247 Willow Creek Ln (3) .
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section ��7j
' � P.O.Boz 848/210 Hospital Street
Mceksville,NC 27028
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001304 Tax PIN/EH#: 5820-80-2267
Billed To: Elizabeth Cox Subdivision Info:
Reference Name: Location/Address: 1443 Willow Creek Lane-27028
Proposed Facility: Residence Property Size: 7.176 acres
**NOTE*��iibgmprovemendOperation 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
Article 11 of G.S. Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THLS
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 1� #People � #Bedrooms�_ #Baths�_
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:� Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size "71q�i Type Water Supply f/�1t' Design Wastewater Flow(GPD) Llp� Site: New� Repair❑
System Specifications: Tank Size �V GAL. Pump Tank GAL. Trench Width C�C� � Rock Depth� Linear Ft.��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROV F T FILTER RISER(S) IF 6"BELOW
FINISHED CRADE. ****NOTiCE: Contact a representative ofthe D ie o ty ealth 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 i ta at on. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: �!�,��"-�/ Date: ���� �
DCHD OS/99(Revised)
' • . ���
.
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Heaith Section
P.O.Boa 848/210 H�pital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001304 Tax PINIEH#: 5820-80-2267
Billed To: Elizabeth Cox Subdivision Info:
Reference Name: Location/Address: 1443 WiAow Creek Lane-27028
Proposed Facility: Residence Property Size: 7.176 acres
ATC Number: 2515
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). 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: �� Date: ?f '��S ���
CERTIFICAT COM
**NOTE** T'he issuance of this Certificate of Completion shall indicate e system on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapte 30A, S ion 1 0"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee t t the sy em 1 function satisfactorily for any
given period of time.
t�.
QC..,
Q� ��
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Septic System Installed By: '/
Environmental Health Specialist's Signature: Date:^,������
DCHD OS/99(Revised)
�:�
, • � T �
. • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC � � � � � M �
Davie County Health Department
� Environmenta/Hea/th Se�dion � _ � 2000
� � P.O. Sox 848/210 Hospital 3treet
� P� �o�xsoiiie, rrc z�o2e
(336)751-8760 ENV{RONft9ENTAL HEALTH
DAVIE COUNTY
***Sl�ORTANT*** THI$ APPLICATION CANMOT HE PROCESSED UNI.�$3 ALL THE REQUIRED
INE'ORMATION I3 PROVIDED. Refer to the INB'ORMATION BULLETIN for instructions.
1. Nama to bo Hi114d ��1 2 f� ��7'� � l d K Coatnat F�rson
MailinQ 11�ddtos• ( � ���C �Y Y 3 6oma Phono Z���� 3 S �
City/Stat.o/ZIP !�(O C KSVi11 Q /��L Z�a2.�' 8winoss phono 7 � � - S7 O �
2. Nam� on p�zmit/ATC if Dilf�rant Lhan Abovo
Mailiaq ]�d�dros• City/8tato/Lip
�D�
3. Application For: e�3ite Evaluation ❑ Impronement Permit/ATC �'Both
a. sYec� to s.�c.: H House ❑ Mobile Home ❑ Busiaess ❑ Zadustry ❑ Other
s. it Residenca: t People Z t Bedrooms � � Bathrooms _�_
[7 Dishwashor fl Garbaqo Di�posai i�'ilashinQ lsachino �Basomant/Plw�biuq ❑ Sas�nt/No ?lumbinq
6. 2! Bu�ino�e/Induetry/Othor: 8pocily type � Pooplo / Sialcs
� Co�odos # ShoMors � Urinals N Rabr Coolors
IF B'OOD3ERVIC�: # Seata 8stimated Water Usage tQ�ion, �: asy)
7. Type of Nater supply: 0 County/City C�'Well O Gommunity
e. Do you anticlpate additions or e:pansions of t6e facility this system is intended to serve7 9'Yes D No
If yes,what type? 1 6C��J fo�M
***lMPORTANT't**CLIENTS MI/ST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
�BELOW. Eit6er a PL.AT or SITE PLAN MUST BESUBMITTED by the cllent wit6 THIS APPLICATION. _ _
Property Dimensions: /• � �P � �r'P1' WRITE DIREGTIONS(trom Mock4ville)to PROPERTY:
Tai Oftice PIN: # .�S Z U - �C�-Z 2(c 7 CQ U 1 n� �-a Cq�� ��
Property Address: Road Name ),�/, ��� w L/�-c� jn ��" v� �a�� ��ar c�n !��
City/Zip �I o c,�s�� ��� 27�2� ��- v n G�, I i v w Lr`ee k L�
If in a Subdivision provide information,as follows: i AS3 s�n��� w i �C-' o�. I'�:
Name: �/'a(�e`'�y lS 7 ,Q cI'QS �QrweP�'� '�^ti"�" sr��'�e
WI� Qd_
Section: Block: Lot: Date Property Flagged: rt����e
G1i,Q�
This is to certify that the infotmallon provided is conect to the best of my knowledge. I nnderstand that any permit(s)
issued hereatter are subject to suspension or revocatlon,lf t6e aite plans or intended ose change,or if the intormatlon
submitted in t6is appllcation is falsified or changed. I,also,understand that I ant responslble for a/1 charg�s lncurred jroni
th�s applicatlon. I,Lereby,give consent to the Aut6orized Representative of t6e Davie County Health Department
to enter upon afwve described property located in Davie County and owued by L�l t G I> e,�� (��h
to conduct all testing procedures as necessary to determine the site suitability.
DATE �� ���v SIGNATURE �:���/( C`�
�
THIS AREA MAY BE USED FOR DRAWING YOUR STI'E PL.AN(Include all of the following: E�aNng and proposed
property lines aad dlmensions, structures, setbacks, and septic locations).
����� �.� �F( ��5�� .���� Slte Revisit Charge .
�v �C�f'� � 6�C K . �� ����S Date(a):
Client NotilicaHon Date:
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Account No. ��5 �' � ��� ��
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Rev[sed DCHD(07/99) Invoice No. ��
n/f CJaude Foster f
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Tax Lot 49.09 �
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Part of Tax Lot 49 raX MQP c-4 �N� ,
Bobby D. Browning .�E � ��
Tax Map G-4 DB 192 O PG 354 �Z86' u j,/���-�__
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Kevin Gerard Wright
, "�°t�1 � � c a/w Kathy Laigh Wright
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DAVIE COUNT'Y HEALTH DEPARTMENT
. � � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001304 Tax PIN/EH#: 5820-80-2267
Billed To: Elizabeth Cox Subdivision Info:
Reference Name: Location/Address: 1443 Willow Creek Lane-27028
Proposed Facility: Residence Property Size: 7.176 acres Date Evaluated: �''-��D(�
Water Supply: On-Si[e Well � .�' Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e% /�U
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH (v �' '
Texture rou
Consistence
Structure /c
Mineralo •l .`r
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: �i�2�/
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-Tenace 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-gaUday/ft2
DCHD OS/99(Revised)
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