620 or 658 Fred Lanier Rd ' DAVIE COUNTY HEALTH DEPARTMENT
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Environmentcal Health Section �, �
P.O.Boa 848/210 Hospital Street �
Mocksville,NC 27028
.�'�, ,� (336)751-87G0 �
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IMPROVEMENT/OPERATION PERMIT Q �
Account #: 990003257 Tax PIN/EH#: 5719-29-9196
Billed To: Joe Gobble Subdivision Info:
Reference Name: Location/Address: Lanier Road-27028
Proposed Facility Residence Property Size: 7 acres
ATC Number: 3801
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION FOR WASTEWAT'ER 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
PERNIIT 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 L� #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�� Design Wastewater Flow(GPD)�� Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widt�,�'� Rock Depth���Linear Ft.�`
Other: �D�
Required Site Modifications/Conditions:
I1VIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FiLTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparirnent for final inspection ofthis
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(33G)751-8760.****
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Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised) L
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. DAVIE COUNTY HEALTH DEPARTMENT �.l•- �v`�
�
• Environmental Heaith Section /� '
� �_ � p.�.Boa 848/210 Hospital Street - .. - .
Mceksville,NC 27028 : .
(336)751-8760
Account #: 990003257 Tax PIN/EH#: 5719-29-9196
Billed To: Joe Gobble Subdivision Info:
Reference Name: Location/Address: Lanier Road-27028
Proposed Facility Residence Property Size: 7 acres
ATC Number: 3801
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 WASTEWATER CONS CTION IS VALID FOR A PERIOD OF FIVE�YE .
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.
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Septic System Installed By: �!L�'J�'J'l�l� n
Environmental Health Specialist's Signature: ��� Date: � � d
DCHD OS/99(Revised)
d v , ;'�'� � �
R .,' t�n � C1 �` � .
�� C,1 :�jt �, E LICATION FOR SITE EVALUATION/IMPROVEhtENT PERMIT& �Q �f
,r,.,� Q 2��` : Davie Coun Health De artment " �
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�` � --•il'�`'+ Environmenta/Hea/fh Section � �U J'
, � A����i P:O. Box 848/210 Hospital Street N /�?QO
" .�43"R��M�fA�t,n Mocksville, NC 27028 4
DA� (336)751-8760 �RONM •
---- . �a�iF�r�H�a�
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIR
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN �or instructions.
1. Name to be Billed Contact Person
Mailing Address � �� -(�""� �• Home Ph4+�v
City/State/ZIP %��O�G/1/J?� h �•C•s �' f �2� Susiness Phone �,�����tL'�Z�•� •
2. Name on Permit/ATC if Different than Above
Mailing Addresa City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC �7 Both
4. System to servtce: � House Cl3" Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: t� Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People � # Bedrooms �_ # Bathrooms _�_
❑Dishwasher ❑Garbage Disposal LF1Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
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7. IL IIu�iness/Indu3try /Other: verify type 1{ People # Sinks`
�
N Commodes # Showers # Urinals $ Water Coolers _
IF FOODSERVICE: # Seats Estimated Water Usage (galions per day) _
a. xype ot water supply: tld' County/City ❑ Well ❑ Community
9. no You anticipate additions or CXpAi1S101]S 0�IIIC rlClllfy'tI11S SySlClll 1S(IifCI1�C(I f0 SCI'VC��Ycs 1�No
If��cs,wliat typc?
***IMPORTANT'�**CLIGNTS MUST COMPLLTE THG REQUIXED PROPERI'Y INrORMATION RGQUCSTL'U
I3ELOtiV. Cithcr a PLAT or SITE PLAN MUST BE SIIBNII7TED by thc clia►t tiviti�TIIIS APPLICATION.
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Property Dimettsions: � �2LG. 1VRITE DIRLCTtONS(from 111ocl:svillc)to PROPIiIt'1'1':
� ��'ax Of�cc PIN: �� .��i ����-�1 q.6' � .�� � f��- ,
���o �����s � � � � �Q� /� �� �t j��/
I'roperty Address: Road Namc a�� !'�� _L�v�-G lri' ����Lv1 /"Y�!
, � `/ "��� � .. ,
City/Zip Z �O Z O � ��-�G' ��►.�L, d31. i�l�
Q � � _.. .
If in a Subdivisiai providc information,as follows:
:/IJ�w� .J`�� _
Namc: ` _ __ _
Section: Block; Lot: llate home corners tlagged: � " 7 � a �'
Tl�is is to certify�ttiat tl�e information provided is correct to tlie best of m��Iccio�vledge. I uiiderstand tl�at any per�nit(s)
issued liercafter are subject to suspension or revoc�tion,if the site plans or intended use change,or if the informatiou
subu�itted in tliis application is falsiticd or clrmged. I,nlso,«�r�lerstanrl tlrat I rrnr respo�rsiGlc for nll clrargc.�s i�rccrr•red fr•a�r
tltis applicnliar. I,l�ereby,give consent fo the Autl�arizc�I Representative of tlie Davie County Ileattl�llepartment
to enter upon above described property located iii Davie County and o�vned by �e F G r�6 -z-
to condurt all teslinb procedures as necessary�to determine the site suitability.
DAT� b � j 7`� d � SIGNATUItE
1'IiIS AIt�A MAY BE US�D I+OR DRAtiVING YOUR SITE PL (Includc all of tlic followiiig: �sisting atid proposed
property lines an�dimensions, structures, setbacks, and septic locations).
� � _ Site Rcvisit Cl�nrgc_.
/ _ _
.. .
_ .
/� _. _ Datc(s):
� `� , . ��� _
; , � _ _
_.
_ _ . .
._. _ _ _
� � Clicnt Notificatioli Datc:
_. EHS:
F\ .
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Sign given �l ��, . ccowit No. ���
� V � � t/
Rc�•ised DC1 D (OS/03 .�((,� � Inv icc No. � I\ �
\ ' r1k ' � .� �--�.
. . . . . . � . .. . .. 1 , . . . . . . . . . . .
.1"
. ` ' ' DAVIE COUNTY HEALTH DEPART'MENT
� ' �� Emironmental Health Section
• : Soi�/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003257 Tax PIN/EH#: 5719-29-9196
Billed To: Joe Gobble Subdivision Info:
Reference Name: Location/Address: LanierRoad-27028
Proposed Facility: Residence Property Size: , 7 acres Date Evaluated: p�2 `��`��
Water Supply: On-Site Well Community Public !/
Evaluation By: Auger Boring Pit 4 Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition '
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Swcture
Mineralo
HORIZON II DEPTH �l p� '
Texture rou
Consistence .�'< '
Structure / ♦
Mineralo / t� : /
HORIZON III DEPTH
Texture rou
Consistence �
Swcture
Mineralo . �
`HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE i
SITE CLASSIFICATION: EVALUATION BY: �G^�
LONG-TERM ACCEPTANCE RATE: �' ' OTHER(S)PRESENT:
REMARKS: 1
LEGEND '
Landsca�e 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 day 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-Slighdy plastic P-Plastic VP-Very plastic
tructure .
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
otes
• 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-gaUday/ff2
DC�ID OS/99(Revised)
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