365 Baileys Chapel Rd DAVIE COUNTY HEALTH DEPARTMENT
� ` � ' Environmental Health Section �`� �� �� a �
P.O.Boa 848/210 Hospital Street ��•�v
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001626 Tax PIN/EH#: 5779-25-5562
Billed To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Bailey Chapel-27006
Proposed Facility: Residence Property Size: 12.18.Acres
ATC Number: 2761
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION 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 �
Dishwasher: � Garbage Disposal: u Washing Machine: � Basement w/Plumbing: �Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �2 ��-� Type Water Supply�i�3�D�sign Wastewater Flow(GPD)�� Site: New�Repair❑
.� ri �
System Specifications: Tank Size���AL. Pump Tank GAL. Trench Width� Rock Depth �� Linear Ft.�
Other: � ����t�1 1.`c7t� '�>>C.�`S , Iri�T1�Ll� LI tJ^S�l�.C. �/�-�� �
Required Site Modifications/Conditions: _ �1T��� �� 1•� - {�;t�:-��'�`
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie C Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:3'O�p,m�.�day of installation. Telephone#is(336)751-8760.****
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Environmental Health S ecialist's Si ature. � Date: � �(e
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DCHD OS/99(Revised)
, , , DAVIE COUNTY HEALTH DEPARTMENT
' � Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mceksville,NC 27028
(336)7S1-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001626 Tax PIN/EH#: 5779-25-5562
Billed To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Bailey Chapel-��,28 ��7°O�
Proposed Facility: Residence Property Size: 12.18.Acres
**NOTE*N�hib�ImprovesinendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION 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 rl�`%-xc. #People 2 #Bedrooms � #Baths 2
Dishwasher: � Garbage Disposal: �Washing Machine: �" Basement w/Plumbing: �=�' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size l� (.:�e� Type Water Supply��Design Wastewater Flow(GPD) s!�'"fO Site: New�Repair❑
�/ �� `��
System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width� Rock Depth �z Linear Ft. L!!',J�
ocn�: � �sT"P.-ipJr�Q,J �C�S l►�sTou- L��►:s Q1 'a.c. �k„J .
Required Site Modifications/Conditions: I�—Y`oT�l,lr (?�✓ C�T�3�� �-� �S� �G NC'�.�� �� �� '�'►'��
`U(`
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 830 a.m.to 930 a.m.or�m.to 1:30 p.m. on the day of installation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: Date: � Z� D
DCHD OS/99(Revised)
. ,. . . ��-
DAVIE COUNTY HEALTH DEPARTMENT
Environmentai Heaith Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001626 Tax PIN/EH#: 5779-25-5562
Billed To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Bailey Chapel-27028
Proposed Facility: Residence Property Size: 12.18. Acres
ATC Number: 2761
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 Sewag eatm and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT S R T � IS V ID FO A PERIOD OF IVE ARS.
Environmental Health Specialist's Signature. Date: 2Z'
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovementJOperation Permit
has been installed in compliance with Article I 1 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. /'�
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Septic System I stalled By: � �� �Y � � ��4'�lZ
Environmental Health Specialist's Signature: 7 I Dat .�Z �� 6 ✓
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DCHD OS/99(Revised)
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APPUCATION FOR SITE EVALUATION/I�fPROVEMENT PEii611T&ATC Q L5 sC ��j�_I�t7 �
Davie County Health Department ,
� Environmenta/Hea/lfi Secrion � � 8 2�� �
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 ENUIROt�n3ENTlIt NEACTN
D�1Vif COUNTy
. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
. /� I
1. Name to be Billed ���� � ea c.� � l�t Contact Peraon ��l-Q __��
Mailing Addreas 1 � iiome Phone "!�— ���� �/�
City/State/ZIP �('� �� �� l p� �` `��� Business Phon ��� �' )`� /
-v�
2. Name on Permit/ATC if Different than Above r '� '�(�'� �
Mailing Addreas ��� ���J-(��{ l Y�{q,�-� � r�/N City/State/Zip �. l �
s. Application For: � Site Evaluation ❑ Improvement Permit/ATC C17lBot���
�
4. Syatem to ser..��a: � House ❑ Mobile Home ❑ Business 0 Industry ❑ Other
5: If. Residence: # People �_ � Bedrooms �_ � Bathrooms � c� ,3
�shnasher ld�Garbage Diaposal YYwashing Machine �sement/Plumbing 0 Basement/No Plumhing
6: If Buainesa/Induatry/Other: Specify type # People N Sinka
� Commodes A Shorera � Uriaals �k Water Coolera
IF FOODSERVICE: #��Seats Estimated Water Usage (gallona �r a$Y)
�. Type of water supply: �County/City ❑ Well ❑ Community
a. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �Vo
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETNE REQUIRED PROYERTY INFORMATION ItEQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the clieot with THIS APPLICATION.
Property Dimensions. -- ~�� ��'v� WRITE DIRECTIONS(troro Mocksville)to PROPERTY:
Tax Office PIN: o, r �'�' ��� � `Y �A 5� �C� I�K-e_�e�,f�
�.�.
Property Add ress: Road Name � �� / 02�- �j i y b y �ct� �{J� �
City/Zip�(I,QN� -2� /U,l'� ,��(� i `�1'" � �����-P � l��
lf in a Subdivision provide information,as follows: H�UDC.1� ��-�►.�1-� aDt-�� �l���,��
rr$�,e: (�l��.e l/2� ���,' �J c���.� t�ti,�� ��'J
Section: Block: Lot: Date Property Flagged: �✓ ��,j�/
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
su6mitted in this application is falsified or changed I,also,undersland that I am responsible for a1!charges incurred from
1hls application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property locatecl in Davie County and owned by
to conduct all te ting procedures as necessary t�determine the site suitability. ^
DATE � /d I SIGNATURE ��- C�
THIS AREA MAY BE USED FOR DRA.WING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
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, "'. �''" � � - DAVIE COUNTY HEALTH DEPARTMENT
, `_ Environmental Heaith Section
� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001626 Tax PIN/EH#: 5779-25-5562
Bitled To: Steve Beauchamp Subdivision Info:
Reference Name: Location/Address: Bailey Chapel-27028
Proposed Facility: Residence Property Size: 12.18. Acres Date Evaluated: �
� Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �
Slo e% �
HORIZON I DEPTH - � - �
Texture rou C C
Consistence � ,- 5 ,-
Structure S 1L
Mineralo � 1• ,`1
HORIZON II DEPTH —
Texture rou C
Consistence .
Structure �j �
Mineralo � ('� ,
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE + O.`'
SITE CLASSIFICATION: � EVALUATION BY. � � �'�
LONG-TERM ACCEPTANCE RATE: �' � OTHER(S)PRESENT: STL-�r l�t,G�IAM�
REMARK�: `
�,' ` ' ` LEGEND
� Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
Mineraloev
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-gaUday/ft2
DCHD OS/99(Revised)
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