148 Buckingham Ln � � DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT �(� �'�
Account #: 9900D1214 Tax PIN/EH#: 5801-84-8865
Billed To: Piedmont Housing Subdivision Info:
Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028
Proposed Facility: Residence Property Size: 1 Acre
**NOTE�*Tfii b�mprovem9ent/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 — #People� #Bedrooms�� #Baths�
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �}�" — Type Water Supply�ia�_ Design Wastewater Flow(GPD)�'�`�" Site: New Lti]' Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth�/Linear Ft��
") t
Other: � � �. n.� F h
Required Site Modifications/Conditions: ��- � aM�
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 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: .�� Date: � 0�1 '�
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(33G)751-8760
Account #: 990001210 Tax PIN/EH#: 5801-84-8865
Billed To: Piedmont Housing Subdivision Info:
Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2459
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 SpecialisYs Signature: Date: � �a� ''CJv
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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.
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Septic System Installed By:
Environmental Health Specialist's Signature: /`'t�1_� Date: �-/�r��
DCHD OS/99(Revised)
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, APPIJCATIQN FOR SITE EVALUATION/IMPRUYEMEM PERMff&A
Davie County Health De�artment '
,�.,,.,
Environmenta/Hea/IfiS�rion �� ��� �::��u,J
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8 6 `� '-.. , . . .
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***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORt�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions.
1. Nama to be Silled - � Contact Person � _�
Mailinq Addreae 1 � ` Home Phone
City/State/2IP . .1��`�� 11`�° . 1�1\_ ���(7�� Buainesa Phon��� �l la— V� 1 1
2. Nama on Permit/ATC if DifFerent than Above
Mailinq Addresa City/State/Zip
s. Appiication sor: ❑ Site Evaluation ❑ Improvement Permit/ATC � 1 Both
a. sy8t�► to se�►ice: � House �Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: � People � # Bedrooms � t Bathrooms C�_
L��Oiahvasher ❑ Garbage Disposal �Waehing Machine ❑ Basement/Plumbinq ❑ Hasement/No Plumbing
��
6. If Buaineaa/Induatsy/Other: Specify type i People # Sinka
i Commcdea / Showera # Urinals # Water Coolera
IF FOODSERVICE: # Seats Estimated Water Usage (g�iona �= a$y)
7. �pe of water supply: 0 County/City ][] Well ❑ Comm ity
!\
e. Do you anticipate additioas or eapansions of the facility this system is intended to serve? ❑Yes No
If yes,w6at type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLiCATION.
Property Dimensions: 1 QC�� WRITE DIRECfIONS(trom Mocksville)to PROPERTY:
Taa Office PIN: # �SiO��s`���iln� �c� y0 l�2��' . �P� t1���c']
Property Address: Road Name '3 � �y� e -}��f�' (��.,���_�'S �Qy � Xw�-�,.
City/Zip �0�"�l`_yJ;,�P `(��� \C�YIP ��� , � C�c�_��l �Qy �Q�
If in a Subdivision provide information,as follows: �(1��` �..(C},.� C�C�5� C'�c�1' c� ���
Name: �-�S`«`QC�. ,�C_z�P �S� � -�t� �e�' �Ca�h��
Cs'� �co _`��P 5\ . 'Th�s S f� iS vLr ��,
Section: Block: Lot: Date Property Flagged LP ` ` '-�'� y ��`�
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. 1,also,understand that I am responsible for all charges incurred jrom
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 Couuty and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE l,(�` I `-v� SIGNATURE __,..._ �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, struct�res, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
' EHS•
Account No. ���0
Revised DCHD(07/99) Invoice No. �1��
' ' ` ' ' DAVIE COiTNT'Y HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001210 Tax PIN/EH#: 5801-84-8865
Billed To: Piedmont Housing Subdivision Info:
Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028
Proposed Facility: Residence Property Size: 1 Acre Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: � gefBorinf Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH ..�
Texture rou
Consistence
Structure
Mineralo � �
HORIZON II DEPTH — S
Texture rou
Consistence �
Structure
Mineralo ' �
HORIZON III DEPTH �.11�
Texture rou
Consistence
Structure �
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE s
CLASSIFICATION ..�
LONG-TERM ACCEPTANCE RATE a
�
SITE CLASSIFICATION: EVALUATION BY: �
LONG-TERM ACCE ANCE RATE: • OTHER(S)PRESENT:
REMARKS: �G
LEGEND
Landsc e Positi n
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
Mineraloav
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-gallday/ft2
DCHD OS/99(Revised)
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