time. �,
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Environmental Health SpecialisYs Signature: /' Date: 3` �3'��7
DC�ID OS/99(Revised)
, DAVIE COUNTY HEALTH DEPARTMENT
, . � Environmental Health Section
P.O.Boa 848/210 Hospital Street
' Mocksville,NC 27028
` (336)751-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003364 Tax PIN/EH#: 5746-99-2928
Billed To: Bernice Stanley Subdivision Info:
Reference Name: Location/Address: Will Boone Road-27028
Proposed Facility Residence Property Size: 3 acres
ATC Number: 4181
**NOTE**This lmprovement/Operation Permit DOES NOT authorize the construction of a 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
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 #Peopl �� #Bedrooms� #Baths�
Dishwasher� Garbage Disposal;� Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply6/��'!� Design Wastewater Flow(GPD)�_�� Site: New�'�Repair❑
/� �
System Specifications: Tank Siz%�GAL. Pump Tank GAL. Trench Widt�i� Rock Depth� Linear Ft��
Other: As stated in 15A NCAC 18A.1969(5)
accepte ys ems m�y ai�b��:�
Required Site Modifications/Conditions:
I1�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G`• BELOW
FINISHED 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(33()751-87G0.****
e
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Environmental Health Specialist's Signature: Date:���� ��
DCHD OS/99(Revised)
.. . .
• � APPUCATION FOR SITE EVALUATION/IM1IPROVEh1F1VT - IT�tA�f'� "('!�
Davie County Health Department � L� U #,f �
' � � � Environmenta/Hea/t/�Section
� P.O. Box 848/210 Hospital Str A�G � 6 z0(�
Mocksville, NC 27028
(336)751-8760 �
;
EhM �e�
***IMPORTANT*** THIS APPLICATION C1lNNOT BE PROCESSED �f#�'(F�kQ D
INFOR2•iATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instru"� '
1. Namo Lo be Billed �(�,n�f r.T��"��_� l� Contact Peraon���(� J''�/ L���/lt�l'
Mailing Addrasa ��� �+/l�����_ Iiomo Phone ��� r �4 L' — � ��Y
City/State/ZIP , �'G�'S(C,'f1��n�, v°,�74�� Husinesa Phone
2. Namcs on Permit/I�TC if Different than Abova
Mailing Addresa � City/State/2ip
3. Applicntion For: Site Evaluation �Z.�Improvement Permit/ATC ❑ IIoth
t�✓�' �
4. system to service: ❑ Fiouse�`� M Mobile Homo ❑ IIusiness ❑ Industry ❑ Other
5. Type ayatem requested: ❑ Conventional ❑ convantional modified ❑ innovaL•ivo p ac Cep te d
6. If :te�idence: S People �i # IIedrooms ,_� N F3athrooms
❑Dirshwashor ❑Garbage Disposal �w�hing Machino ❑Dasement/Plumbing L"JDasement/No Plumbing
7. If Duuinesa/Industry /Othar: verify type # Peopla S Sinks
# Coaunodea # Showara # Urinals # Wator Coolera
IF FOODSERVICE: �# Seatu Estimated Water Usaga (gailona por day)
s, xypo oE water supply: ❑ County/City t;a' well ❑ Community
s. no you anticipate additions or expansions of tlic facility tl�is system is inte�ided to scrvc? ❑Ycs No
If ycs,»•liat typc?
***I,".fPO1tT4NT'"**CLI['sN7'ShfUSTCOdfPLETL•T►IG RL•QUII{LD PROPCRTY INrORMATION RLQULSTGD
I3GI.0\V. �ithcr a PLAT or SITC PLAN�1UST BESUII�IfITTEU by thc clicnt witli TI(iS APPLICATION.
Property Diniauions: �VRIT�DIRCCTIONS(front Nlodcsvillc)to PROI'I'sRTI':.'
Tax Ofrcc PIN: �� �'40- [ �- �- cf•2 b /=t d,i,� ,���/-�-.CI s��a r� �-'rQ �A
� Property Address: Road Name 9%1 ,� �c O PP 1�V �,,�1 i l/ E���(��l�c _ /2cQ_�I�d: � �?
City/Zip�p�Cks r;1 I�: � ?6 � g ���C�/ /
I[ili a Subdivision providc infortnatioti,as follo�vs:
Name:
Section: Blocic: Lot: Date home corners ilagged: � ! � �
Tl�is is to ccrtify tl�at tl�c information provided is corrcct to tl�c bcst of my knowlcdgc. I undcrstand that any permit(s)
issued licrcafter are subject to suspensioi�or revocation,if the site plans or intended use cliaiige,or if tlie information
submitted in tl�is application is falsiGed or clianged. I,also, rurdersta�rrl tliat I nnl respolisiGle jor n!!clurrges iacrrrrecl froni
t/1is npplicntiun. I,hcrcUy,give conscnt to tlic Autl�orizcd Rcpresentative of thc Davic Cou��ty IicaitL Dcparhncnt
to enter upon above described property Iocaled in Davie Cou�ity and owned by
to conduct all teslii�g procedures as necessary to determic�e the site suitability.
DAT� /� �(� -� SIGNATU '
THIS AR�A MAY B�USLD TOR DRAWING YOUR SIT�PLAN(Includc all of tlic follo�vii�g: +xisting and proposed
property lincs and dimensions, structures, sctbacics, and scptic locations).
Sitc Rcvisit Cl�argc
, ��„ __ .Q�
v (.r.�...�,,��- . Datc(s):
� �� Clicnt Notification Datc:
�I-IS:
Sign givcn /�l a '� Account No. � �
� �9'�,�
Reviscd DCIiD(OS/03 Invoicc No.
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8244 . . . � `�
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„ _� . ”r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
� . �� Soil/Site Evaluation
' � APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003364 Tax PIN/EH#: 5746-99-2928
Billed To: Bernice Stanley Subdivision Info:
Reference Name: Location/Address: Will Boone Road-27028 /
Proposed Facility: Residence Property Size: 3 acres Date Evaluated: � `13l1�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slope%
HORIZON I DEPTH f< <i
Texture grou
Consistence (�
Structure r' l
Mineralo ,.
HORIZON II DEPTH •i �
Texture rou
Consistence
Structure ! S !
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
Landsc�pe 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
Tes�urg
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
ONSIST +.N . .
NIQiS�
VFR-Very friable FR-Friable FI-Firm VFI-Very�rm 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
StrLctLre
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
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 OS/OS(Revised)
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