138 Greene Court Lot 7DAVIE COUNTY HEALTH DEPARTMENT
• . Environmental Health Section
• P. O. Boz 848/210 Hospital Street!
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002772 Tax PIN/EH #: 5841-05-2770
Billed To: Donald Thompson Subdivision Info: Pudding Ridge Lot # 7
Reference Name: Location/Address: 138 Greene Court -27028
Proposed Facility: Residence
Property Size: see map
ATC Number: 3470
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 -2— #Bedrooms #Baths_
Dishwasher Garbage Disposal: Washing Machine: Basement w/Plumbing:Z' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) �Wo Site: New ❑ Repair ❑
System Specifications: Tank Siz%QdGAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Widt L "Rock Depth Linear F�
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISIIED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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.****
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Environmental Health Specialist's Signature: Xb // Date: G
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
y Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002772 Tax PIN/EH #: 5841-05-2770
Billed To: Donald Thompson Subdivision Info: Pudding Ridge Lot # 7
Reference Name: Location/Address: 138 Greene Court -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3470
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This 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 CON RUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: G Date:
CERTIFICATE 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.
ho
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
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Date: _.
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f.1AY 2 3 203
ENVIRONMENTAL HEALTH
DAVIE COUTITY
)N FOR SITE EVALUATION/161PROVEhiENT PERMIT & ATC
Davie County Health Department
E17vir0n1neJ7W Heath Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed�r [1) 0V&�?jpS0-3
Mailing Address 61291 ---Jr— GT
City/State/ZIP pC,�S Ylc tc Al C Z 70z K
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person [ Q—�
Home Phone
Business Phone
City/State/Zip
3. Application For: Site Evaluation Improvement Permit/ATC Both
4. system to Service: House Mobile Home Business Industry Other
5. If Residence: # People # Bedrooms # Bathrooms If
Dishwasher Garbage Disposal ashing Machine asement/Plumbing Basement/No Plumbing
6. If Business/Industry/Other: Specify type
# Commodes
# Showers
IF FOODSERVICE: # Seats
# People # Sinks
# Urinals # Water Coolers
Estimated Water Usage (gallons per day)
7. Type of water supply: County/City
s. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
Community
Yes No
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 63 X FO X2oO X /SD K
Tax Office YIN: #
Property Address: Road Name / 36 &I?V�' Cr
City/Zip /✓%OCayatp< 27028
If in a Subdivision provide information, as follows:
WRITE DIRECTIONS (1'roin Mocksville) to PROPBRTY:
6o/ sQ %/J C?f,) ff 49,A9 — 1?.JC�T'
o -J CN,* 7b /1/4*V ,3,9 Gz
OJ Att/hAIJ6- A�106= /.J/'D
601F aw-'SF 2/G117- o -J G2ez�c= C7;
Name: 1?- u Db/JCr R/06r LoT ayit er A? 8 &0CeeJF C7,-
Section: Block: Lot: Date home corners flagged: SI fl03
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I aur responsible fur all charges incurred fi-unr
this application. I, hereby, give consent to the Authorized Representative of the DA vie County Heal thepar(l yellt
to enter upon above described property located in Davie County and owned by 044�� J, -; �js?!0Sw-0
to conduct all testing procedures as necessary to determine the site suita)A,ty ?%
DATE .5 /Z 3 / CO -1 SIGNATURE( 4 Zteg l/ (..W��7�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sign given -
Revised DCHD
Site Revisit Charge
Date(s):
Client Notification Date:
EHS: .
Account No. �1:2 -7�
Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �/"m P
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS I
2 3 4
Landscape position A -
.0
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence
/
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �� EVALUATED BY:
LONG-TERM ACCEPTANCE RE:
REMARKS: S�� /91 P ;�
DCHD(01-901
(S) PRESENT:
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 flay 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
iC-Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:i, 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 - gal/day/ft2
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