247 Willow Creek Ln „ DAVIE COUNTY HEALTH DEPARTMENT 2• �0
� Environmental Health Section
. P.O.Boz 848/210 Hospital Street '
. '� Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001534 Tax PIN/EH#: 5820-$0-5237
Billed To: Randall 8� Pamela Durham Subdivision Info:
Reference Name: Location/Address: Willow Creek Lane-27028
Proposed Facility: Residence Property Size: 1.39 acres
ATC N�1r b�r: 2678
**NOTE** 'lhis mprovement/Operation 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 � � #People � #Bedrooms 3 #Baths a.
Dishwasher: � Garbage Disposal: ❑ Washing Machine: �' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size /•.3 g �• Type Water Supply WG/( Design Wastewater Flow(GPD) 3 L D Site: New�' Repair❑
System Specifications: Tank Size �d� 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 CountyHealth Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(33G)751-8760.****
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Environmental Health Specialist's Signature: � Date: J"o? �`D j✓
DCHD OS/99(Revised)
• •.
DAVIE COUNTY HEALTH DEPARTMENT � �
� ' ' ' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760
Account #: 990001534 Tax PIN/EH#: 5820-80-5237
Billed To: Randall�Pamela Durham Subdivision Info:
Reference Name: Location/Address: Willow Creek Lane-27028
Proposed Facility: Residence Property Size: 1.39 acres
ATC Number: 2678
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: vP/"� G��' 6�.�' Date:��„2��
CERTIFICATE OF COMPLETION
**NOTE** 'The issuance ofthis 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. ,, --�-p �—�G� �--�^i�=s
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Environmental Health Specialist's Signature ate:
DCHD OS/99(Revised)
. . , . n i1 L� � � 0 l'1 L5
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' � �/ APPUCJiT10N FOR SITE NALUATION/iAiP{30VEh9f���fiPrRij�&R�'C ����
Davie County Health Department � � � ��� ; J
�.� � Environmenta/Hea/[fi Section ��-�-
� P.O. Box 848/210 Hospital Street
��^^�`-1 `' �"'`"� Mocksnille, NC 27028 ENVIRONMENTAL HEALTH
S . +-e- P � "^ (336)751-8760 DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS �1LL THE REQUIRED
INFOR2�ITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Hilled yi Ar�r,, /����A»'��� [ )u�f/l G;� Contact Peraon � m
Mailing Addresa �7� G ,�r,����' �Q� Home Phone ���/-�jlyG
City/State/ZIP ���s/ ./�O f�L-q���� Business Phone / ;J/ -�y 9 q����� ��
«�
2. Name on Permit/ATC iF Different than Above �J
a�� �.
Mailing ]lddress City/State/Zip � ��
r'.2(ovi c�9^-�'' /��r _
3. Application For: Site Evaluation ❑ Improvement Permi �ATC_ Both
a. sy8tem to se=,.ice: ❑ House �Mobile Home � Business ❑ Industry ❑ O�her
5. If Residance: A People � R Bedrooms �^ # Bathrooms �_
U Dishwasher [l Ga=bage Diaposal [7�Washinq MacYii.ne ❑ Hasement/Plumbing U IIasament/2lo Plumbing
6. If Buainesa/Induatry/Other: Specify type # Paople �1 Sinka
Y Commodes �i Shoxera �I Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per a�y)
�. TyPe of water supply: 0 County/City ell ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Ycs k�o
If ycs,whut type?
***IMPORTANT***CLIENTS MUST COMPLETETIiE REQUIRL'D PROPGRTY INrORMATION ItCQUF.S7'CD
BELO�i'. Either a PLAT or SITE PLAN MUST BESUl3MITTED by the client witl�TI-IIS APPLICATION.
I'roperty Dimensions: �, 3� �L' WFUT�DIRECI'IONS(from Mocksvilie)to PROI'CR7'1':
Tax OiTice PIN: # �Sa O�fl5a3� �D` �O�T/�" � � D � CJ3-�J/�- t�/�-C�
�'� p� LL'� G 49a o000`!-9 Ty/� p(p ,�� L'
Property Address: Road Name S {� 1 �.}p� p� r��'a /1-so v� �rw��{� `�'�- �'►J /►1 R-�'"� C�K� ���
vv�)lv�,,+ ci�e�K )yN�t
c;ty z�p �r-v �3a�T�� ri,;I� 7� a�v ,,��,�'h�w c�ee.�.�
� ��N�
If in a Subdivision prov�de mformation,as follows: ��Q 195T 1'�.c7 �c.7cJ��� w�C�Y T,��y�-l��S
. �
Namc: ('L_���� ►��l�e R. `("h� SCCaar� a�v�le t,c.�o CY
fl ra )ti I� ,�c.+c'i' 1�-t' �s S��"� RC��s5 �R�M
Section: Block: Lot: Datc Property Fla�ed: �$�y
—1 -�- - 3r�owN:�.o.
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if tt�e information
su6mitted ia this application is falsified or changed I,also,understand that I am responsible jur all charges incurred from
rhis vpplicatioa. I,hereby,give consent to the Authorized Representative of the Duvie County HealtU Depurtment
to entcr upon a6ove described property locatcd in Davie County and owned by
to conduct all testing procedures as necessaty to determine the site suitability.
DATE — � � SIGNATURE � ����� �'� "
THIS A.REA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc followin�: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Rcvisit Chargc
Datc(s):
Clieut Notiiication Datc:
EHS:
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ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
January 26 , 2001 .
Randall&Pamela Durham
141 Legion Hut Road
Mocksville,NC 27028
Re: Site Evaluation/Willow Creek Lane
Tax Office Pin : # 5820-80-5237
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
January 23, 2001. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
/�,�o�;�..�c��.�l�.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di .
��� � �� DAVIE COUNT'Y HEALTH DEPARTMENT
Environmental Health Section
� W - • ` Soi]/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001534 Tax PIN/EH#: 5820-80-5237
Billed To: Randall & Pamela Durham Subdivision Info:
Reference Name: Location/Address: Willow Creek Lane-27028
Proposed Facility: Residence Property Size: 1.39 acres Date Evaluated: /--��T -lj f
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 L
Slo % 02
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH l, '� � "
Texture rou
Consistence � �
Structure � IC
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
Mineralo�v
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/99(Revised)
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