152 Fulton Rdt DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003792 Tax PIN/EH #: 5777-28-9726
Billed To: Audree Blaikie Subdivision Info:
Reference Name:
ATC Number: 4251
Location/Address: Fulton Road -27006
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 CONST CTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: 1% ZS
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 t a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date: C, /
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Y; ��5�, ` Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028 n �1
(336)751-8760 0-1
IMPROVEMENT/OPERATION PERMIT
Account #: 990003792 Tax PIN/EH #: 5777-28-9726
Billed To: Audree Blaikie Subdivision Info:
Reference Name: Location/Address: Fulton Road -27006
Proposed Facility Residence Property Size: 11.60acres
ATC Number: 4251
**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 f%7 #People _ #BedroomsAA9 #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) %dP Site: New Repair ❑
System Specifications: Tank Siz%%�iAL. Pump Tank GAL. Trench Width �� Rock Depth � Linear Ft. ldz�
Other:
As stated in 15A NCAC 18A.1969(5)
Required Site Modifications/Conditions: accepted Systcros may also be used
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISIIED 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)
r
� ' ffNov
t73
PLICATION FOR SITE [VALUATION/IMPROVE&IENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
9. Sys Lem to Service: ❑ House ❑ Mobile Homo ❑ Business ❑ Industry -ETIO-t-her
5. Typo system requested: 2--c-onventional ❑ conventional modified ❑ innovative I3aCeepted
6. If Posidence: 11 People S Bedrooms 11 Bathrooms
❑Dishwashor ❑Carbago Disposal Mashing Machina ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /other: verify type tl People A Sinks
N Commodes �_ U Showers t1 Urinals 0 Water Coolers _
IF FOODSERVICE: tf Seats Estimated Water Usage (gallons per day)
S. Typo of water supply: County/City ❑ Wall ❑ Community r�.rf
9. Do you anticipate additions or eXpanSiolls of the facility this systelil is intended to serve? El Yes 2 0
If yes, what type?
***1111P0R7�1N7*** CLIENTSAfUST COAIPLETETIIE REQUIRED PROPERTY INFORNIATION REQUESTED
BELOR'. Either a PLAT or SITE PLAN AfU.ST B-rSU11Af1TTF,D by the client with THIS APPLICATION.
Properly Dinlcusions: //i G Q r le e S /
Tax Office I'IN: it 9 7 �` �- % Z 4,
Property Address: Road N:unc IS— 2-
City/Zip
city/zip fitjAW6,g, hJC a Me
If in a Subdivision provide information, as follows:
Name:
DIRECTIONSWRITE •
rew0
Section: Block: Lot: Date ]ionic corners flagged: is/-
'I'llis is to certify that the fnforiliation provided is correct to flit best of 1113' knowledge. I understand that any permfl(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. 1, also, understand !lint l am reslyousible for all charges hicarred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department
to enter tlpoii above described property located in Davie County and owned. by /TkZ..e
to conduct all testing procedures as necessary to determine (lie site suitability.
DA'L'E " ZI ZAS—
THIS
AREA MAY BE USED FOR DIUMING YOUR S1'I'E PLAN (Include all of the following: Existing and proposed
property lilies and dimensions, structures, setbacks, and septic locations).
Sign given
Revised DCIID (05/03
Site Revisit Charge
Date(s):
Client Notircation Date:
EI -IS:
.Account No.
3//a
Il voice No. �� 3
* *I1't�1i�S
RZMTI0N IS
APPLICATION CANNOT BE PROCESSED UNLESS ALL
PROVIDED. Refer to/ the INFORMATION BULLETIN for
TIIE REQUIRED
instructions.
be
&L(1-ee
1. Name to Dilled
Contact Person
t4j,,-4-ee
Mailing Address
Gf
/5- 1 �d/V
Homo Phone
9 9 1- — 794/, .3
City/State/ZIP
,,/ 1(
-/�C
1 ///ems? CP C
? / DDG Business Phone
% � / - 220-
2. llama on Permit/ATC
if Different than Above
Mailing Address
City/State/Zip
3. Application For:
❑ Site Evaluation
❑ Improvement Permit/ATC $'cloth
9. Sys Lem to Service: ❑ House ❑ Mobile Homo ❑ Business ❑ Industry -ETIO-t-her
5. Typo system requested: 2--c-onventional ❑ conventional modified ❑ innovative I3aCeepted
6. If Posidence: 11 People S Bedrooms 11 Bathrooms
❑Dishwashor ❑Carbago Disposal Mashing Machina ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /other: verify type tl People A Sinks
N Commodes �_ U Showers t1 Urinals 0 Water Coolers _
IF FOODSERVICE: tf Seats Estimated Water Usage (gallons per day)
S. Typo of water supply: County/City ❑ Wall ❑ Community r�.rf
9. Do you anticipate additions or eXpanSiolls of the facility this systelil is intended to serve? El Yes 2 0
If yes, what type?
***1111P0R7�1N7*** CLIENTSAfUST COAIPLETETIIE REQUIRED PROPERTY INFORNIATION REQUESTED
BELOR'. Either a PLAT or SITE PLAN AfU.ST B-rSU11Af1TTF,D by the client with THIS APPLICATION.
Properly Dinlcusions: //i G Q r le e S /
Tax Office I'IN: it 9 7 �` �- % Z 4,
Property Address: Road N:unc IS— 2-
City/Zip
city/zip fitjAW6,g, hJC a Me
If in a Subdivision provide information, as follows:
Name:
DIRECTIONSWRITE •
rew0
Section: Block: Lot: Date ]ionic corners flagged: is/-
'I'llis is to certify that the fnforiliation provided is correct to flit best of 1113' knowledge. I understand that any permfl(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. 1, also, understand !lint l am reslyousible for all charges hicarred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department
to enter tlpoii above described property located in Davie County and owned. by /TkZ..e
to conduct all testing procedures as necessary to determine (lie site suitability.
DA'L'E " ZI ZAS—
THIS
AREA MAY BE USED FOR DIUMING YOUR S1'I'E PLAN (Include all of the following: Existing and proposed
property lilies and dimensions, structures, setbacks, and septic locations).
Sign given
Revised DCIID (05/03
Site Revisit Charge
Date(s):
Client Notircation Date:
EI -IS:
.Account No.
3//a
Il voice No. �� 3
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APPLICANT INFORMATION
Account #: 990003792
Billed To: Audree Blaikie
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5777-28-9726
Subdivision Info:
Location/Address: Fulton Road -27006
Property Size: 11.60acres Date Evaluated:
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L,
Sloe %
9
7 G
HORIZON I DEPTH
Texture groupGL
Consistence
Structure
Mineralogy
l
HORIZON II DEPTH
Texture group
Consistence
/
r
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
/17
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: YJW
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
mdq
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Hrl
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
LYoSeS
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 05105 (Revised)
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