343 Serenity Hills Trail Lot 1Account #: 990002860
Billed To: Larry Frazier
Reference Name:
Proposed Facility: Residence
ATC Number: 3523
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 #-3q3
Tax PIN/EH #: 5864-43-6171
Subdivision Info: Riverbend Hills Lot #
Location/Address: Serenity Hills Trail -27006
Property Size: 17 acres
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 CONSST/RUCTTIION IS VALID FOR A PERIOD OF F VE YEARS.
Environmental Health Specialist's Signature: `/ V�G / Date: i
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion ze-s35tem'described on Improvement/Operation Permit
has been installed in compliance with ticle 11 of G.S. Chapter ion .1900 "Sewage Treatment and
Disposal Systems," but shall in NO t en as a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date: -: C
/I-
ATC
`
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section Q� l0-
~ P. O. Boz 848/210 Hospital Street „
` Mocksville, NC 27028
(336)751-8760 Cis
IMPROVEMENT/OPERATION PERMIT
Account #: 990002860
Billed To: Larry Frazier
Reference Name:
Tax PIN/EH #: 5864-43-6171
'7 !rcA
Subdivision Info: Riverbend Hills Lot # x
Location/Address: Serenity Hills Trail -27006
Proposed Facility: Residence Property Size: 17 acres
ATC Number: 3523 –4f-343
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of aseptic 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 ? 5
Dishwasher: 9 Garbage Disposal: K Washing Machine: a Basement w/Plumbing:. Basement/No Plumbing: 13
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: El
Lot SizeType Water Supply 6122e Design Wastewater Flow (GPD) `�dC� Site: New Repair 173
System Specifications: Tank Size Z0 GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PI
FINISHED GRADE. ****NOTICE
system between 8:30 a.m. to 9:30 a.
Avde�<��,��
GAL. Trench Width JC Rock Depth l` Linear Ft.4<� 0
RA
IT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
Nct a representative of the Davie County Health Department for final inspection of this
p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
f--
Environmental Health Specialist's Signature: Date: illl eL L/
DCHD 05/99 (Revised)
O lu
APPLICATION 1'011 SITE EVALUATION/1hIPROVDIENT PE•I MIT & A -1C
t Davie County Health Department
Eaviroamenta/Hea/t/i Section
B i
Box 848/210 Hospital Street
r t e
Mocksville, NC 27028
(336)751-8760
***IMPORTJTNT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRLD
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruct-ion.r.
1. Name to be Billed L.yif—a)L '�jtA?uz"j— Contact Person Icy, -
Mailing Address 12-25 Orr- home Phone — 7yo -s9(/ a
City/State/ZIP &UJVWC, - /V( Business Phone 3j6 —29,-
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/'Lip
3. Application For: tier Site Evaluation Pl Improvement Pennit/ATC L Doth
4. System to Service: LN House ❑ Mobile Home ❑ Busine§s ❑ Indust-ry ❑ Other -
5. Type system requested: fir Conventional ❑ ' conventional modified ❑ innovative
6. If Residence: it People 3 i1 Bedrooms 3 11 BaLhrooitw 3.5
UDishwasher L7Garbage Disposal 0/washing Machine 0:15asement/Plwnbing ❑Basement -/No Plu,ibing
7. If Business/Industry /Other: verify type
9 Commodes It Showers
IF FOODSERVICE: It Seats
8. Type of water supply: ❑ County/City
ii Urinals
0 People 11 :;illi::;
11 Water Cooler:
Estimated Water Usage (gallons per day)
OK14e11
❑ Couununi Ly
9. Do you anticipate additions or expansions of tllc facility this systelll is intell(ica to sl`rve? ❑ Yes
If yes, what type?
Ll No
***1A1P0RTANT*** CLIENTS jVUST M11PLETE THE REQUIRED PROPLRTY INFORAIATION RI,QUISS'I'I:D
BELOW.. Eithcr a PLAT or SITE PLAN MUST BESUBi1ffTTED by the elicit with TIIIS APPLICATION.
Property D11llcllsions: a 5
Tax Office PIN:����'�
Property Address: Road Nanle6Tuay,z�1 1Ae,-6 7kAi-
City/Zip Aom-,,,a-, N,,,,
WRITE DIRECTIONS (f -om Aluc((sville) to PItUI'P:I:TY:
arm
g0,4z r-
ty lrt- h 0/uo 14, L C S
v
If ill a Subdivision provideinnformation, as follows.
Name: :�F� ' fo
Section: Bloch: Lot: + Date Monte corners llabged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlit(s)
issued hereafter arc subject to suspension or revocation, if tile site plans or intended use change, or if (lie infornlatioii
submitted in this application is falsified or changed. I, also, understand that 1 run responsible fur all chruges inctn•red front
this application. I, hereby, give consent to the Authorized Representative of the Davie Comity Ilcaltll Dep:u-tulcill
to cuter upon above described property located in Davie County and owned by
to conduct all testing procedures as ilecessary to determine tilt site suitabili(3.,
T
DATE SIGNATUI
THIS AREA MAY BE USED FOR DRANVING YOUR ITE PL(Inude all llm clc foulg: Existing :old proposed
property lines and dimensions, structures, setbacks, az d septic oc tions).
y Site Revisit Change
Sign given
Revised DCHD (05/03
Client Notification Date:
EHS:
Account No. �� d
Invoice No.
4
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PETr7[
Davie County Health DepartmentEnvironmental Health Section
P. O. Box 848 Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed !�—)r, 0 to �"tG h e s Cr ,• �•k. «,� i �S� �. Contact Person Q" ib
Mailing Address -Sol �A c c S i ; I Home Phone 'tto ` i IS 'Z 7/-13
City/State/Zip At 1)Un nG6 IN ► L. Z 2 as 6 Business Phone 4 f° el k 1'7 cSr 7
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
❑ Dishwasher
0" Site Evaluation
House ❑ Mobile Home
# People
City/State/Zip
❑ Improvement Permit & ATC
❑ Business ❑ Industry ❑ Other
# Bedrooms
# Bathrooms
❑ Both
❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice:
# Showers
# Seats
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
# Water Coolers
7. Type of water supply: ❑ County/City 'M Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
f BrITTED WITH THIS APPLICATION.
Property Dimensions: / 7. /32 a �•- J (J /�• 37 '/K, `ARITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: # SFS to 3 - S - 5-2 39 /
Property Address: Road Name e Ise IK GrI�F'Q4(J
1 `� 1
City/zip A4 V a-h�' �� ��D�
If in Subdivision provide information, as follows:
.Sere niCAI
Name: ► Yer'8e n
Section: Lot #:
1
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 the information submitted in this application is
falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, 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 c. ✓ %'D M . c.., c S C, fir '�JNwC to conduct all testing procedures
as necessary to determinethe site suitability.
L /
DATE (
' I/ l - SIGNATURE
Revised DCHD (06-96)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_/— LOT-/
Soil/Site Evaluation
APPLICANT'S NAME
PROPOSED FACILITY /
SUBDIVISION _�'Ve, hGn�JY;��s
Water Supply:
On -Site Well L-"" Community
DATE EVALUATED /
PROPERTY SIZE 17,, ',
ROAD NAME
Public
Evaluation By: Auger Boring [ef�' Pit r/, Cut
FACTORS
1
2 3
4 5 6 7
Landscape position
Al
Slope %
HORIZON I DEPTH
//
-•
Texture group
S` Z
1e ,c SC
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
/P
Consistence
-
P
r l
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
16Y,2 e�lfg 6Z J -
EVALUATION BY:
PRESENT:
I
'
LEGEND
Landscape Position /" )
R - Ridge S - Shoulder L - Linear slope FS - F of slope N - Nose slope W ' /
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 �G/f
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
Mineralogy
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
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