521 Pudding Ridge Rdi
A" t
Account #: 990003409
Billed To: Mark Dellinger
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 #: 5841-08-6904
Subdivision Info:
Location/Address: Pudding Ridge Road -27028
Proposed Facility Residence Property Size: 1.218 acres
ATC Number: 3926
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 1 of 13.S.h pter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY 7k ke as a tu antee that the system will function satisfactorily for any
given period of time. AWWI-Aldl k,
Septic System Installed By:
Environmental Health Specialist's Signature: Z-24 .& Date:
DCHD 05/99 (Revised)
a 6 1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003409 Tax PIN/EH #: 5841-08-6904
Billed To: Mark Dellinger Subdivision Info:
Reference Name: Location/Address: Pudding Ridge Road -27028
Proposed Facility Residence Property Size: 1.218 acres
ATC Number: 3926
**NOTE** This Improvement/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 1 l 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 —1012
Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: 13 Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) G Site: New Repairp
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAY
FINISHED GRADE. ****NOTICE: Contact a r
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m.
Px.�Pr Oles�c'�
GAL. Trench Widt � Rock Depth � Linear Ft.
ROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
of the Davie County Health Department for final inspection of this
on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: Date: `� ��k
DCHD 05/99 (Revised)
**V 12, 2004 11-42 000-000-00000 Page 2
. Nnv In n4 nl:tnp clwie nminty envhealth Jib Ybl 8Ytl6 p.1
' 4YYL1(it IIUN FOH n111 I:Vgwnnt)N/IMPRUVFMF.NT PERMIT q qTG
Davis CrttHly Health Department
Environmental Health Sed)pn
D.O. twnz 049/210 Nompitsl &tratiL
Mockaville, NC 27028
(336)751-8760
•••IMPOR7A(rr••• TNLy API LIGATION CANNU't BF. PAOCIVSJSD 7JNLcgS ALL ?N$ ItSOULRYD
Itr10RNA2•tuN r8 PAO/VJI'DJS�O_�i Refer to the` INVOR-MATION RVLLLTIN for �i/7n'/ssttrµu—.ctti—yon,(.
1L/tl one so be Dillod �• `�S II J7) ..L. Cant.. % Y.roon .r•• rr-A-
Ly/ yP _...... _
Addr./.
-^" CItY/atau/zlv //'y'j /i A rwry( .i/r
a. -•T." M•m. on /+ttnU./aTe It Dltt.r•ut then Al-_
/MalltnD Addroa. �itY/acate(Lip __ J _
✓ 1. ApplICAtion sot: q Site .;:valuation Q as
ImProvmont Petrotlt/ATC Id -loth
-4.• yynrem ro 3•.vlcar q Houde 0 Nabil.. Ilome ❑ eusincen O Industry E3 other_
._-6.
Tp. •Y.t" rvaw•r.n. ❑ Cuor.ucar.o.l ❑ rtewv.ntl au.l M.dtr(.d ❑ l.nev.Li—
�i If R.nidencc: a 1'euple / . Bedroome o Bathrooms
✓ C901ehvaahar I..k rbs2e Mop, aa) a.htne Machine ❑a•erwen[/Plua.rl nq ❑1a.•m•nt/Me PiurNdng
7.
It .v.!.n..■/lwdustry /etherveetty typ• s PoeP3. a .tnka —
r w,w•e.e . rI—— _ t Urin•1w a ".tor Cealor. —_
IF 1100DSERV208: 0 Seats ►..otinated Nater Usage, (9.11nne p.e d.!)
D, Typo of ..ter supply: � county/City ❑ NeIl ❑ Cna.nnni ry
Do Yew muclpAr.. +Jalr.Jnew nr expausinn. of Iho f9cilily (hi. !yacht it Inlcadcd to cel vel ❑Vey kMU
"•lMP YxRT"" (1 Hlkj • 411157COMPLETETHV. )PEO 4NED Ylltlpr.N l Y INWRMATIUR REVCLSTEn I
llLLUW a;rthcemPLAI•r51'1''.PI.,%NHIMMI:StIMAIII ;D by flitelltal with TMSAI'YLICATION.
!_�•^'1'rnpe Yly Dlmeusimts: r �-^'NAITF MKU rIONS(from Motksvllwc) in►hp►I; Itry:
.'ax Ufrcr PlNt a._5Y1_1 io 8 4,gb4
�Prnperly .Lddrerr• (load Name 5-2LZ f� r _ _ ,e -rAtC /I f T -T 41
/! �..... 1 1� h5 �t'l
1f In o $abdivision prn.idc Informatirin, as tallows:
Name. -�yy-- /� r w -
VJ
5ocllhn: Mark: Lal: . _—,.— Dale home earners Rapgcd; L�t'�" ^� C U AVE 'J�
Thle it 1s certify that the lluormalmi p. uvided a torrect to the belt of n y knunicdge. F under+land that any pertnh(t) ;"jai 1� WAU
islued hcl talUr are, suhjeet to xuxptnO, n or revocation. 1( (lie site plans ne hlituded use change, or If Clio infot oration v �.t�+
tubmlued in ibis spp{icatien h latsiiied a chaaQttit i, atsa. undercrand drat t am mvponsible fur all chargry incurred from il-
flri.t oppliration. 1, he.rrlry, give consent .o the Atdharired Rtpreycn(stivr of dlic Uavle County llcsllh Department
to enter upon above described pngtcrly Inewtcil to Davie County end mune by
In en»Jua Al Ic i9tn/gf pre�d{orc+ As nrv, aury rn detcr,niue the site euftab tv. -i
'I'll IS AREA AIAY Cal. INED FUR DRo.WING YOUR SITE PLAN (Include all n wing: Etisting and proposed
property lines and tlinMnsions. sdrucwm.- . setbacks. mud .optic lacations). _
Site Revisit ('11a1$e
----
Client NotirrcwtinM prate:
Slkn ytven••,.N Acrupnl No.
Re, iwi p('1it) (05103 InvolteNh.
NOV 10,2004 1',:31 3,16 751 6785 r'ngc• 1
11,1'33. *-
an owr
LIDO ACRES TOTAL
J. W. JONES. SR. 'P
142-224 ti e�y�
V
KtuuCfu I rACTr0
HOWARD? BODER
76-601
I abed 00000-000-000 96:11 b00Z'ZI AON
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APPLICANT INFORMATION
Account #: 990003409
Billed To: Mark Dellinger
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5841-08-6904
Subdivision Info:
Location/Address: Pudding Ridge Road -27028
Property Size: 1.218 acres Date Evaluated: /�"/7 ,6 Z
Community
Evaluation By: Auger Boring Pit
Public �/
Cut /
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
f; C�
Texture group
4-
cc/.
Consistence
Structure
Mineralogy
HORIZON II DEPTH
>
Texture group
Consistence
l
Structure
Mineralogy
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
SITE CLASSIFICATION: dJ 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
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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