653 Duke Whitaker RdDAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section 1.10�0�
P. O. Boa 848/210 Hospital Street "
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990001117 Tax PIN/EH #: 5801-84-3247.02
Billed To: Travis Hedrick Subdivision Info:
Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028
Proposed Facility: Residence Property Size: 1.9 Acres
**NES* Thi bfmproveeme
OTnt/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 #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 gAYl Type Water Supply Ld Design Wastewater Flow (GPD) C4 D Site: NewEr Repair 11
System Specifications: Tank Size AtV GAL. Pump Tank GAL. Trench Width Rock Depth _ZL Linear Ft.&,V,*
Fell=
Required Site Modifications/Conditions:
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.****
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Environmental Health Specialist's Signature: U ` Date:
DCHD 05/99 (Revised)
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DAVIE COUNTY H,pd �ylo-0I
HEALTH DEPARTMENT Y
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001117 Tax PIN/EH #: 5801484-3247.02
Billed To: Travis Hedrick Subdivision Info:
Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028
Proposed Facility: Residence Property Size: 1.9 Acres
ATC Number: 2923
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 WASTE WATE C NST UCTION IS VALLIID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /`� Date: -21-0 7�1
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.
f
Septic System Installed By: 4 /
Environmental Health Specialist's Signature:
141
(y �� Date:
DCHD 05/99 (Revised)
ON FOR SITE EVALUATION/IMPROVEMENT PERMI
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) ?51-8760
EC EOV El
MAY 14 2001 �
(IMRONMpViAt NEALiN
OAVIECOUNly
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the. INFORMATION BULLETIN for instructions.
1. Name to be Billed oox - V1 Contact Person ,
Mailing Address (O�J D', &_ wy`1 iTl,t ,-f /7 Home Phone
AJ I . // A/ /J n r -i „ e-,
City/state/2IP
2. Name on Permit/ATC if Different than Above
Business Phone
Mailing Address City/State/Zip =,Q
3. Application For:_ " ImprovemenPermit/ATCc ❑ Both
4. system to service: . ❑ House EVMobile Home ❑ Business n Industry ❑ Other
5. If Residence: # People �! #,Bedrooms 3 J*Bathrooms
IK Dishwasher II Garbage Disposal hf Washing Machine 11 Basement/Plumbing 11 Basement/to Plumbing
6. If Business/Industry/Other: Specify type
# Commodes # showers
# Urinals
# People
# sinks
I Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
1. Type of water supply: County/City ❑ Well ❑ Community
S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U-14-0—
If yes, what type?
***IAfPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with Tit IS APPLICATION.
Property Dimensions: 0 OuG t'GS WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # -SUI" 0 `t
Property Address: Road Name��
City/zip 'MOO ,41/1/d/e _ % ag t Sli//b' lo lie . � Id &J, ! 1w
If in a Subdivision provide information, as follows: / n✓I' 6) O 01ali�_e UAi ff& ke/ t �
Name: U
o
Section: Block: Lot: Date Property 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 1 am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilealth Department
to enter upon above described property located in Davie County and owned by
to conduct all
/testing precedures as .^.^.c-cssai y `ao deter wine the site suits itity.
DATE 1 ' �� —O ® 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
Date(s):
I Client Notification Date:
EHS:
Revised DCHD (07/99)
Account No.
Invoice No. _
C
APPLICATION FOR SFFE EVALUATION/IMPROVEMENT
Davie County Health Department
Enlrironmenfal Health Section
P.O. Bou 848/210 Hospital Stre
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. yy
1. Name to be Billed �^ V� Hedrlcl Contact Person
Mailing Address 4� &L 1/y , j J� Some Phone
City/State/ZIP /!/OGKS61/ Xe' 17mp Business Phone
2. Nam& on Permit/ATC it Different than Above
Mailing Address City/State/Zip
3. Application For: fYSite Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to service: ❑ House iYMobile Home ❑ Business 0 Industry ❑ Other
S. If Residence: # People # Bedrooms # Bathrooms I /a
In Dishwasher II Garbage Disposal Pf Washing Machine 11 Basement/Plumbing II Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated water Usage (gallons per day)
1. Type of water supply: W-county/City O Well O Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes WKO-
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED I
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. 11
Property Dimensions: APS ck/- S -� (WRITE DIRECTIONS (from Mockcville) to PROPERTY:
Tax Office PIN: $I l" �`f'-�� �'�l- �'2J4JI
Property Address: Road Name A16-
City/Zip
1 City/Zip D ksv,2/ 17a
If in a Subdivision provide information, as follows: -ru-
ml 8-4 &ems
Name:
Section: Block: Lot:
Date Property 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 front
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 precedures ws ^.ccrs;a;y ;v dete-:uine the site suitagiiity.
DATE q -J�-O ® 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
Date(s):
Client Notification Date:
I EHS•
Revised DCHD (07/99)
Account No. 111-7
Invoice No. I q,16
t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
v SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Accouht #: 990001117 Tax PIN/EH #: 5801-84-3247.02
Billed To: Travis Hedrick Subdivision Info:
Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028
Proposed Facility: Residence Property Size: 1.9 Acres Date Evaluated:
Water Supply: On -Site Well / Community Public
Evaluation By: Auger Boring I/ Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group�'.
Consistence
Structure
/L S"111
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
r.
SITE CLASSIFICATION: G`)�_ EVALUATION BY:5�
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 - CrumbGR - 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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DAVIE COUNTY HEALTH"D�'�TM�NT
ENVIRONMENTAL HEALTH SECTION
P. 0. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
May 3, 2000
Mr. Travis Hedrick
653 Duke Whittaker Road
Mocksville, NC 27028
Re: Site Evaluation/Duke Whittaker Road
Tax Office PIN: # 5801-84-3247.02
Dear Client:
As requested, a representative from this office visited the aforementioned site on
May 2, 2000. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/mp
Enclosure(s)
of i
(3.88A)
3247
722 � ,\ ! , i
' / 321
J�)
AAA
3161
,4R
(15.15
8865
(1.39A)
9167