123 Kluenie Rd DAVIE COUNTY HEALTH DEPARTMENT
• - .., �- Environmental Health Section
, P.O.Boa 848/210 Hospital Street
. Mocksville,NC 27028
(33G)7S]-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002221 Tax PIN/EH#: 5736-34-9779
Billed To: Michael Hicks Subdivision Info:
Reference Name: Location/Address: Kluenie Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3109
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prioi 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 STTE PLANS OR THE INTENDED USE CAANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT 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 f✓L/� Design Wastewater Flow(GPD)��v Site: New� Repair❑
i� �'
System Specifications: Tank Size/�Q�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ftoi�
Other:
Required Site Modifications/Conditions:
I1V'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FiLTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis
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(336j751-8760.****
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Environmental Health Specialist's Signature: Date: �-���—
DCHD OS/99(Revised)
. . ' DAVIE COUNTY HEALTH DEPARTMENT
' , Environmental Heaith Section �
. ` ��,.
, P.O.Boz 848/Z10 Hospital Street �
Mocksville,NC 27028 ��� �
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002221 Tax PIN/EH#: 5736-34-9779
Billed To: Michael Hicks Subdivision Info:
Reference Name: Location/Address: Kluenie Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3109
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AtTfHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance ofa building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE iNTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ,,�� #People� #Bedrooms V� #Baths�_
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:❑ Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size
�`/AG Type Water Supply��� Design Wastewater Flow(GPD)_ i����te: New.� Repair❑
System Specifications: Tank Size�AL. Pump Tank GAL. Trench Width��`Rock Depth���Linear Ftm.?P.��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Count�—� al inspection ofthis
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 instalL� )751-8760.****
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Environmental Health Specialist's Signature: Date: �����v
DCHD OS/99(Revised)
.. • • , DAVIE COUNTY HEALTH DEPARTMENT ��.
' Environmental Heaith Section
' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002221 Tax PIN/EH#: 5736-34-9779
Billed To: Michael Hicks Subdivision Info:
Reference Name: Location/Address: Kluenie Road-27028
Pro osed Facilit : Residence Pro ert Size: see ma
ATC Number: 3109
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /1'��Date: ��^��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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 i be taken as a guarantee that the system will function satisfactorily for any
given period oftime. � /Y>t7
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Sept Sys y
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Environmental Health Specialist's Signature: Date: ���-�
DCI�OS/99(Revised)
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• � Q � PLICATION FOR SITE EVALUATION/IMPROVEMENT PERM13�C ItTC
� � � Davie County Health Department �
,��� Environmenta/Hea/th Section
D ���Q 2�2 � P.O. Box 848/210 Hospital Street
������ N�����`j� Mocksville, NC 27028
4�e�� OV�� (336)751-8760
c�v�R ��E�
** 1�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORNATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions.
1. Name to be Billed F�11C-�'11�ef t '. ��C�S Contact Person /�/1�"^E �-//�
Mailinq Address '''1 Q �-1�Q Sf'�r��5 �N P Fr.J Aome Phone Q�� •��S� �.,�
City/State/ZIP 1"'1d7J1�1(�C.� Business P e 3�10 3YS��Q��O� )Vis�J:��
2. Name on Permit/ATC if Different than Above � ��o �.- J Z S'3 �4 S��-
���
Mailing ]�dcltess City/State/Zip
3. Application For: ite Evaluation�' ❑ Improvement Permit/ATC �Both
4. system to sezvice: D House �Mobile Home � Business ❑ Industry ❑ Other
5. If Residence: � People � # Bedrooms � # Bathrooms �
Dish�►asher ❑ Garbaqe Disposal ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People $ Sinks
N Commodes 1k Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Z�pe of water supply: ❑ County/City Well ❑ Community
s. Do you Anticipate additions or expansions of the facility this system is intended to serve? �Yes �O
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETH� REQUIRED PROPERTY INFORMATION REQUESTGD
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
Property Dimensions: /�- �� ( ) �
�� WRI7'E DIRECfIONS from Mocksville to PROPERTY:
Tax Office PI • # �,�3 �d- 3 y I ��� �e�� So�� PAST �E� ��Y�t�S
Property Address: Road Name �.O'L`'�-n /`� ' " • c� ('�0�'��• I�T ��� �L' ��a�q�. �
c�tyiz�P �"�� � Tp Q�- �n v a�nc:� Kd• (��oJ�
lf in a Subdivision provide information,as follows: o( C�"1 f (�,S fi(uEi�l � 1� �J2nj'
Name: t �� �� 0!1 ��Jti►�C �n1e1T.
}4�� 35 io o�� nt��.bcx�
Section: Block: Lot: Date Property Flagged: �— "�-D'- � 2
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 sitc plans or intended use change,or if the information
submitted in this application is falsified or changed 1,also,understand that I ain responsible for all cltarges iucrrrred fron:
this application. I,hereby,give consent to the Authorized Representative of the Davie County Heaith Dcpartment
to enter upon above described property located in Davie County and owned by
to conduct all testGn proced res as neccssary to detcrmine thc site suitability.�� ^
DATE— ag �a SIGNATURE ��� 5��..��'�'�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of thc following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
� Sitc Revisit Charge.,
Date(s):
�- Clicnt Notification Datc:
EHS:
Account No. ��� 1
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Revised DCHD(07/99) Invoice No. � �9 �
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•V ;j,• �,• DAVIE COLTNTY HEALTH DEPARTMENT
' � � Environmental Health Section
. Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002221 Tax PIN/EH#: 5736-34-9779
Billed To: Michael Hicks Subdivision Info:
Reference Name: Location/Address: Kluenie Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: z�'l�� �
Water Supply: On-Site Well Community Public ./
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEP'TH " G�'
Texture rou �'i
Consistence
Structure /
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH `
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , �
SITE CLASSIFICATION: r � EVALUATION BY: � G/
LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT:
REMARKS:
LEGEND �
Landscape Position
R-Ridge S-Shoulder L-Lineaz 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
ois
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
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 colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DC�ID OS/99(Revised)
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