275 McCullough Rd .! . . .. , . . .
• a. .� DAVIE COUNTY HEALTH DEPARTMENT �� �J/8��..y"
' Environmental Health Section
� _ ., P.O.Boa 848/210 Hospital Street
� _.
,. � Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002454 Tax PIN/EH#: 5746-09-2873
Billed To: William Ward Subdivision Info:
Reference Name: Brent/Kerrie Wall Location/Address: McCullough Road-27028
Proposed Facility: Residence Property Size: 2.50 Acres
ATC Number: 3281
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION FOR WASTEWAT'ER 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 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� Basement w/Plumbing� Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste: �
Lot Sizec�v�.l� Type Water Supply�� Design Wastewater Flow(GPD)C� Site: New•� Repair❑
�l''• �� �
System Specifications: Tank Sizi��GAL. Pump Tank GAL. Trench Width Rock Depth �o� Linear F�:f�
Other:
t
Required Site Modifications/Conditions:
INIPROVE111ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health 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.o ay of installation. Telephone#is(33G)751-87G0.****
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Environmental Health Specialist's Signature: � Date: ` '�/���
" DCHD OS/99(Revised)
�
� ' . �o�-�
, DAVIE COUNTY HEALTH DEPARTMENT
• ' Environmental Health Section �
` P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002454 Tax PINIEH#: 5746-09-2873
Billed To: William Ward Subdivision Info:
Reference Name: Brent/Kerrie Wall Location/Address: McCullough Road-27028
Proposed Facility: Residence Property Size: 2.50 Acres
ATC Number: 3281
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �v�% v��
CERTIFICAT OF COMPLETION
**NOTE** The issuance ofthis Certificate of Compl ion all indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Art' le 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY t as a guarantee that the system will function satisfactorily for any
given period of time. '
J
3�'��,��'
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Septic System Installed By: �(�? ('D `//
Environmental Health SpecialisYs Signature: � Y�D Date: oL
DC�ID OS/99(Revised)
. . e _ . . .. � . .. . � . . � � . . . . � . . .
. . ,. . . � . . . . . ���..�..i..�� . .
• , . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PEIiMIT � � � � � � �
' , Davie County Health Department
� ~ Environmenta/Hea/th Section � � $ ���
P.O. Box 848/210 Hospital 5treet
Mocksville, NC , 27028 . ENVIRONMENTAL HEALTH
(336)751-8760 DIIVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORI�Il4TION IS PROVIDED. Refer to the INFORI�ITION BULLETIN for instructions.
1. Name to be Billed � (� �. (�//�-�('� Contact Person _ � •�...• (�(��n,Q
Mailing }lddress��/,�'JZ n�.e, Hu1� �j�S Home Phone q��'���6�
City/State/2IP _6}Jx/Q-,�/� �e,� �7 p U G Business Phone '�'t�Y—����
2. Name on Pezmit/ATC if Different than Above �r[..T �d, Q� �M�L �4��
��
Mailing Address City/State/2ip
3. Application For: �' Site Evaluation p Improvement Permit/ATC �Both
4. system to service: LY House ❑ Mobile Home ❑ Business 0 Industry � Other
5. Zf Residence: # People �_ # Bedrooms � # Bathrooms �.
� Dishxasher LI Garbage Disposal )4 Washing Machine Ba ement/Plumbinq �'Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People $ Sinks
N Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage �gaiions per day)
7. Type of water supply: (�County/City 0 Well ❑ Co�nunity
e. Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑Ycs EI'�to
lfycs,what type?
***/A�PORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PRQPERTY INFORMATION REQUESTED :
I3CLOW. �ither a PI.AT or SIT�PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
, �
Properly Dimensions: Z• �� � WRITG DIRGGTIONS(from Mocicsville)to PROPGR7'Y:
T�X orr�� ��nt: # -�.r''2�- ��? -�$?3 sou �� e�� �i � .� To
Property Address: Road Namc Mc�v�- •�n v� 11 j�1 �Cv,t�l. a u� � R.U, R�C��'�
c;ty�z�P r�J��✓.L,t� /l,t�. a�o zrr O�l �u�,Cc o u� 1� l�D T o _
If in a Subdivision providc information,as i'ollows: �� �J�11 �-��� — ��S:dc,t_
Namc: 3�� �'L•-u��a,t�t �.:n.�1L�
Scction: Block: Lot: Datc Property i'lagged: q� �g�u�
Tl�is is tu ccrtify that the information provided is correct to the 6est of my knowledgc. 1 undcrstand that any permit(s)
issucd hcrcaftcr are subject to suspension or revocation,if the sitc plans or intendcd usc change,or if the information
submitted in this application is falsified or changecL 1,also,rardersla�rd llrat I ni�r respo�rsible for n!!clinrges incurred fronr
t/ris applicatio�r. I,l�creby,givc consent to the Authorizcd Representative of the Davie County Health Departmcnt
to cnter upon abovc describcd property locatcd in Davie County an�f owned 6y ��Gh w� �- ��/t..i_'lr�._�L
to conduct ull testing proccdures us neccssary to determine thc site suitab'1'ty. .
� — -0 7/ � G��
DATC � (7 SIGNATUR� -
� THIS AREA MAY B� USED�'OR DRAWING YOUR SIT�PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, und septic locations).
""�� r
Sitc Revisit Chargc
��,� �,�,h.G .�,Q.'�►•�.. ��.�Gn— ��,a, ���'''1, Datc(s):
� �aN=�"`�'�^ • Clicnt Notification Datc:
� CHS:
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, Account No. ��00 Q2y'$��'
Reviscd DCHD(07/99) : . Invoice No. �l �b �—
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� ` DAVIE COUNTY HEALTH DEPARTMENT
' , Environmental Health Section
-- ' Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002454 Tax PIN/EH#: 5746-09-2873
Billed To: William Ward Subdivision Info:
Reference Name: Brent/Kerrie Wall Location/Address: McCullough Road-27028
. Proposed Facility: Residence Property Size: 2.50 Acres Date Evaluated:�:2��D2
Water Supply: On-Site Well Community Public �l
Evaluation By: Auger Boring Pit � Cut
FACTORS 1 2 3 : 4 5 6 ' 7
Landsca osition
Slo %
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH " .3 d
Texture rou
Consistence
Structure / /
Mineralo
HORIZON III DEPTH
Texture rou
Consistence �
Swcture
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo I
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE . /
SITE CLASSIFICATION: ____�� EVALUATION BY: _____---
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-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 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
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
DCHD OS/99(Revised)
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