108 Highland Road Lot 21.[ 1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002147
Billed To: The Ward Group of NC, LLC
Reference Name: .
Pr000sed Facilitv: Residence
Tax PIN/EH M
5822-23-0876.21
Subdivision Info:
Dutchman Hills Lot#21
Location/Address:
108 Highland Road -27028
Property Size:
see map
ATC Number., 3061 '
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 WASTEWATFR C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: o Date: ;2
e rc,uvrv>,,
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 I 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be t guarantee that the system will function satisfactorily for any
given period of time.
°y
Septic System Installed By: _
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990002147 Tax PIN/EH M 5822-23-0876.21
Billed To: The Ward Group of NC, LLC
Reference Name:
Proposed Facility: Residence
Subdivision Info: Dutchman Hills Lot# 21
Location/Address: 108 Highland Road -27028
Property Size: see map
ATC Number: 3061
**NOTE** This Improvement/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
PERMrr 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 C7 #Baths :2—
Dishwasher X Garbage Disposal: ❑ Washing MachinoAT Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift �7-#Seats Industrial Waste: ❑
Lot Size Type Water Supply 6_ Design Wastewater Flow (GPD) cW Site: New-121'Repair ❑
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width��� Rock Depth/ Linear FtZPe
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENTFILTER. RISER(S) IF 6 `° BELOW
FINISHED 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. n e day of installation. Telephone # is (336)751-8760.****
0
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
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MERRRELL Jr.
D.B.
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APPUCATION FOR SHE EVALUATION/IMPROVEMENT PERMIT & ATC r D� �� ? r
P Davie County Health Department
enwronmental Health Section 17-1
P.O. Box 048/210 Hospital Street SAE? 2-
n Mocksville, He 27026
y + (336)751-8760
ai.i:
***D>PORTANT*** THIS APPLICATION CANNOT BE PROCESSW UNLESS ALL, HE REQUIRED
INMM&TION IS PROVIDED. Refer to t:he INFORHhTIOH BULLETIN for instructions.
1. Nu. to be Billed content Verses J
� %
Mailing address /% /rA� en S$ some Mums 99C�J'- rSr�Y D 9
city/atats/slp _/tl //di/✓G'_ Ale, o27o06 Business Phone
Z. uses on Pessit/atc if Diffasent than above
Nailing Address city/state/alp
3. Application Fors ffRita Evaluation D Improvement Permit/ATC O Both
*. system to service, P souse O Mobile Home O Business 0 Industry D Other
s. If Residence; 1 People 1 Bedrooms 1 Bathrooms
0 Dishwasher D Garbage Disposal O Mashing Machine D saseesnt/plumbing O Basement/No Plumbing
a. z! sueiesea/radustry/others, specify type / People s Sinks
1 commodes / Showers 1 Urinals
1 NaGs coolers
I! FOODSERVICE: #f Seats Estimated Mater Usage (gallons per day)
7. Type of water supply: 8County/City D Well D Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? O Yes ONO
If yes, what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETRE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a FII.�A./T^orrSITE PLAN MUSTBESUBMITTEDbythe client with THIS APPLICATION
Property Dimenslo , Rte! t . n: / 3 A" 5 / WRITE DIRECTIONS (from Moclsvllle) to PROPERTY:
Tax Office PBV: it�tg09a - )U - In?.SSJ 02�� Zm/ Alit/ALA 72 9--c.ie t-
Property Address: Road Name ae / pL'rA441 eh IVyoIrOe4 o&
City/zip _%'/9 gyi � e J7ae
If In a Subdivision provide Information, as A,/ follows:/ //
Name: k�`�'1 /%`�lid
Section: Block: Lot: 0?/
Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I underoland that any permit(,)
Issued hereafter are subject to suspension or. revocation, If the site plans or intended we change, or If the Information
submitted in this application Is falstfied or changed 1, also, understand that I am responsible for all charges Incurredfmin
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located In Davie County and owned by
to conduct all testing procedures as necessary to determine the site ssitallpity.
DATE_ 17-1�2A9-606)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN
property Tina and dimensions, structures, setbacks, and septic Ise
Revised DCHD (07/99)
of the following: Existing and proposed
Site Revisit Charge
Client Notification Date:
EHS:
Account No.
Invoice No. •=_1 � :- ► .- ,,
k121
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation .
APPLICANT INFORMATION PROPERTY INFORMATION
Account .#: 989900111 Tax PIN/EH
#: 5822-14-6855.21 '• ,
Billed To: Gray Potts Subdivision Info: Dutchman Hills Lot # 21
!Reference Name: Gray Potts Location/Address: Eatons Church" Road -270288
Proposed Facility: ; Residence Property Size: 51 Acres Date Evaluated: 7/h
Water Supply: , On -Site Well Community Public • "
Evaluation By, Auger Boring ng _
Pit �
Cut
FACTORS A. 2 3 4 .5. 6 7 ...:..',
Landscape position -' 1.;
.. —
Slope % 4 -6 -
HORIZON I DEPTH 6,1 -
Texture
t`Texture ou C G
Consistence
Structure
Mineralogy.
HORIZON II DEPTH </ 1 /'Y6 In
Texture group
Consistence .
Structure )
Mineralogyr'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON N DEPTH
Texture group
Consistence
•.Structure,
Mineralogy
SOIL WETNESS . .
RESTRICTIVE HORIZON -
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ri
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 - LoamSI Silt
SICL -,Silty clay loam SII: -Silty loam CL' -Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay ' '
,CONSISTENCE
Mois
VFR - Very friable FR - Friable FI - Firm " VFI - Very firm EM - 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 - gal/day/ft2
DCHD 05199 (Revised)
ME
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SEMEN