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120 Woodberry Trail � DAVIE COUNTY HEALTH DEPARTMENT � ,� � Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 990001664 Tax PIN/EH#: 5860-20-2133 Billed To: Ira Simpson Subdivision Info: Reference Name: Location/Address: Woodberry Trail-27028 Pro osed Facilit Residence Pro ert Size: 7 1/2 acres ATC Number: 3997 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 CONSTRUCT ON IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ��/Z �-r CERTII ICATE OF COMPLETION **NOTE** The issuance of this 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 WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. 77`� ��'� � i -a�—D� � `/��"�e� t �T� J�� -f J , � �� o �� ,.� � .�k� , . , � 1oox��2 c � � � � Se ' Sys nst led By: � /�� nvironmen Hea Special' s Signafure: Date: f l/' DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT . . " Environmental Health Section G��L � �� . • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990001664 Tax PIN/EH#: 5860-20-2133 Billed To: Ira Simpson Subdivision Info: Reference Name: Location/Address: Woodberry Trail-27028 Proposed Facility Residence Property Size: 7 1/2 acres ATC Number: 3997 **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 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 Dispos�xl�!� Washing Machin� Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size�/� Type Water Supply�/Design Wastewater Flow(GPD) �(� Site: Nevy.� Repair❑ System Specifications: Tank Size GAL. Pump Tanlc��(Z GAL. Trench Width �G Rock Depth�o� /Linear Ft�� J Other: '" ��' '' `. � Required Site Modifications/Conditions: I1�'IPROVEI�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFI.UENT FILTER. RISER(S)TF G "BELOW FINISFIED GRADE. ****NOTICE: Contact a representative ofthe Da ie Coun 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 da lation. Telepho e#is(33C►)751-87G0.**** -pG{t d�c�i/�� well ��D�'�C �J� z"�.�. � i. S�Q �l �� `�Y`' �� 1 � ��-�� ,�'� ... ��, �8 s��rl /�h�� --� w J _' Environmental Health Specialist's Signature:_��G, �` Date: S DCHD OS/99(Revised) � D � � . �' p � � APPLlCATION FOR S1TC EVALUA7lON/IM1iPROVE6IFM PERh11T& � Davie County Health Department F " Environmenta/Hea/th section EB 1' 4 ZDD� P.O. Box 848/210 Hospital StreQt Mocksville, NC 27028 ��NdgfNT (336)751-8760 ��'ECO�N��H ***IMPORTAN'l*** THIS APPLICATION C1INNOT I3E PROCESSED UNLESS ALL THE REQUIRED INFORMATION I5 PROVIDED. Refer to the INFORMATION BULLETIN for instructions. ��. Namo to ba Hillad ��l ��_�� Contact Peraon �/! �/��/'TL[/tl�L�*�/Y��s�� `�Mailisig Addresaa�J�j „So�eewaae� �� Home Phone ��' ��• �g City/State/ZIP �(��*bn� .�(;/�/Y(,,_ �.C. ��/��Business Phono ✓l. Nawe on Permit/ATC iE Different than Abova__�/L!f 8�► ' ��,��60��(�_f� �/C •�Mailing Addreas City/Stato/Zip `-a. 7►pplication For: ❑ 5ite Evaluation � Improvement Permit/ATC ❑ Doth c�. syatem to servico: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Typa ay�tem requested: �Conventional ❑ conventional modifiod ❑ innovative �a. If Rasidence: # People _�_ ## nedrooma �, � Bathroomrs �_ �/ �Diuhwaahur I�GGarbage Disposal �Tashinc� Machine ❑Basement/Plumbing ❑Hasement/No Plumbing 7. If IIuainesa/Znduatzy /Othor: verify type $ Peoplo # Sinks # Commodon # Showors # Urinals $ Water Coolors IF FOODSERVICE: # Seatu Eutimated Water Uaage (qailonn por day) �8. Typo oE water supply: ❑ County/City I�Well ❑ Community �9. no you anticipate additions or cxpai�sions of tl�c facility tl�is systcm is intci�dcd to scrvc? 0 1'cs [,�io If ycs,�vhat typc? , , ***I111P �1fUSTG'Oh1PLETET(II`s RL•'QUIRED I'RO!'LRTY INI�OiZMATION RCQUCSTGD - 13GL0 �ithcr a PL �PLAN MUST BIi SUllAU7'TED by tl�c cticnt with 7'Fl IS AI'YLICATION. �Property Diui t�sions: � �—,�2} `�� 1VI21TC DIRGC"T10NS(frotn 119ocltsvillc)tu PROI'GRTI': f �� T�X orr��rirr: �f� �$"� - z�- �.I 3,3 fii i L� ��v��:�L� ✓PropertyAddress: Road N�mc (,.�o��elC��! !�/�/,[j�'�!,_-Yr�Ll��l> �� (L�— . City/Zip If in a Subdivision providc informalion,as foIlo�vs: � � . Namc: � ✓ �cction: Block: Lot: �c homc coritcrs tlaggcd:,� ' 7 " �� Tl�is is to ccrlify tliat tlic information pruvidcd is correct to ttic best of my]uio«�Icdge. I undcrstand tl�at any permit(s) issucd hcrcafter are subjcct to suspcnsion or revocation,if tl�e site plans or intcnded use changc,or if tlic information submitted ili tliis application is falsified or ct�anged. I,also,«i�rlersln�irl drat I aut responsiLlc for al!clrarges i�rcrrl•rerlfroni 1/ris applrcaliar. I,hcrcby,givc conscut to tl�e Authorizcd Represcntativc of thc Davic Coui�ty IIcaltli Dcpartmcnt to cntcr upon abovc dcscribcd property locatcd in D�vic Coti�ity�n�l otiti�tted by � tu conduct all testing procedures as necessary�to delern�ine the site suitability. � ✓TL,��" b J �-SIGNATUI � TIiIS AREA A'IAY B�US�D FOR DRAWING YOUR SITE PLAN(Iucludc all af tlic follotivit�g: Existing and proposcd property lincs and dimensions, structures, setbacks, and septic locations). Sitc Revisit Cl�argc Datc(s): , . . Clicnt NotiGcation Datc: � ' `� ��°`~l�' . �FIS: Sign givcn /v V Account No. (� Rcti�ised DCHD(OS/03 I�ivo�cc No. �� " ��-, � � _- .�. 4Yw,' ___ _�� ,w _� y�"1 ��/ '� .... 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'.a„rr. �, • • . �..... . . 1 , . , ..... .. . , � • ./ . . 1• , .. . / . ' \ � �ti/ � . , DAVIE COUNTY HEALTH DEPARTMENT � �� ," , � Environmentai Health Section P II' . P.O.Boa 848/210 Haspital Street . ^�� Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000839 Tax PIN/EH#: 5860-20-2133 Billed To: David Conner Subdivision Info: , Reference Name: David Conner Location/Address: Pamela Lane-27006 Proposed Facility: Residence Property Size: 12.084 Acres ATC Number: 2238 **NOTE** This ImprovemenUOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALTTHORIZATION 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: � Basement w/Plumbing: 0 BasemenilNo Plumbing: �_ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �' Type Water Supply� Design Wastewater Flow(GPD)__�� Site: New� Repair❑ �� System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�(� Rock Depth 1� Linear Ft.�� Other:�.L'JJ y0��f � �r.11��l�✓ 4'�(�/� � Required Site Modifications/Conditions: I11'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the 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.**** . �-� ��'�/ar G �� _ �� I� ��1�1 �� , � � b � G� , - Environmental Health S ecialisYs Signature: � "l �`J Date: !l/��3�� P DCHD OS/99(Revised) . , � , • DAVIE COUNTY HEALTH DEPARTMENT ' . , Environmental Health Section P.O.Bog 848l210 Hospital Street � Mocksville,NC 27028 (33G)751-8760 Account #: 990000839 � Tax PIN/EH#: 5860-20-2133 Billed To: David Conner Subdivision Info: Reference Name: David Conner Location/Address: Pamela Lane-27006 Proposed Facility: Residence Property Size: 12.084 Acres ATC Number: 2238 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). 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 Specialist's Signature: -��(��-�j � Date: /!l1�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article l l 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) - ' DAVIL COUIYTY H�ALTIi D�I'ARTIVI�NT � Environmental Health Section Soil/Site Evaluation AI'PI.ICANT iNFORMATION YROPERTY INFORMATION , ,�Account #: 990001664 Tax PIN/EH#: 5860-20-2133 Billed,To:. Ira Simpson Subdivision Info: Reference Name: Location/Address: Woodberry Trail-27028 . Proposed Facility: Residence - Property Size: 7 1/2 acres Date Evaluated: ��'s' J �- -�---- 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 e% o " ' .� a �� <J HORIZON I DEP'I'H ' << N � �i �' �� Texture rou C Ga— C Consistence l �' .ft � Structure Cve- (3/`� � Mineralo HORIZON II DEPTH �//' �' ' �`' 2 : �'�*' Tcxture rou ' e G Consistence - ,r �'f �i Structure • /'Yl /J� � Mineralo ' _�l / 2' I HORIZON III DEPTH J� G � 't �9� �' p�� Texture rou �" � . / Consistence '� (' Structure !"p � �,2. Mineralo b � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROI.ITE CLASSIFICATION � LONG-TERM ACCCPTANCE RATE SITE CLASSIFICATION:�� U� �'Z(� EVALUATION BY:�/� LONG-TERM ACCEPTANCE R TE: � OTHER(S)PRESENT: REMARKS: '� �''� ��`'� �' LEGEND � Landscapc Position R-Ridge S-Shoulder L-Linear slope FS-Foo[slope N-Nosc slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Textur S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loatn SCL-Sandy clay loam SC-Sandy clay SIC-Silry clay C-Clay CONSISTENCE oi VFR-Vcry friable FR-Friable FI-Firm VFI-Very firm 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 truct rc 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic V�IineraloEX 1:1,2:1,Mixed Notes Horizon depth-In inches Dcpth 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(Revisccl) _