993 Farmington Rd (2)DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002015 Tax PIN/EH #: 5841-56-8334
Billed To: William Leonard Subdivision Info:
Reference Name: Debbie Seats Location/Address: Farmington Rd -27028
Pro osed Facility: Residence Property Size: 1 acre
ATC Number: 2993
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 MRN;;M
FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
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.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002015 Tax PIN/EH #: 5841-56-8334
Billed To: William Leonard Subdivision Info:
Reference Name: Debbie Seats Location/Address: Farmington Rd -27028
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 2993
**NOTE** This 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 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 /� y� #People _ a2 #Bedrooms Q*#Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
/ ❑
Lot Size T�� Type Water Supply Design Wastewater Flow (GPD) Site: New ❑ Repair ❑
System Specifications: Tank Sized GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width Rock Depth_ Linear Ft.��(�
IMPROVEh1ENT/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.****
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
t 6
0V
PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
,En V#0=07ta/ Heath Section
1 P.O. Box 848/210 Hospital Street
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.
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: V-1founty/City ❑ Well 11 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VJ N-0
If yes, what type?
***Id1P0RTANT*** CLIENTS MUST COMPLETE TIIE REQUIRED PROPERTY INFORMA110N REQUESTED
BELOW. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
_f -,j c /
Property Dimensions: , e r� dv`l e � ` WRITE DIRECTIONS (from A1ocksville) to NZOPEIRTY:
Tax Office PIN: # � -S� -�3�y Q a -y)
Property Address: RoadName vl-► ; n on �(`' � e jwP_ e- &1 C7 Geri CJ -e 4,e
City/Zip C .QUI if fin; Id�nG i n
If in a Subdivision provide information, as follows:
Name: J /
Section: Block: Lot:
Date Properly Flagged: (� l ( 8 . 6 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 arc 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 ani responsible fur all charges incurred front
this application. 1, 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 suitability.
DATE Rn - CSA SIGNATURE �� C
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).
3 IT I __� D4 S 7
Revised DCHD (07/99)
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. a 15
Invoice No. D_ 1 C� / ��
1. Name to be Billed (i) f I I j 6i rvE h
— — Contact' Person 2 e
re2in&6d
Mailing Address q75 Far i /l G 7
`7
U,,_ R4 • Home Phone
City/State/ZIP oc_kQ�J IK- I
81L 670,Business Phone
2 . Name on Permit/ATC if Different than Above
f 1 8, - rn I r� ►',� r �0
5-a
Mailing Address J a rv� q
City/State/Zip c50 0-\
3. Application For: Site Evaluation
❑ Improvement Permit/ATC
�f�[c
Both
❑ Industry Il Other
/
t Eft
4. system to Service: ❑ House Mobile
Home ❑ Business
j,
5. Iff Residence: # People's
# Bedrooms 3 1t Bathrooms
_ _
17 ❑ -Washing LI II Basement/No
Plumbing
Dishwasher Garbage Disposal 14
Machine Basement/Plumbing
6. If Business/Industry/Other: Specify type
# People # Sinks
# Commodes # Showers
# Urinals )t Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: V-1founty/City ❑ Well 11 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VJ N-0
If yes, what type?
***Id1P0RTANT*** CLIENTS MUST COMPLETE TIIE REQUIRED PROPERTY INFORMA110N REQUESTED
BELOW. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
_f -,j c /
Property Dimensions: , e r� dv`l e � ` WRITE DIRECTIONS (from A1ocksville) to NZOPEIRTY:
Tax Office PIN: # � -S� -�3�y Q a -y)
Property Address: RoadName vl-► ; n on �(`' � e jwP_ e- &1 C7 Geri CJ -e 4,e
City/Zip C .QUI if fin; Id�nG i n
If in a Subdivision provide information, as follows:
Name: J /
Section: Block: Lot:
Date Properly Flagged: (� l ( 8 . 6 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 arc 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 ani responsible fur all charges incurred front
this application. 1, 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 suitability.
DATE Rn - CSA SIGNATURE �� C
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).
3 IT I __� D4 S 7
Revised DCHD (07/99)
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. a 15
Invoice No. D_ 1 C� / ��
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DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #:
990002015
Billed To:
William Leonard
Reference Name:
Debbie Seats
Proposed Facility:
Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5841-56-8334
Subdivision Info:
Location/Address: Farmington Rd -27028
Property Size: 1 acre Date Evaluated:
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
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)