301 Bamboo Ln DAVIE COUNTY HEALTH DEPARTMENT -z
• Environmental Health Section
P.O.Boa 848/210 Hospital Street
_ Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990002659 Tax PIN/EH#: 5863-16-4711
Billed To: Frank Tharpe Subdivision Info:
Reference Name: Location/Address: 301 Bamboo Lane-27006
Proposed Facility: Barn Property Size: see map
**NOTL�* iIs�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 I 1 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 r/12 #People #Bedrooms.A,: #Baths
Dishwasher: 13 Garbage Disposal: ❑ Washing Machine: Basement w/Humbing: ❑ Basement/No Plumbing:
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
Lot Size Type Water Supply�� Design Wastewater Flow(GPD) /!f� Site: New Repair
System Specifications: Tank Size/Pleb GAL. Pump Tank GAL. Trench Width 121,— Rock Depth✓, Linear Ft. .LD
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 K 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.****
l'T
Environmental Health Specialist's Signature: Date:\?2 —
DCHD 05/99(Revised)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002659 Tax PIN/EH#: 5863-16-4711
Billed To: Frank Tharpe Subdivision Info:
Reference Name: Location/Address: 301 Bamboo Lane-27006
Proposed Facility: Barn Property Size: see map
ATC Number: 3398
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: J? -2
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 guaranteethat the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
? APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT `r 0
Davie County Health Department f
fit;vironmentaiIfeaith Section MAR
P.O. Box 848/210 Hospital Street c�Q3
Mocksville, NC 27028
(336)751-8760 fIV4�AA��ENTgj/l
E�O�j �lTy
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed A 1 � , L�� Contact Person �ICIk 7T(Jl'j'TS
Mailing Address 3101 'R7AAl gain LA EJEE / Home Phone
City/State/ZIP A pAtA kl 't' C 2� b Q(n Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: O"Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry W-Other &e k)
S. If Residence: # People # Bedrooms # Bathrooms
U Dishwasher U Garbage Disposal U Washing Machine U Basement/Plumbing LI Basement/No Plumbing
6. If Business/Industry/Other: Specify type ?'P'am # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats _/ Estimated Water Usage (gallons per day)
f
7. Type of water supply: s County/City ❑ Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 51 o
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: / v WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # 5-n if 71/ 1,=y,0 le +0
Property Address: Road Name _�Q� AI►x,/111�N t' bid got In �aJ km k jG d,IT A
City/Zip t\hdA)e E 1?-f- 0 n I I Ur,l " 46 3 ES SfkyallG►'��
If in a Subdivision provide information,as follows: �'� n1Ct. "�"D tt'1��;�DO L In e
Name: �461M
Section: Block: Lot: Date Property Flagged: I /l�l
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
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 N k A:-1` -1�-P1 arg
to conduct all testing procedures as necessary to determine the site suitability.
DATE �— T—Q� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS•
Account No. Off. (,P7P� /
Revised DCHD(07/99) Invoice No. 7 t4
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` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation ,
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002659 Tax PIN/EH#: 5863-16-4711
Billed To: Frank Tharpe Subdivision Info:
Reference Name: Locatiof,!dd,,,.�ss: 301 Bamboo Lane-2J7006 l
Proposed Facility: Barn Property Size: see map Date Evaluated: ?/ /O
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope%
HORIZON I DEPTH -
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH '• 3 i
Texture group
Consistence 10
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ,fr
SITE CLASSIFICATION: //v7 EVALUATION BY:� .
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
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)
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