127 Godbey Acres LnDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003566 Tax PIN/EH #: 5708-58-7381 & 5708-67-0378
Billed To: Polly Maynard Subdivision Info:
Reference Name: Location/Address: Godbey Acres Lane -27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4050
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 CONSTRUC/TION IS VALID 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 described on Improvement/Operation Permit
has been installed in compliance with Article 11 G. Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be takas 4 guarantee that the system will function satisfactorily for any
given period of time. (" 11 ',,-)
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section�o P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003566 Tax PIN/EH #: 5708-58-7381 & 5708-67-0378
Billed To: Polly Maynard Subdivision Info:
Reference Name: Location/Address: Godbey Acres Lane -27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4050
**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 #People #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 Type Water Supply < Design Wastewater Flow (GPD) A 40 Site: New-E�Repair ❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width;:� Rock Depth Linear F
Other:
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.****
Environmental Health Specialist's Signature: Date: ,
DCHD 05/99 (Revised)
'E
F APP
- 5 2005
RTIt
DAME COUNTY
)N FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
EnvironmentaiHealth Section
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.
1. Name to be Billed /0) L -
Mailing Address / y -I-) --/ k::!10 V 1�26
City/State/ZIP )V6r'ks' &-Lr/ AIC.
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: Site Evaluation'
4. System to Service: ❑ House M Mobile Home
Contact Person
Home Phone
7� Business PhonL.1
City/State/Zip
Improvement Permit/ATCBoth
❑ Business ❑ Industry ❑ Other
S. Type system requested: Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
QZf.hwasher ❑Garbage Disposal MI-M,ing 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 ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
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: / Cl< C12-e-
5-7ofr
Tax Office PIN: # S7o p 6 7 0 3170'- r'
Property Address: Road Name
cityizip AW ks v l Ile—
If
l -
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
y W - 'T. LeFi- t~ eoKu LA,
�at:rh1 wstt
Date home corners flagged: Z/- G - d
ra f#wQ�4�
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 stuita i i
DATE 7G/� / SIGNATURE i h �c� F1��?✓'ti
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, a se t'c locations).
iCl
Sign given
Revised DCHD (05103
Date(s):
Client Notification Date:
EHS:
Account No. -�-"
Invoice No. 7 -7 7
Totol 2 36 '
S540-27
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003566 Tax PIN/EH #: 5708-58-7381 & 5708-67-0378
Billed To Polly Maynard Srtbdivision Info:
Reference Name: Location/Address: Godbey Acres Lane -27028
Proposed Facility: Residence Property Size: 1 acre Date Evaluated:!�
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit I
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L—
Slope %
HORIZON I DEPTH
Texture grou2
Consistence
"r
Structure
l
Mineralogy
HORIZON II DEPTH
i
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: EVALUATION BY: lle�E21
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 Sl - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
oist
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 - Sdbangular 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
DCI ID 05/99 (Revised)
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