215 Mohegan Trail . l �
� - � , DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003731 Tax PIN/EH#: 5754-13-6347
Billed To: Clayton Homes Subdivision Info:
Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028
Pro osed Facilit Residence Property Size: 2.529 acres
ATC Number: 4204
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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 I 1 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
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Environmental Health Specialist's Signature: /` ('��' Date: �
CERTIITCATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completio s 1 ind'cate the system described on Improvement/Operation Permit
has been installed in compliance with Articl 1 of G. Chapter 130A, Section .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY t en as guarantee that the system will function satisfactorily for any
given period of time. � � ��)
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Septic System Installed By: r� �C����
Environmental Health Specialist's Signature:�� Date: � ��`�
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �
"'• '' P.O.Boz 848/210 Hospital Street � 'f- .z(— � S
Mocksville,NC 27028
(33G)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003731 Tax PIN/EH#: 5754-13-6347
Billed To: Clayton Homes Subdivision Info:
Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028
Proposed Facility Residence Property Size: 2.529 acres
�,T�,�y�ro b�r: 4204
**N �s 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������ #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 v � Type Water Supply y�� Design Wastewater Flow(GPD)� Site: NewJ� Repair❑
S stem S ecifications: Tank Size �� ��
y p ��GAL. Pump Tank GAL. Trench Width�� Rock Depth� Linear Ft��
As stat�d in 9.�vR C��AC 18A.1969(5)
Other: ��ccepted Systam� may�iso be used
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROV D EFFLUENT FILTER RISER(S) IF G"BELOW
FINISHED CRADE. ****NOTICE: Contact a representative f e avie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m. n e ay of installation. Telephone#is(33C)751-87G0.****
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Environmental Health Specialist's Signature: Date:---��
DCHD OS/99(Revised)
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�..ei'�'�� '�(� 'Y � .
• �F'�3 1'��• � �
. �rq / � ��
V �' tl' � TIUN FOR SITC CVALUATION/L51PIi0VCh1ENT PCRb11T&ATC
$ 244�j Davie County Health Department
SEP • Environmenta/Hea/t/�Section
P.O. Box 848/210 Hospital Street :
r�����`���� Mocksville, NC 27026 �.
�i;�'��;;���pU��� (336)751-8'160 '
*IFtPORTANT*** THIS APPLICATION CIlNNOT BE PROCESSED UNLESS ALL TIiE RLQUIRED
INFOI2bil�TION IS PROVID�D. Refer to the INFOR2SATION BULLETIN for inatruc�iona.
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1. Nama to bc Dilled Ci-J Contact Pcrnon n J�1i"�-
Mailing Addrasn l.� KC� � �U v� � lioma Phone �`i' �' �U� l
CiCy/stata/ZZP 1 vL Dusine�a Phono V � ��D�"��
2. Namn on Permit/ATC if DiffQrent tharl Abova � C� I ���
Mailing Addroas ��� N�oh�eaar� � ra�I City/StatQ/Zip ���C�JV� �IG � IvC-, a7oag
3. ApplicaCion For: ❑ Si.te �valuation ❑ Tmprovement Permit/ATC �B th
4. Syalem eo service: O Houae �Mobile Home ❑ IIusines3 ❑ Induutry ❑ Other
5. Typo u}•utom requeatad: MJ Convantional ❑ convantional modified � innovaLivo pacCepted
6. If Ra�idence: IF People 1 # Eiedrooms �_ I� I3athrooms �_
ldDin2iwanhor ❑Oarbago Dinpo�al 4dWashing 24achino ❑Danoment/P1iu�J�ing ❑Uanemont/tto Plun�ing
7. If Duainesa/Induutry /Othar: verify type # Peopla fF Sinka
# Commodoa R Showora tf Urinala 1! S•faCor Coolora
IF FOODSERVICE: �� Seatu Estimated j4ater Uaaga (gailons per day)
a. Typo oi• wator supply: ❑ County/City '�Well ❑ Community
s. no you anticipato adQition� or expansions of tl�c facility tliis systcm is iutcndcd to scrvc? C�1'cs [�Yo
If��cs,�ti•h1t typc?
***IAIPOItTf1N7't**CLILN'I'S I�tUST COhlPLETETlI� REQUlItED PROPCRTY 1N1�OIt111ATION REQULSTGU
[31;i3O�V. �tthcr 1 PI.nT or SITI's PLAN hIU.ST BESUI1dfITTED by tl�c clicnt wilh TIIIS APPLICATION.
I'roperty Dimcnsions: ' � ��/ 1VItITC DIRGCT10N5(1'rum 11�locicsvillc)tu I'1tOPLR'I'1':
•r:�a orr,�o i�iN: i� �� �'-� � �j ' � ��-�
Property Address: Road Namc d��� �� 1Ct,l
���y�Z�n,�o�l���I I� N a7�a g .
If in a Subditi�ision providc iuforniatia�,as follotivs:
Nainc: � / I � --��_ �--
Scction: Bloclt: Lot: Datc l�onic coriici•s 17aggcd: � o s
'I'l�is is to cci•lify tl�at tlic infoi•iiiation providcd is ca•rcct to tlic best of iu}�l.notivlcdgc. I undcrstaiid tliat any peririil(s)
issucd l�crcaftcr are subjcct to suspcnsion or rcvocation,if ttic sitc plans or intcndcd usc chaugc,or if lhc information
submicccd in �his applicacion is falsiGcd or changed. I,also,rrndcrstaird tlrrrll�tni resf�onsiGlc fa•n!1 clirubrL'S!/!C!I/'Ycrl frurrr
tlris applicntio�r. I,t�crcby,givc consciit to tlic Autt�oi•izcd Itcpresciitati��c of tlic Da��ic Couuty IIcallh llcpai•t�ucnt
to ciitcr upoii abovc dcsc�•ibcd property locatcd in Davic County and oiti�ucd by
to conduct all tcsting proccdures as ucccssary to dctcrmi»c tlic silc sui Uility.
DAT� �7/Lo�D`� SIGNAT'UItl: �
TIIIS AR�A 111AY B�US�D I'OR DRAtiYING YOUR SIT�PLAN(I udc all of ilic follo�viiig: Laisting aiid proposcd
property li►ics and dimeiisioi�s, uctures, set cics, and septic locations).
� ,� oT � � Sitc IZcvisit Cli�rgc
� a 8 . D:itc(s):
, � �
. ��a
� Clicut Nolircation Datc:
� Z� `f
� � �I-IS:
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Sign givcn Q� "• �lccouut No. � ��"
, ����Rcviscd llCII (OS/03 I�ivoicc No.
• • DAVIE COUNTY HEALTH DEPARTMENT
.
-� ', �• Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003731 Tax PIN/EH#: 5754-13-6347
Billed To: Clayton Homes Subdivision Info:
Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028
Proposed Facility: Residence Property Size: 2.529 acres Date Evaluated: ��'�fJ�`
Water Supply: On-Site Well �r Community Public
Evaluation By: Auger Boring Pit Cut^��
FAC'I'ORS 1 2 3 4 5 6 7
Landsca e sition ,L
Slope % �/ �
HORIZON I DEPTH „"<- . �-
Texture grou ' S' ,L
Consistence r i� ls/-
Structure — �
Mineralo ,'
HORIZON II DEPTH �' �'
Texture rou
Consistence � i
Structure rl! >
Mineralo l' •/
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTNE HORIZON
SAPROLITE r
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE -+
SITE CLASSIFICATION: EVALUATION BY: �/�//
LONG-TERM ACCEPTANCE RATE: f OTHER(S)PRESENT:
REMARKS:
LEGEND
i.�ndc�ca_pe 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
Textur�
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
ONSIST .N .
Moic
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
, r> >
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
1:1,2:1,Mixed
lY�
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 OS/OS(Revised)
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