685 Joe Rdri
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
(-Vqs J Oe -RL
Account #:
990000911
Tax PIN/EH #:
5767-43-2971
Billed To:
David Hilton
Subdivision Info:
Reference Name:
David Hilton
Location/Address:
Joe Road -27028
Proposed Facility:
Residence
Property Size:
200'X 250'
ATC Number: 2348
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 CO TION IS LID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature Date: '71,00
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 wil ,fa ion sa i Drily for any
given period of time.
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Septic System Installed By;-�
Environmental Health Specialist's
DCHD 05/99 (Revised)
Date: cS aJ
a DAME COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990000911
Tax PIN/EH #: 5767-43-2971
Billed To:
David Hilton
Subdivision Info:
Reference Name:
David Hilton
Location/Address: Joe Road -27028
Proposed Facility:
Residence
Property Size: 200• X 250'
**N *�Ibgr. 2348
Is mprovement/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 nC)OLS#People 2 #Bedrooms 3 #Baths -2—
Dishwasher:
Dishwasher: 0"" Garbage Disposal: ❑ Washing Machine: Cid Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size X Z50; Type Water Supply OCU— Design Wastewater Flow (GPDa Site: New Repair ❑
System Specifications: Tank Size IWO GAL. Pump Tank GAL. Trench Width :v Rock Depth Linear Ft. aco
Other: 1-B,-2>TeA60T1o.-S �. , kStALL, LEJeS -110. C. M ��3,
Required Site Modifications/Conditions: �c�ST4� �,� c D�iiDt7Q. k-17C(P %,Ftp Wz_L d l4� EP 5 c9,
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.****
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Environmental Health Specialist's Signature Date:1710
DCHD 05/99 (Revised)
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APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Account #:
990000911
Billed To:
David Hilton
Reference Name:
David Hilton
Proposed Facility:
Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5767-43-2971
Subdivision Info:
Location/Address: Joe Road -27028
Property Size: 200'X 250' Date Evaluated: / _
Water Supply: On -Site Well `� Community Public
Evaluation By: Auger Boring '� Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slo %
&17r,
HORIZON I DEPTH
. - !fl
0 -
Texture group
64-
LConsistence
Consistence
Structure
Mineralogy
i
HORIZON II DEPTH
- 2-
- T11
Texture group
C_ s C
Consistence
S
Structure
1L
Mineralogy;
HORIZON III DEPTH
Texture group
Consistence
5
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
-
En
LONG-TERM ACCEPTANCE RATE
D.
,
SITE CLASSIFICATION: P5
LONG-TERM ACCEPTANCE RATE: 0,_1
REMARKS:
EVALUATION BY:
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
Mois
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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r
APPLICATION FOR SITE EVALUATION/IMPROWMENT PERMIT & AT
Davie County Health Department D
' : • Snvlrvnmental MMIM SeWon
P.O. Bos 848/210 Hospital Street DEC 2 0999
Mockaville, NC 27028
(336)751-8760 -
***nV0RTJ"** THIS APPLICATION CUM= BR PRO=SSJW UNLESS ALL Tisa REQUIRED a
INI'ORMATION IS PROVIDED. Refer to the INI'ORMATION BULLETIN for instructions.
3f. Base to be Billed .LG V13b; /7`i1f 1 conta►ot Person 50h
NaU
iling Address o?qQ IVo Cam/([ as acme Phone
City/state/sIP MICAS Ui 1a, NC- 0?70X Business Phone 7L7/ - 1600
s. Mame on Permit/ATC is Different than Above 757— Ff-,kel
Nailing Address City/state/sip SaV--e—
` 1. Application ror: 0 Site Evaluation 0 Improvement Permit/ATC Both
4. 6ystes to service: K House 0 Mobile Home 0 . Business 0 Indus
5. If Residence: i People --� i Bedrooms
# Dishwasher O Garbage Disposal Xwashinq Machine
S. I! Business/Industry/Other: specify type
try 0 Other
i Bathrooms
0 Basement/Plumbing 0 Basesent/No Plumbing
i People i Banks
i Commodes i showers i Urinals i water Coolers
It 1=SERVICE: # Seats Estimated Water Usage (gallons per may)
7. Type of water supply: 0 County/City /Pell 0 Community
9. Do you anticipate additions or expansions of the facility this system Is intended t e o
If yea, what type? G�
**"IMPORTANT"** CLIENTS MUSTCOMPLETETHE REQUIRED P1101? TY. RMATION REQ
BEiJOW. Either a PLAT or SITE PLAN MUST BESUBMITIED by the client , i Ti'ISPR, Q
COU ,
Property Dimenslons: �w k OC Sd I WRITE DIRECI10�I8 ([rom Mock:viQe) TY:
Tax Office PIN: # -113-2971
Property Address: Road Name �0 �- i�ac.� ,�� P-Zo- -U1'n
City/Zip Mh CKStsi l Ica AJC—
If
J e.
If in a Subdivision provide information, as follows: P i 6,-, -A,_ ems-
AMW
Name: 5,C lagg�
Section: Block: Lot: Date Property Flagged= i v� IL514 oe-
This is to certify that the information provided is correct to the best of my knowledge. I understand that any per a s -
Issued hereafter are subject to suspension or revocation, if the site plans or Intended ase change, or If the inform�adon
submitted in this application is falsified or changed 1, also, understand that I am respoaaible 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 Gam► u A 20 (, r , } I-IV,
to conduct all testing procedures as necessary to determine the site suitability.
DATE I %/ �� 9 9 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property Imes and dimensions, structures, setbacks ind septic locationsk
se
A
Revised DCHD (07/99)
Site Revisit Charge
Date(s): 11,4%oD
CLP.-nt Notification Date: I
-A-L4----�. � Account No.
Invoice No.'
o T