5262 Hwy 801SAccount #: 990002493
Billed To: Amy Wagner
Reference Name:
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #: 5766-58-8946
Subdivision Info:
Location/Address: Hwy 801 S.-27006
Property Size: see map
12-Z
Z
ATC Number: 3308
**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 #People �_ #Bedrooms #Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine -P"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size (, Type Water Supply —&/j)j Design Wastewater Flow (GPD) Site: New W Repair ❑
System Specifications: Tank Size 1 DGAL. Pump Tank GAL. Trench Width,,—f �,"Rock Depth _ Linear Ft.,K
�6
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: n II Date:
DCHD 05/99 (Revised)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Account #: 990002493
Billed To: Amy Wagner
Reference Name:
raciuty: Kesiaence
ATC Number: 3308
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5766-58-8946
Subdivision Info:
Location/Address: Hwy 801 S.-27006
Property Size: see map
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, ection .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE CONSTRUCTION IS VALID FO PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:- Date: �� z
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 :�1 v ice.. <'/ Date: /
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmenta/Hea/th 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 Am n ' p Contact Person
Mailing Address g DO1(�� J, Home Phone I ,� r )
City/State/ZIP _ ( dyaMci 1 I ( ai100 0y Business Phone 33 W - 1 5 1 - 5' { 34
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/zip
3. Application For: O'Site Evaluation improvement Permit/ATC ❑ Both
4. System to service: ❑ House Q'Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _ # Bathrooms _
FALshwasher O Garbage Disposal WWa% shing Machine ❑ Basement/Plumbing FI 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: ❑ County/City [U/Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes W o
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: 5-C -e— u
Tax Office PIN: # 5 7� G 59 a l 7 `p
Property Address: Road Name �M 701 SoAlt
City/zip ALG.m Zi COD
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
3 hlocb Un L'Akk.
Date Property Flagged: Iola F/ b Z'
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 suitability.
DATE � O ' ' OZ SIGNATURE ( Awl � 1 VVI v
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).
Site Revisit Charge
Date(s):
Client Notification Date:
F
EHS:
Revised DCHD (07/99)j�
1l —,7, _o
Account No. �I 3
Invoice No.
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164 (360)
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7536
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(8.92A)
0
0374
3292
m
& CAROL M
DA
WAGN
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(4.23A)
7051
(24.08A)
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DA RL EDWARD
WAGNER
300
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(1.71 A)
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(1.82A)
4374
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a
(2.19A) 9259
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4214)
(254)
N
FACTORS
1
2 3 4 5 6 7
Landscape position
. ,
�--
DAVIE COUNTY HEALTH DEPARTMENT
' J
Environmental Health Section
Texture group
Soil/Site Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #:
990002493
Tax PIN/EH #:
5766-58-8946
Billed To:
Amy Wagner
Subdivision Info:
Reference Name:
Texture group
Location/Address:
Hwy 801 S.-27006
Proposed Facility:
Residence
Property Size: see map Date Evaluated:
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring 6�_ Pit
Cut
Texture group
FACTORS
1
2 3 4 5 6 7
Landscape position
�--
Slope %
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: 4�(
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
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S - Sticky VS - Very Sticky
SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angul
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineraloev
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
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
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