332 Longwood Drive Lot 36Account #: 989900635
Billed To: Wayne Frye
Reference Name:
Proposed Facility Residence
ATC Number: 3871
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #:
5862-51-8196.36 WF
Subdivision Info:
Redland Way Lot # 36
Location/Address:
Longwood Drive -27006
Property Size: 135 x 287
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 5awaKTreatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE -9 IO S V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: Z�
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.
MA4 r— VA716'
6, -z7
Septic System Installed By:t``i`'�SiLWp�
Environmental Health Specialist's Signature: ate:
&I
1 Dj
DCHD 05/99 (Revised)
I DAVIE COUNTY HEALTH DEPARTMENT t(SA)
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900635 Tax PIN/EH #: 5862-51-8196.36 WF
Billed To: Wayne Frye Subdivision Info: Redland Way Lot # 36
Reference Name: Location/Address: Longwood Drive -27006
Proposed Facility Residence Property Size: 135 x 287
ATC Number: 3871
**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
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 flaze #People #Bedrooms #Baths
Dishwasher: el/ Garbage Disposal: ❑ Washing Machine: G?"'- Basement w/Plumbing: Basement/No Plumbing: ❑
Commercial Specification: Facility Type#People #People/Shift #Seats Industrial Waste: ❑
Lot Size Qa11 Type Water Supply 1%n--. Wr� Design Wastewater Flow (GPD), -3-,00 Site: New 171Repair ❑
System Specifications: Tank Size 1L'GQ GAL. Pump Tank GAL. Trench Width 3(,d' Rock Depth 12:* Linear Ft. SD��
Other: 3�1�-i%i
Required Site Modifications/Conditions: I w t C'e-.im)(L, " 1U d-_9 W 0-4z, V
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. 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.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signatur Date:
70
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DCHD 05/99 (Revised)
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APPLICAIION FOR SIZE EVALUAIION/ IMPROVEMENT PERMIT & ATC
�-- C E n W ounty Noalth Department
• ' �J LV/nmenta/ Health Smdon
P.O. 848/210 Hospital Street
FEB 1 9 2003 sville, NC 27028
(336) 751-8760
CANNOT BE PROCESSED UNLESS ALL
o the INFORMATION BULLETIN for
I
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UAVIECnim, —11
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1. Name to be Billed ' ) .ContactPerson /%A:
Hailing Address _ aY some phone J 0jj—
Ci /state/EIP / D/L, /0
ty C, Rosiness Phone
2. Name on peruait/ATC if Different than Above
Mailing Address City/state/Sip
3. Application ror: 1? Site Evaluation ❑ Improvement Permit/ATC ❑ Both
a. systam to services 0'—House ❑ Mobile Home 0 Business ❑ Industry ❑ Other
5. If Rasidence: i People ! Bedrooms ! Bathrooms
❑ Dishwasher ❑ aarbage Disposal ❑ Washing Machine
6. If Business/Industry/Others Specify type
i# Commodes I Showers
❑ Basaoent/Plumbing
# People _
# Urinals
❑ Basaaant/No plumbing
/ Sinks
0 Yater Coolers
Ir rOODSERVICE: # Seats_� Estimated Hater Usage (gallons per day)
7. Type of Mater supply: 9--County/City ❑ well ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes ❑ No
If yes, what type?
'"IMPORTANTh" CLIENTS MUST COMPLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: A, )-&5 -7L WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Offlce PIN: #
Property Address: Road Name 19a.)c
City/ztp A-1pid'yed , MZ
If in a Subdivision provide Information, as follows: 7A- — D-7-1,91 4-1,XOl
Name: "TP G',(' /"- A- [�
Section: Block: Lot: 3 Date Property Flagged:
This is to certify that the Information provided Is correct to the beat of my knowledge. I understand that any permit(s)
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 falsified or changed. 1, 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
to conduct all testing procedures as necessary to determine the site sulta illty.
DATE G —D,/' SIGNATURE - --
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
i
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
IEHS:
Account No. l0
Invoice No. �`
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900136 Tax PIN/EH #: 5861-59-5239.36
Billed To: Westview Development Co. Subdivision Info: Redland Lot # 36
Reference Name: Location/Address: USHighway 158-27028
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slo %
%
HORIZON I DEPTH
eq-/
Texture group
UL
Consistence
7777
rr
Structure
Mineralogy
1.1
1
HORIZON II DEPTH
14 r
^ 1
Texture group
Consistence
Structure
L.
Mineralogy1
i 1
HORIZON III DEPTH
Texture group
Consistence
r
Structure
Mineralogy1�
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
,l
SITE CLASSIFICATION: VS
LONG-TERM ACCEPTANCE RATE: D. "a 4
REMARKS:
EVALUATION BY:
OTHER(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
6ICL - Silty clay 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
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
DCHD 05/99 (Revised)