751 Markland Rd � . , . DAVIE COUNTY HEALTH DEPARTMENT �'��
, Environmental Health Section
� ' � ,. • r.o.Bog sasnio x�p�r�i sn��t /�;l��/
. � Mocksville,NC 27028 �rI� �/ `
(336)751-8760 �
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IMPROVEMENT/OPERATION PERMIT
Account #: 990001203 Tax PIN/EH#: 5779-86-4332
Billed To: Danny Minor Subdivision Info:
Reference Name: Danrry Minor Location/Address: Markland Road-27006
Proposed Facility: Residence Property Size: 1.85 Acres
�'��l�,�nbgr: 2451
**N * is mprovementlOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION 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 (1�• 1-�UM� #People �' #Bedrooms 2 #Baths Z
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
. Lot Size ���S��S Type Water Supply��=u- Design Wastewater Flow(GPD) �� Site: New�Repair❑
i
System Specifications: Tank Size�O�� GAL. Pump Tank GAL. Trench Widt 2 L Rock Depth �r 2�� Linear Ft.��1
Other: 1 �STQ.��"��o.J �}L , I�JS't[�,.�- L�til�'a ��o.C. µt.-1.
Required Site Modifications/Conditions: ���T�- �^� �'JT�`� K�-'� �, ��*'� ��'�- k►=E� �O a�
Lt.9.� • .u.�.� ' r.�.No�n6
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFF'LUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 S ecialisY ��2 '' Date: �/ � 00
DCHD OS/99(Revised)
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�„ . , . DAVIE COUNTY HEALTIi DEPARTMENT
` < Environmental Health Section
P.O.Boa 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001203 Tax PIN/EH#: 5779-86-4332
Billed To: Danny Minor Subdivision Info:
Reference Name: Danny Minor Location/Address: Markland Road-27006
Proposed Facility: Residence Property Size: 1.85 Acres
ATC Number: 2451
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). 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 WASTEWA CO TION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: Date: 0�
� 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 in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time. .'�
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Septic System Installed By: ` —`��T 1 ' `� ��'�-�
Environmental Health SpecialisYs Signature• Date: � r1 �� �
DCHD OS/99(Revised)
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. ' s �o��� � ,�`C�'� �—��'9'° � � � � ��� --
;: ; . � APPLIC,ATION FOR SITE EVAWATION/IMPROVEMENfi'PERMIT&ATC D
„ . Davie County Heaith Department
;:' , � Envir�vnmenta/h►ea/tri se+c��on ��AY.� � 20D0
. �• P:O. Bos 848/210 Hospital Street
. ` k��` �� � M�ocksville, NC 27028
(336)751-8760 :s=..: .:. ::...:... .
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***IMPORTANT*** THIS APPLICATION QiNMOT 8E PROCESSED UNLESS ALL THE REQIIIRED �
INFORI�ITION I3 PROVIDED. Refer to the INFOR1rATION BULLETIN for instructions.
D � s�-�
i. t�ame to be silloa GIY�'�U ��DY4�A4S �I YIO�. coatact roraon
Mailinq Addreae i t /�"`G, �Y1�,lL lw Home Phone 9�r0'���i T 7 vy i
City/State/ZIP _ WII�(1Vl_CE, Nc a�oo� Suaineas Phoae
2. Nam�a on Permit/ATC iP Different than Above
r�ita� �+aaress City/State/Zip
s. Application For: �5ite Enaluation ❑ Improvement Permit/ATC I�oth '�
a. sysr.�m to se�co: ❑ House [�'Mobile Home ❑ Business ❑ =ndustry � Other 1
s. =f Residence: � People _� t Bedrooms � � Bathraoms �
O Diahwaahar ❑ Garbaqe Diaposal fSidashing Machine ❑ Sasement/Plumbinq O Sasement/No Plumbing ,
6. If Susinasa/Induatry/Othar: Specily type � People � Sinka
� Coawdea � Sho�rara � Urinals � Water Coolara
IF It'OOD3ERVICE: # S@8t8 EStiL18t@d W8t@I' U88ge (gallons par day)
�. Type of water suppiy: ❑ Couaty/City td'Well ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes e�o
If yes,wLat type?
***IMPORT�NT***CLIENTS M[ISTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
(BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICAT�ON.
Property Dimensicns: /. r1 ��'2�S WRITE DIRECTIONS from Mocksville)to PROPERTY:
TaaOffi ePIN: # '7 9" g�� �'332 � '�'O 5
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Property A.ddress: Road Name 1� iQ,Y"k L�,n.d� �� �0 �G.V'� �.�Yl� � ��_
City/Zip �U�V'(�,Vl���� ��.. 1_ 11�1 I_� C OA1 l _
If in a Subdivision provide information,as follows: �������
Name:
Section: Block: Lot: Date Property Flagged: �''�O r 4 O
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 inteaded use change,or if the information
snbmitted in this application is falsified or changed. I,also,understand that I am responsible jor all charges incurred from
this appllcatlon. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie Connty and owned by
to conduct all testing procedures as necessary to determine the site su' ility.
DATE �3�"IOO SIGNATURE. �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Ezisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
D3�te(s):
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�� �� Client Notification Date:
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2� � � This map is for PERC TEST
and BUILDING PERMIT purposes
only. The Davie County
Tax Administrator's Office
assumes no liability for any
5 �� � information contained on this map.
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(777�
COUNTY-ID:H800000005
' �. �/����� ��79J May 30,2000 12:14 PM
" . `�,��Q�
� Parcel Identification Number
, � R OA D 5779-86-4332
.\
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• ` s DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
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,. _ .
� , ' ' � , Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001203 Tax PIN/EH#: 5779-86-4332
Billed To: Danny Minor Subdivision Info:
Reference Name: Danny Minor Location/Address: Markland Road-270 6
Proposed Facility: Residence Property Size: 1.85 Acres Date Evaluated: G� / BL7
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
„�
FACTORS' � 1 2 3 . 4 5 6 7
Landsca e osition ✓ L '
Slo % °
HORIZON I DEPTH - - - �
Texture rou
Consistence -� �r"
Structure
Mineralo `► ( T �/�
HORIZON II DEPTH - - -2Z `
Texture rou 5�
�'Consistence ` �i
� Swcture
Mineralo ; � �Y
HORIZON III DEPTH ' 2 - �
Texture rou
Consistence yS5 �
Structure S
Mineralo � ' '
HORIZON IV DEPTH
Texture rou
Consistence
Structure .
Mineralo
SOI1.WETNESS
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE •
SITE CLASSIFICATION: � EVALUATION BY: �t�*-�e.W��^-+
LONG-TERM ACCEPTANCE RATE: Q '� � OTHER(S)PRESENT: `
REMARKS: �--�t��..�c�_Y
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-Sil[
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-Granulaz ABK-Ang lo�ky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
. Mineralo�v ,----'"""--
1:1,2:1,Mixed �
Notes
Horizon depth-In inches �
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land s ce�
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free wat inches m land surfac o soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suit ),U(unsuitable
LTAR-Long-term acceptance rate-gaUday/ft2
DC�-ID OS/99(Revised)
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