135 Livingston Rd , . DAVIE COUNTY HEALTH DEPARTMENT
. - � ' ' Environmental Health Section ��, �_ � �_ � 2
P.O.Boa 848/210 Hos pital Street
Mocksville,NC 27028
� � (336)751-8760
IMPROVEMENT/OPERATION PERMIT �
.
Account #: 990002209 Tax PIN/EH#: 5851-73-8928 r�j5 �,j'�l�
Billed To: Michael Williams Subdivision Info: J
Reference Name: Location/Address: Livingston Road-27028
Proposed Facility: Residence Property Size: see map
**NUTE'�*TfiTs�mprovem8nt/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AIJTHORIZATION 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
PERNIIT IS SUBJECT TO REVOCATION IF STTE PLANS OR TI�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 �a Design Wastewater Flow(GPD)�_ Site:�New� Repair❑
,� ,�
System Specifications: Tank Size 00 GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Fto��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Da 'e 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 th day installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: � Date: �—���-
DC�ID OS/99(Revised)
� ' • DAVIE COUNTY HEALTH DEPARTMENT ���
Environmental Health Section
' P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002209 Tax PIN/EH#: 5851-73-8928
Billed To: Michael Williams Subdivision Info:
Reference Name: Location/Address: Livingston Road-27028
Pro osed Facility: Residence Property Size: see ma
ATC Number: 3108
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED 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 Treahnent and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT O T C ION IS VAL R A PERIOD OF FIVE YEARS..
Environmental Health Specialist's Signature: - � Date: �� � �Z
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation 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 taken as a guarantee that the system will function satisfactorily for any
given period of time.
�i�✓/ ���7 7�ni.Ti�a
� 9D �—j0 ,�'n�s,l r l pvt Z
1a, 1
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Septic System Installed By: ������Q'd/�
Environmental Health Specialist's Signature: Date:^,�s,�,/� '
DC�ID OS/99(Revised)
� 1 . +♦''�
� � 4 �I UCATION FOR SITE�VAlUAT10N/IMPRAVEMEM'PERMIT&ATC
�Y � � � Davie County Health Department �
� �,� Environmenta/Hea/th Section
A�,^p `L�2`'"�� P.O. Box 848/210 Hospital Street
,",f��� Mocksville, NC 27028
� h �''ct��j'� (336)751-8760
`t �.,'„
***I1�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI�ESS ALL THE REQUIRED
'INFORI�TION IS PROVIDED. Refer to the INFOR2�,TION BULLETIN for instructions.
L. Name to be Billed ���f G v!G7�' � VV i I I%GJ�� Contact Person 1''f�`"1 G(�1 �i1/�' 'I��Gf/yl f
t/ l' (�G] �] '
Mailinq Address 37y5 i�I Gi� �!�y I�� Home Phone / /�� ��� /
City/3tate/ZIP •/I�G ��s (/I l / e 'V�[�/ � ��L� Business Phoae '"/ � I � ��I� 1/^J �/�
� 2. Name on Permi.t/ATC if Different than Above '�jGj/�l � G� �il��/v C�; ` �~�
Mailing Address � City/State/Zip
�Application For: J�Site Evaluation �7 Improvement Permit/ATC ❑ Both
✓� system to service: � House ❑ Mobile Home � Business ❑ Industry ❑ Other
�5. If Residence: # People _� # Bedrooms � N Bathrooms ,.,
t�IJ DishMasher O Garbaqe Disposal P(Washinq Machine y4 Basement/Plumbing CI Basement/No Pl�bing
6. If Business/Industsy/Other: Specify type # People � Sinks
# Commodes # ShoNers # Urinals # Water Coolers
IF EOODSERVICE: # Seats Estimated Water Usage (galions per aay) �
�7. 2�ipe of wate= supply: 1� County/City ❑ Well ❑ Community
�. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes JE�No
If yes,what type?
'�**IMPO OMPLETGTHE REQUIRED PROPERi'Y INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN UST BESUBMI7TED by the client witti THIS APPLICATION.
1 �
Property Dimensions: ��S ���� ( � �'e'�`.a'VRI7'E DIRECTIONS(from Mocksville)to PROPER7'Y:
,
�x Office PIN: # ,�8�� " 7 3� $ �� v n H�w I5� c�u N�� �'G� ec�s-t-
Property Address: Road Name �1 I/i I'1 oJ 'f'U�'1 1"(J�/C� F�u�'Y� M�C �S I/►��e- 7 m �'+ G�,S
c�ty�z�p �Y1 a�k S v i 11 e z�a� +c�� �► L c F-r -t-v L�V;�� -��h
lf in a Subdivision provide information,as follows: T U U[�( ;, Cw�f' . �ir S�f' G�t r V�
lName: CjU t'Gt�GJ� �/ 1�1-FU (.t�UUGf�s �GO �'ee�-f�
�ion: Block: Lot: ate Property Flagged: �"`' � ° y'
� �
�\�This is to certify that the information provided is correct to thc best of my knowledge. I understand that any permit(s)
r,� 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 cliarges incur�ed from
t/�is application. I,hereby,give consent to the Authorized Representative of the D vie ounty'Health De artf�ent
to enter upon above described property located in Davie County and owned by �o � �/" -f' �i � 1!u�'I��
to conduct all testing procedures as necessary to dctcrminc the site suitubility.
�DATE m G r t � v� V L� SIGNATURE rY��/�l � �����
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of ttie following: Existing und proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
� � Date(s):
/ •
i � � � Client Notification Date:
�
EHS:
Account No. �
Revised DCHD(07/99) Invoice 1�10. ��� �
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Y •� ' DAVIE COUNTY HEALTH DEPART'MENT
• � Environmental Health Section
. .. . .
., � Soil/Site Evaluation
APPLICANT INFORMATION � PROPERTY INFORMATION
Account #: 990002209 Tax PIN/EH#: 5851-73-8928
Billed To: Michael Williams Subdivision Info:
Reference Name: Location/Address: Livingston Road-27028
Proposed Facility: Residence Property Size: _ see map: Date Evaluated: .� �
�—�
Water Supply: � On-Site Well Community � Public ��
Evaluation By: -Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osidon � L
Slo e%
HORIZON I DEPTH `' �'
Texture ou L ,s
Consistence
Structure .
Mineralo
HORIZON II DEPTH � �
Texture rou
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: �� - EVALUATION BY: -G
� � � ' �
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-Tenace 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-Slightly 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 �
MineraloQv
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
DCHD OS/99(Revised)
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