355 Rabbit Farm Trail Lot 22DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900423 Tax PIN/EH #: 5870-52-5109.000EP
Billed To: Lee Downey Subdivision Info: Rabbit Farm II Lot # 22
Reference Name: Location/Address: Rabbit Farm Trail -27006
Proposed Facility: Property Size:
ATC N b r: 1984
**NOTE** its mprovement/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 0 6055- #People �> #Bedrooms 4 #Baths 1-2)
Dishwasher: u Garbage Disposal: e Washing Machine: 1710"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift ''#�yS�e-ats Industrial Waste: ❑
Lot Size Sr-IWk1 g Type Water Supply � Design Wastewater Flow (GPD) 4W Site: New [3 Repair ❑
System Specifications: Tank Size{900GAL. Pump Tank
Other: L jN . T>WV 1 w rJ
n
GAL. Trench Width 31- ''Rock Depth 12- Linear Ft. 41M
f
Required Site Modifications/Conditions: � � d� �tJ�f7� �, %%i' 's " 0AC &VS u
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 f° 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.m. on the day of installation. Telephone # is (336)751-8760.****
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IEnvironmental Health Specialist's Signature: Z
C— I
DCHD 05/99 (Revised) SPS
i+.,., 0"a.t, v,.as-.• --- . .« ;'4"t ..: ,e---.,..', F-rc<- ..� , ' • - r - . ,•t.
AUTHORIZATION NO: 19 a DAVIE CQUNTY HEALTH DEPARTMENT
' - Environmental Health Section PROPERTY INFOR11AT ON
Penrittee's P.O. Box 848
Name: 'Do Lo Mocksville,NC 27028 Subdivision Name; �T
`` �G'k Iv'!11 �[.'� Phone # 336-751-8760 " Lot:
Directions to property: iT
-To Section:
' AUTHORIZATION FOR ,�o70,'
r� � �
�� ��11� . WASTEWATER Tax Office PIN:# M— /0' 2 - a
SIS�TEM CONSTRUCTION ['
ti= iLL r; , C' �-=� Road Name: rte'."' Q �"dip: .Z O
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ON
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTI
IS VALID FOR A PERIOD OF FIVE YEARS.
WIRONMtWAL HEALTH SPEtiAV T DATF- ISSUED
19 8 DAVIE C'pUNTY HEALTH DEPARTMENT
IMPRO EMENT AND OPERATION PERMITS PROPERTY IQNFORMAT ON
Pe e
Nae.:.
m� e, )P j rq Subdivision Name:
. Directions -to property: L.L 1 �.', ` �.t .: :.41 G "K=- Section: Lot: -
IMPROVEMENT �7r/ ,�.�
PERMIT Tax Office PIN:#U 1�= 5•�y l�
r ..µ t Road Name: tT /-1p: 66
D6
**NOTE** This
Improvement Permit DOES NOT authorize the construction or installation 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)
f > ***NOTICE*** TILS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE 04TENDED USE CHANGE. YOUR WASTEWATER
ENVIRON NTAL HEALTH SPECIALIST. DA IS UED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE'
{ INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE 13 # BEDRO64�H # BATHS # OCCUPANTS -4�~ GARBAGE DISPOS (. es No
COMMERCIAL SPECIFICATION:
S�PPECCI6-PE
FICATION: FACILITY TYIPE^�_. ' # PEOPLE # PEOPLE/SHIFT # SEATS IND/USTRIAL WASTE: Yes or No
LOT SIZES � j� WATER SUPPLY GLS DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
��-�-�_
SYSTEM SPECIFICATIONS: TANK SIZE v�;AL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH I Z LINEAR FT.
OTHERISO l
1S
REQUIRED SITE, MODIFICATIONS/CONDITIONS: �tJS`T tel_ (�/ �,..-�X�2 .� �Iov` L^)",
IDcF
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FTL . } *RISE?I(S) IF 5.. I3EU31FINIEtIiEi1 GRADE
_
V -01Z IV SIP ILIo
A \
D O \
r IJ
Ate.,
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY ALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF IN TION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
I � S INSTALLED BY:
AUTHORIZATION NO.
A&OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 0996 (Revised)
1.
APPUCAMON FOR SITE EVALUAl1UN/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Enviroamenfa/Nea/th 5ftWon
P.O. Box 848/210 Hospital Street FEB 2 3
Mockaville, NC 27028
(336)751-8760 ENVIRONMENTAL HEALTH
-MTV
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
Name to be Billed Lee "QbLkJye U►
Mailing Address SQq 1 A r-, � '�Cnoc��
City/State/ZIP �/lil i�iS'iUN"��iSZPn-,� NC RJ Q' 1
Z. Name on Permit/ATC if Different than Above
Hailing Address
3. Application For: -O'Site Evaluation
Contact Person ---S/ / A e'
City/state/ p
Q Imlarovemei�Wrmit/ATC ❑ Both
s. system to service: IdHouse ❑ Mobile Home 0 Business 0 Industry ❑ Other
a. If Residence: # People # Bedrooms # Bathrooms
/g/Dishwasher .81110arbage Disposal ashinq Machine
6. if Business/Industry/Other: Specify type
# Commodes
# showers
D Basement/Plumbing 0 Basement/No Plumbing
# People # Sinks
# Urinals # Nater Coolers
IF FOODSERVICE: ii Seats Estimated slater Usage (gallons per day)
7. Type of water supply: 0 County/City lf!riiell 0 Community
e. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes ""o
If yes, what type!
ft"IMPORTANT•"11 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: A 0 /'0 Y. o? Si7 ,X 900 W DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # 5g r1b o - "x0 9 , OOD�T to i0 y +0 CO t it Qi rn t( d
40�
Property Address: Road Name Rabbis Farm Tral I O kle lePIL�y►-) '� �O
City/zip /' a—ance, dQoo� end +aKe- A f '11)i -o �Ct��✓i
If in a Subdivision provide information, as follows: Farm . f"d 1IOw d 1 r4 road fi�?
Name: 6a5b'+- � � Phase a G�-der. R/R • y lof on �e��•
Section: Block: Lot: c� 04 Date Property Flagged:
This Is to'certiry that the information provided is correct to the best of my knowledge. 1 understand that any permi((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 snuffed from
this application. 1, hereby, give consent to the Authorized Representative or the Davie CounV Health Department
to enter upon above described property located in Davie County and owned by )6h n A/00 5- (2* q I S
to conduct all testing procedures as necessary to determine the site suitability. &,ide/� CO, f20Gf lip Se / / 7'-0
DATE —/ "o( / — `7 % SIGNATURE
THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all or the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
toe PIAced '-/ re -of -'a5_5 where +ked esf. confer -3
e hme- w' N be bui If . T6e, �60��fV zest
Perk wjf-kln 5-0 fecf Of bulldir►s `51 S 0rc:
acK e) le -N- 5)off O
�oc� �ec� half wad b 6 1 7(-('0 C4.
Revised DCHD (07/98)
Account No. 70_
Invoice No. eJ 13
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME LL�
PROPOSED FACILITY!!:6051
SUBDIVISION _r
SECTION 2 LOT 0Z
DATE EVALUATED Z T9
PROPERTY SIZE �� �'S
ROAD NAME 94;&i , fA P,- 2—
Water Supply: On -Site Well t/ Community Public
Evaluation By: Auger Boring V-' Pit Cut
FACTORS
1
2
3 1 4 5 6 7
Landscape position
Sloe %
%Zo
HORIZON I DEPTH
O — Zy
d — (r
o
Texture group
C.
Consistence
FESS S
Structure
5
G
Mineralogyj
;
I
HORIZON II DEPTH
Z
-
'
Texture group
G 1-
C_
C�
Consistence
r
—
Structure
Mineralogy
1`
HORIZON III DEPTH
76,-
-q
Texture group
Consistence
—
r
Structure
S
Mineralogyt
: I
HORIZON IV DEPTH
p
Texture groupC,fL
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
J
LONG-TERM ACCEPTANCE RATE
o
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
Landscaue Position
511euT,
EV C.�4
EVALUATION BY: 'a.
LEGEND
OTHER(S) PRESENT:
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 clay loam SIL - 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 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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