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546 Deadmon RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section '� �' P. O. Boz 848/210 Hospital Street � � Mocksville, NC 27028 (33G)751-87C0 Account #: 990002062 Bilied To: Bobby Bodford Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT ��.�� (.7.. U� Tax PIN/EH #: 5747-62-1606 Subdivision info: Location/Address: Deadmon Road-27028 Property Size: 5 acres ATC Number: 3017 **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 5EE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �� m�'� #People 2 #Bedrooms �J #Baths 2, j Dishwasher: d Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size q Q�'�S Type Water Supply �� Design Wastewater Flow (GPD) �� Industrial Waste: ❑ Site: New � Repair ❑ System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench Width �� Rock Depth �2-� � Linear Ft.�'7� Other: .� 1.� 1STQ�;R�Ji �o,J �pxs:.-'S ( NST7�,l..L_ L.t ti3 `S �� o.C. !� ��J . Required Site Modifications/Conditions: ��2 , �CL`P �� oF-� }��s�, V-�cr-.P oJ'r �F I1�IPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF Cr `� BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 930 a.m. or 1:00 p.m. to 130 p.m. on the day of installation. Telephone # is (33C►)751-87G0.**** �.� � a ��,5 � � G�� , �� _ � ��s � x��' , �� "�� ,..��2' nPP¢cx. � V _ � � Environm tal Health Specialist's Signature: DCHD OS/99 (Revised) Date: � 3 � � , . . Account #: 990002062 Billed To: Bobby Bodford Reference Name: Pr000sed Faci ATC Number: 3017 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5747-62-1606 Subdivision Info: Location/Address: Deadmon Road-27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST 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 ST VA FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: /Z .�� CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletio has been installed in compliance with Article Disposal Systems," but shall in NO WAY be given period of time. Septic System Installed By: Environmental Health Specialist's Signature : DCF-ID OS/99 (Revised) �•. ystem described on ImprovemendOperation Permit 130A, Section .1900 "Sewage Treatment and that the system will function satisfactorily for any Date: � ",�-�-�z � ' ., , .��,. � AP•ZI�ATION FOR S07E EI�ALUATiON/Ihfi'ROV[M11ENT I'ER�iT , • Davie County Health Department � Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 �� , �� `��,-� -- a 2ao� / ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALI, THE R�� INFOF2MATION IS PROVIDED. Refer to the INFOFtMATION BULLETIN for instructions. 1. Name to be Billed ��, �jnp/�Uk Contact Person S� \u'�'� -,-�o-� / � ( -' � �1 � (7 Mailinq Address S w �� Home Phone City/State/ZIP l`� V Business Phone 2. Name on Permit/ATC i£ Dif£erent than Mailing Add.ress City/State/Zip 3. Application For: � Site Evaluation ❑ Improvement Pe-mit/ATC l�t3oth --t- e r r-� h-P d.^.ca� �� n a. system to service: 0 House �ile Home ❑ Business ❑ Industry KOther'�.JO��Iu�� 5. If Residence: � People �-- # Bedrooms 3 # Bathrooms �� S Fl Dish►rasher L=i�Garbaqe Disposal h ashing Machine I_I Basement/Plumbing II Basement/No Plumbing 6. If Business/Industsy/Other: Specify type # People # Commodes # Showers # urinals # SinY.s # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Zj�pe of water supply: �County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility tl�is system is intendcd to servc? ❑ Ycs ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETGTH� REQUIRED PROPERTY INI'OItMAT10N RGQUI;S'TGU [3ELOW. Eithcr a PLAT or SlTE PLAN MUST BESUBMI77'ED by thc clicnt �vitli THIS APPLICATION. Property Dimensions: �� WRI7'E UIRCCI'lONS (from Mocicsvillc) to PROPI:R'1'1': Tax Officc PIN: # ��7 � �� - 1co Q lO �O� � S�� 'f�' �iAd•�• �•J _ Property Address: Road Namc � e � ►�-� � /��` �� A.� ' 1- - c� n� �Q�� ,n, �� City/Zip�ot�s��1 -2 �C�2�� Ilt�+7�rP i��J �C`.� �e�vR-2._ If in a Subdivision provide information, as follo�vs: (� _R � S S �, � �S IVame: Scction: Block: Lot: Datc Property Flagged: �� .�`(� � This is to certify that the information providcd is correct to the best of my knowledgc. 1 understand that any permit(s) issucd hcrcaftcr are subject to suspension or revocation, if thc sitc plans or intcndcd usc change, or if tl�c information submitted in this app(ication is falsified or cliangcd 1, nlsn, rurdersta�td tlrut I m�r responsible for al! chrrrges iucrrrrerl fronr tbis application. I, hereby, give consent to the Authorized Representative of the Davic County caltl Department to cntcr upon abovc dcscribcd property locatcd in Davic County and owncd by eQ� �e ^'�� ~�� to conduct all tcsting procedures as neccssary to determine the site suitability. n �� DATE ��" ��t7 ( SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includc all of thc following: �xisting and pro� ed property lines and dimensions, structures, sctbacks, and septic.locations). Da tc(s): Revised DCHD (07/99) Account No. -----�� Invoicc No. �� Z _ - , �_ .::�..� .�_ ._ . ...,.:��:.�ectr�n:w��.,v: 90 I o 'I r-�I 544 _ - r-� 1210� 60 t '- `,�201 ' FL�p,O � Zol * 3302 I o�P�Mo `1 `* l�`�`�l `��'� * `�� 2204 1,�201 ��'� 0198 ` o� , � �� '�2 � `�� 9183 •s� ��01 `��'� 8087 � �t�� p> '� �,��51 7062 �o'� ' �� 6958 / � 1.80A) � ��'' -,� .� � 4992 � K500 �8 � ' * 1�?3 y�4/ -- S�, " `<.`Y� 9 1��06 � s� W [ "~ � W � 12.49A 4384 547 K50000008802 5.00A 0465 a� .� . �I� �. 148 ' DAVIE COUNTY HEALTH DEPART'MENT � � �' - � � � Environmental Health Section , . � Soil/Site Evaluation � APPLICANT 1NFORMATION Account #: 990002062 Billed To: Bobby Bodford Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Swcture Mineralogy HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS PROPERTY INFORMATION Tax PIN/EH #: 5747-62-1606 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: 5 acres Date Evaluated: (7 On-Site Well Community_ Auger Boring � Pit 1 2 3 L �i � �� - (,� _ O � r Gt_ Gtr .t�c� � . �- ,�c SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � LONG-TERM ACCEPTANCE RATE: �� 3 �- � � 4 EVALUATION BY: Public Cut 5 I 6 I 7 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 Mineraloev 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fll - 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) ■ ■ ■ ■�■ ■■■ ■�� ■ ■��i ■��■ i��■ 0■ ■■�■�■ ■■��■ ■��■ ■��■�■ ■■��■ ■■��■ ■■■��■ ■�■��■ ■ ■ ■ ■ ■ ■ ■��\■ ■��\ ■�� ■��■■■ ■��■�■ ■■■��■ ■■■��■ ■��■�� ■��■ ■��■ ��■■ ■�■�■■ ■■�■�■ ■��■�■ ■■��■ ■■�■ ■�■■ ■�■■ ■�■■ ■��■ ■�■�■ ■■�■■ ■��■ ■��■ ■��■ ■��■ ■��■��■ ■��■■�■ ■��■■■ ■■��■■■ ■�■�■�■ ■�■��■ ■��■ ■��■■�■�■■■ ■■��■■■ ■��■ ■��■��■ ■��■■�■��■■ ■��■�■�■�■ ■��■■��■■ ■��■ ■��■��■ ■��■��■■■ ■��■�■��■■■ �a�■��■��■ ►`u��■��■ ■��a��■ ■■�■��■��■ ■■■��■��■�■ ■■��■■�■■■��■ ■ ■�■■■