144 Sheffield Farms Trail Lot 19DAVIE COUNTY HEALTH DEPARTMENT
- - Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
990001403
Oakwood Homes
John Putnam
Residence
4891-72-7260
L0 +g t 4
Sheffield Farm Rd. -27028
5.4 acres
58
**NOTE** This Improveernent/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
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 OW,115 #People 'l #Bedrooms _4 #Baths 7—
Dishwasher: Garbage Disposal: ❑ Washing Machine: S!r Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift , (##SSeJ
ats Indus13ial Waste:
Lot Size S-4 nType Water Supply Design Wastewater Flow (GPD) `T LD Site: New u Repair ❑
System Specifications: Tank Size i7V� GAL. (Pump Tank GAL. Trench Width Rock Depth �� Linear Ft. 460
, Other: 4 Pex (&xn Z ;�"e->- I STnu- ut�t_=sn 0 -5-
e -Z).
Required Site Modifications/Conditions: 1l�&I ALL O r, C --t>V t7 IZ r F txt �� ca:r 6. K,P do".
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 a BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. t9 44730 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: e.if
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DCHD 05/99 (Revised)
Proposed Facility:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990001403 4891-72-7260
Oakwood Homes
John Putnami Sheffield Farm Rd. -27028
Residence Property Size: 5.4 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 WASTEWA ON MON IS VAEID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: qkam
CERTIFICATE OF COMPLETION
**NOTE*.* The issuance of this Certificate of Coi
has been installed in compliance with
Disposal Systems," but shall in NO W
given period of time.
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Septic System Installed By:
Environmental Health Specialist's Signatur8
DCHD 05/99 (Revised)
ndicate the system described on Improvement/Operation Permit
S. Chapter 130A, Section .1900 "Sewage Treatment and
is a guarantee that the system will ction satisfactorily for any
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APPLICATION FOR SFIE EVALUATION/IMPROVEMFAIf PERLHf & AT0 U jj
* Davie County Health Department lug
Envivonmenfel Health Section
P.O. Bar eye/xis Hospital street pt 2 2000
Moakovilla, RC 27026
(9961761-6766 MUL HEALTH
wwwlr`WtRtTAMT*** THIS APPLICATION CAMWT BE PROCEBMD UNLE80 ALL TBE-R)EQUIRED
INa'OawxoN IS viae DED. Rotor
id�Ier to the noutISITION BULLETIN tar inetsaati/ons.
1. frac to Billed I- I i IA1yLr_A �9YY)P .lI' II contact person Jb 11 wi h,,% VA
rrslina Address )�4 X C 1 Ar) o1I
# e, /i I AYI Wk J tens phone -?()w— Salo —(p-7'9 `i
clew/state/sip o u cess. n scalness phone �p�-1� Sa $• `i S 1 b
a. Hua en Vomit/ASC It Dietersnt than above
IOeillnq Address - City/stats/sip
s. Application lar: 0 Site Evaluation 0 Improvement Parsit/ATC l3�eOth
6. srsten to servsoe, U Rouse P""ile Rome O Business O Industry O Other
a. IfReside nce: I people / Bedrooms /' _ 1 Bathrooms
WR�Diehoaober O aarbiae Disposal Nad,lae D aucant/Plwbina .0 Dasoaant/ao pluablae
6. 29 amines/zA&Mtrt/otter, speolty type 1 people I flaks
1 Connodes 1 showers 1 Orinais I Rater coolers
ii FOODSERVICE: # seats Eatimated Water Usage taaicas par day)
7. Type of water supply: % O, County/City 0 well a Community
6. Do you anticlpite' additions or expansions of the fscWty this system Is Intended to serve? O Ya B No
If yes, what type?
***IMPORTAM'***CLIEN smmTCOMPLIMETHE REQUIRED PROPERTY INFORMA71ON REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the ehest with THIS APPLICATION
Property Dimensions: ' WRITE DIRECTIONS (from Moclavine) to PROPERTYi
„
Tax OMcePIN: 1%��0� ink L=as PaS 'c' °Nhii ih 1e�
PropertyAddremn Rad NameA42�74f)' 1 54(P% P+OGo,t Coro rr)1 L.L. r•�.
City/Zip_�llocA4 Jy" P- T)+OrAA +o "4 old)—W fie:1 �1 ,►='
HinaSubdivision provide Information, asfollowst /u1n K -C. )M p�+�j�ei�:e;��ji r�"rr
Name: '5J IerrtR
Sections Blocks Loh Date Property Maned:
This IS to certify that the lulbrmatiou provided is correct to the bat of my knowledge. 1 understand that any permits)
leaded hereafter are subject to suspension or revocation, If the site plans or Intended we change, or If the information
submitted ie this application is fblelRed or ebanged, I, also, understand that i am revponslble for all charges incatredfiont
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described properly located In Davi CAYunty and awned by TaUn(A ,/ L c--3i-e r
to conduct all testing procedures as aeepis ry to dete a as site suitability.
^ Sa
DATE of V 5 J NATURE / j p
THIS AREA MAY BE USED OR DRAWING YOUR SITE PLAN lade all of the following: Existing and proposed
property lines and dimensions, structures, setback„ and septic locations). WN r3
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Site Revisit Charge
Revised DCHD (07199)
5(0
Kp
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Client Notification Data
Account No.
Invoice No./ 71 l v
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... 0
7
LONG-TERM ACCEPTANCE RATE' t F O,
SITE CLASSIFICATION: 'EVALUATION BY:
LONG-TERM ACCEPTANCE RATE O' OTHER(S) PRESENT:
REMARKS: talA 61 _90erp
LEGEND
Landscape Position
' Foot slope slopeRidge Shoulderslope
CCConcave slope CV -'Convex slope, -TerraceFlood 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
d clay SIC - Silty clay C = Clay
SC - Sandy Y 4'
CONSISTENCE
oist
VFR - Very friable FR —Friable FI - Firm " , VFI -Very firm EFI - Extremely firm
Wet
NS -Non sticky' S'
S -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
i.'
MineraloEy
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 05/99 (Revised)
OEM
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