162 Guy Gaither RdDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990000947
Billed To: Elizabeth Roberson
Reference Name: Sue Vaughn
Proposed Facility: Residence
ATC Number: 2329
Tax PIN/EH #: 5800-17-6664
Subdivision Info:
Location/Address: Guy Gaither Road -28634
Property Size: 1.57 Acre
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 WASTEWAT R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 1� .���//� ((//�) , Date: 6-2 " % t�
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 guarant that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
AV e4 C4'
DAVIE COUNTY HEALTH DEPARTMENT
lot Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000947
Billed To: Elizabeth Roberson
Reference Name: Sue Vaughn
Proposed Facility: Residence
Tax PIN/EH #: 5800-17-6664
Subdivision Info:
Location/Address: Guy Gaither Road -28634
Property Size: 1.57 Acre
**NOTE*- I ni b�mproveme nt/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 #People � #Bedrooms #Baths
Dishwasher: 53 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) �6� Site: New 2T Repair ❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width ��� Rock DepthLinear Ft. S'_
Other: /Y
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.****
. -0Environmental Health Specialist's Signature: 49�111Date: 9),,2--/Z—Z2
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT( t o " IE
Davie County Health Department D
Emdronmenta/Hea/t 5;9clfon JAN 13 2i OO
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
.L
***I1dPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed d610,0 Contact Person g t re 0
Mailing Address 16)�: 5 r�; K4! ICCJ /�� Home Phone M6 ^ qqa -94/0
City/State/ZIP M(iv�..t� Cl%Y �0 �/�'
Business Phone 3�� � � �a•� S� rJ Q _
2 . Name on Permit/ATC /��if Different than Above _ � � r" 0 AAA �)aYV
Mailing Address 11P)q Gty u City/State/Zip I dl i( rn !L'4 ' a nj'.
3. Application For: X Site Evaluation R Improvement Permit/ATC Both
4. system to service: ❑ House ,� Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People 3 # Bedrooms 13 # Bathrooms
❑ Dishwasher 11Garbage Disposal PS� Washing Machine ❑ Basement/Plumbing ❑ 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)
7. Type of water supply: VCCounty/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo
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: �, 2 WRITE DIRECTIONS (from Mocksvillee) to PROPERTY:
Tax Office PIN: # _ — � / weS� 6 '7 /,) _ P jO � ed Pd,
Property Address: Road Name G'L-t il 7L, k i r `—
City/Zip /hg-( r� (M �1 �`'c� 0-NL44
If in a Subdivision provide information, as follows: Lk -A
Name:
Section: Block: Lot:
Date Property Flagged: l// :—/3 Z)ez—)
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 lnecessary to determine the site suitability.
DATE �_�� 3 ._ 0 V 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).
Revised DCHD071
� ,moble
r Ide
Site Revisit Charge
Date(s):
Client Notification Date:
EHS•
Account No. Z�Z
Invoice No. ,0•o��
APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
PROPERTY INFORMATION
Account #: 990000947 Tax PIN/EH #: 5800-17-6664
Billed To: Elizabeth Roberson Subdivision Info:
Reference Name: Sue Vaughn Location/Address: Guy Gaither Road -28634
Proposed Facility: Residence Property Size: 1.57 Acre Date Evaluated: a72- V3� OCA
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public L�
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
4
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH`
7
Texture group
C/"
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: I t
REMARKS:
EVALUATION BY: Z( q
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)
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