P3840 Duard Reavis Rd". ..
Account M 990003313
Billed To: Lonnie Reavis
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 #: 5802-85-7193
Subdivision Info:
Location/Address: Duard Reavis Road -27028
Property Size: 14.31 acres
ATC Number: 3840
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 1799 6.�b 4 W1✓ #People 2 #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 14 AZOE Type Water Supply Design Wastewater Flow (GPD) I�ZO Site: New Repair ❑
System Specifications: Tank Size1CM GAL. Pump Tank GAL. Trench Width3a� Rock Depth l Z� Linear Ft. 6CIE�
Other: I -2i-tom'
Required Site Modifications/Conditions: �'`���u- o� C.`��tR-t�[�''1�t'-?,-=E �C0
t
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " 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.****
,o i- ►�'►7to
Sr u..
toot
Environmental Health Specialist's Signaturer___�, Date:
DCHD 05/99 (Revised)
Account #: 990003313
Billed To: Lonnie Reavis
Reference Name:
Proposed Facility Residence
ATC Number: 3840
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5802-85-7193
Subdivision Info:
Location/Address: Duard Reavis Road -27028
Property Size: 14.31 acres
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 1 l of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatm and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONST R AL FOR A PERIOD OF F VE YEARS.
Environmental Health Specialist's Signature: Date: `O -
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 guarantee that the system will function satisfactorily for any
given period of time.
eo
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
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D �CEPWE
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC --
Davie County Health Department
Environmental Health Section AUG 2 2004
P.O. Box 848/210 Hospital Street 1
Mocksville, NC 27028
(336) 751-8760 ENVIRONMENTAL HEALTH
DAVIE COUI N
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PRnOVIDED.0 Refer�{ntoo tJhe./INFORMATION BULLETIN for in(strruuctions.
1. Name to be Billed �y�/�p // F,/T/V S Contact Person
Mailing Address y -/,T/ GSA �/ Home PhoneZ��J�..7
City/State/ZIP Jt� / ! i(e Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip /
3. Application For: 13 Site Evaluation 13 Improvement Permit/ATC E Both
4. system to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry R'Other CA/'�f L�
5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7.,' If Business/Industry /Other: verify type # People # Sinks `
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: ❑ County/City i2rWell ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: ' ` `�, �L� WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # o'Z' OS k-ovI I -to Vt7
Property Address: Road Name k7VQJ—)
City/Zip`�C%k—S
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot: Date home corners flagged:
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
to conduct all testing procedures as necessary to determine the site suita ility.
DATE 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).
Sign give Account No.�(_�
Revised DCHD (05/03 Invoice No, /
5
�N'/
APPLICANT INFORMATION
Account #: 990003313
Billed To: Lonnie Reavis
Reference Name:
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/sAe, Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5802-85-7193
Subdivision Info:
Location/Address: Duard Reavis Road- 028).D47
27
Property Size: 14.31 acres Date Evaluated:
Water Supply: On -Site Well c/ Community Public
Evaluation By: Auger Boring Pit Cut
SITE CLASSIFICATION: f i� EVALUATION B
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:- 1
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)
Landscape position
Texture group
Consistence
NAMMA
MEN KWOM
HORIZON II DEPTH
Texture group
Consistence
MpjM
A&M
Mineralogy
HORIZON II DEPTH -
• .®-�-®-
-a�®®�--
Consistence
MjAr'
Mineralogy
Texture group
Consistence
Mineralogy
SOIL WETNESS
NTA V 'Rei NJ I ICLASSIFICATION
•
SITE CLASSIFICATION: f i� EVALUATION B
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:- 1
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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