349 Longwood Drive, Lot 40N ;
Account #: 989900635
Billed To: Wayne Frye
Reference Name:
Proposed Facility Residence
ATC Number: 3872
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #:
5862-51-4791.40 WF
Subdivision Info:
Redland Way Lot # 40
Location/Address:
Longwood Drive -27006
Property Size: see map
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 Treatt and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT T S VA FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: L
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Comp etio i sh ll indicate the system described on Improvement/Operation Permit
has been installed in compliance with icl 11 f G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WA be ak as a guarantee that the system will function satisfactorily for any
given period of time.
fto it _
4441
FWelc
Septic System Installed By:
Environmental Health Specialist's Signature D lho
DCHD 05/99 (Revised)
Account #: 989900635
Billed To: Wayne Frye
Reference Name:
Proposed Facility Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #:
5862-51-4791.40 WF
Subdivision Info:
Redland Way Lot # 40
Location/Address:
Longwood Drive -27006
Property Size: see map
ATC Number: 3872
**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 ' Ill- #People #Bedrooms #Baths 2 'C)
Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ER Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ° O^1'4C(26ype Water Supply ceOAN Design Wastewater Flow (GPD) Site: New 2( Repair ❑
System Specifications: Tank Size lfkVGAL. Pump Tank GAL. Trench Width Sir I Rock Depth 12—
„ Linear Ft. sb'
Other:
31
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a repres tative of the Davie County Health Department f r final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m.
rye
p.m. on the day of installation. Telephone # is 336)751-8760.****
F\i;�CX1ca,3 (P F:5w2
a
1 �'u
Environmental Health Specialist's Signature: i
DCHD 05/99 (Revised)
Date: �%
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D �jl' 1t 1 rMI ALUAIION/IMPROVEMENT PERWY & ATC
Da i 1 3unty Health Department
F
E mental Health SecflonFEB 1 9 2�0b• 48/210 Hospital StreetMo aville, NC 27028
(336)751-8760
ENVIRONMENTAL HEALTH N t 4 21"101
* * * IMPOR - OT BB PROC SS'BD UNLESS ALL T RE D
INTORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i etruatfA5fW7,4EN
Uftk(
i. Hams to be billed � /� '� z� � Contnot Person Y�/ �'OIIN l Y
)S!'/9-�-C/ C(�
ailing Address � 3 � � Borne phone
City/state/21P UlY, c., Business phone
2. Nacos on permit/ATC if Different than Above
Hailinq Address city/state/zip
3. Application For: 0 Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. eystem to services I -House ❑ Mobile Home ❑ Business ❑ industry ❑ Other
5. if Residence: i People 1 Bedrooms f Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Haohine ❑ Basemant/plumbing ❑ Basamant/No plumbing
S. If Business/industry/Others specify type
# people f Sinks
# Commodes 1 showers I urinals f Water Coolers
Ir FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water 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?
",tIMPORTANT"11 CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBM1TTED by the client with TIIIS APPLICATION.
Property Dimensions: 6 5 /k r61S 4
Tax Offlce PIN: it 5" ) --5 — 3q
Property Address: Road Name //ZdL S
City/zip c&Ayed , A -Z , 97'e?o"
If In a Subdivision provide Information, as follows:
Name: �R p `E,
Sectlon:�� Block: Lot: `f
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
1�q- D-7-/,91 4-i,3�;ai
Date Property Fogged:
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 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
to conduct all testing procedures as necessary to determine the site salla flity.
DATE � Y 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).
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
I Client Notification Date:
I EIIS:
Account No.
Invoice No.
4wDAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900136 Tax PIN/EH #: 5861-59-5239.40
Billed To: Westview Development Co. Subdivision Info: Redland Lot # 40
Reference Name: Location/Address: USHighway 158-27028
Proposed Facility: Residence Property Size: see map
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit '__'
Date Evaluated: G} 3h3
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L -
Slope %
LA 71,
HORIZON I DEPTH
Texture group
Consistencecr%511
Structure
-
Mineralogy
HORIZON lI DEPTH
Z—
Texture group
G
Consistence
i
Structure
Mineralogy;
HORIZON III DEPTH
!�
-S
Texture groupt
K
Consistence
Structure
K
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S -SH4L
LONG-TERM ACCEPTANCE RATE
?� - 0 .9 1
0,
SITE CLASSIFICATION: VS
LONG-TERM ACCEPTANCE RATE: D'
EVALUATION BY: lZP-- * w�
OTHER(S) PRESENT:
REMARKS: PTI
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 ,
SICL - 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)
SEP -01-2004 10:13 AM WAYNEDAPHNFRYE 336 998 7081
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