391 Powell Rd.t
I
Account #: 990002243
DAVIE COUNTY HEALTH DEPARTMENT / o ' o
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Billed To: Dinna Johnson
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5718-69-8639
Subdivision Info:
Location/Address: Powell Road -27028
Property Size: see map
ATC N�rtib r: 3505
**NOTE** This �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 I/ #People_ #Bedrooms j! #Baths
Dishwashente Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: 173
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
Lot Size Type Water Supply Aell Design Wastewater Flow (GPD) 0 Site: New 0"' Repair
System Specifications: Tank Size IOWGAL. Pump Tank
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPI
FINISHED GRADE. ****NOTICE: Contact a represent e
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. tgll p n
%S !P;..
Ae
C�X19j/
%3
GAL. Trench Width 5�G Rock Depth 1Y Linear Ft.*, IO
0�RD EFFLUENT FILTER. RISER(S) IF 6 " BELOW
tht'15a'vie County Health Department for final inspection of this
the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: Date: 2A&
DCHD 05/99 (Revised)
Account #: 990002243
Billed To: Dinna Johnson
Reference Name:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #:
Subdivision Info:
Location/Address:
5718-69-8639
Powell Road -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3505
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This 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 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT - ONTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
CERTIFICAZa
O PLETION
**NOTE** The issuance of this Certificate of Completiothe system described on Improvement/Operation Permit
has been installed in compliance with hapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in N AYuarantee that the system will function satisfactorily for any
given period of time.
X e-72 ,1�.
A
Septic System Installed By: / Q. r' v�� �� �� l
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
Al
,1UN 2 6 2003
r�nI1R(1:.��1•i'IIisL H1J14ti �l
ON FOR SITE EVALUATION/IMPROVEMENT PER6IIT S ATC
Davie County Health Department
B=ironmentaif/eaith Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 '
***XKPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed
So rA
Mailing Address ..J a3 PAY, A
City/State/ZIP IOf'�C�-Il N,4
2. Name on Permit/ATC if Different than
Mailing Address
3. Application For: 11 Site Evaluation
k H
4. System to Service: ou8e ❑ Mobile Home
5. Type system requested�onventional
6. If Residence: # People2,-
Contact Person Q�� _
Home Phone 3 36 — Aq ? 5_1Business Phone 3 3�' — /10 —0 Za '74
City/State/Zip
❑ Improvement Permit/ATC oLli
❑ Business ❑ Industry ❑ Other
❑ conventional modified
It Bedrooms 7,—
innovative innovative 77
It Bathrooms A 2
'UDishwasher ❑Garbage Disposal t ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type It People 11 Sinks _
# Commodes It Showers # Urinals It Water Coolers
IF FOODSERVICE: # Seats Estimated
Water Usage (gallons per day)
8. Type of water supply: ❑ County/City ka Well ❑ Community
9. Do you anticipate additions or expansiolrs of the facility this systeinl is• intended to serve? k1<1cs ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COAIPLETETHE REQUIRED PROPLRTY IMORMATION REQULSTEI)
BELOW. Either a PLAT or SITE PLAN AIUST BESUI3MITTED by the client with '1'l1IS APPLICATION.
Properly Dimensions: -,QA-e-
�--�-'q / Q
I'ax Office PIN: 4 S7�ap - / �(� � /
Property Address: Road Name U 0�✓�l '
City/Zip .2- 70 14'
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (1'rom Mocksville) to PROPER Y:
clevLrteol- ye)
2oa�ff
APA
Date !Ionic corners flagged: _&
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernrit(s)
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 uni responsible for all charges incurred frons
this application. I, hereby, give consent to the Authorized Representative of the Da��Ic County IIcalth /cpartmcul
to enter- upon above described property located in Davie County and owned by
to conduct all te`stin procedures as necessary to determine the site suit ilily.—r
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all ethe following: Existing and proposed
property lines and dimensions, structures, -setbacks, and septic locations).
Site Revisit charge
S
Sign given -1 3 - o
'_J 3
^vised DCH (05/03
Datc(s):
Client Notification Date:
EIIS:
Account No.
Invoice No. 3
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APPLICANT INFORMATION
Account #: 990002243
Billed To: Dinna Johnson
Reference Name:
Proposed Facility: Residence
Water Supply:
Evaluation By
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5718-69-8639
Subdivision Info:
Location/Address: Powell Road -27028 -
Property Size: see map Date Evaluated:
On -Site Well
Auger Boring
Community Public
Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH "
Texture group
Consistence r
Structure /
Mineralogyi r—
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 113
SITE CLASSIFICATION: l
LONG-TERM ACCEPTANCE RATE: ' y
REMARKS:
EVALUATION BY: ) tl/
OTHER(S) PRESENT:
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
Mineralogy
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 - gal/day/ft2
DCHD 05/99 (Revised)
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