212 Sowers Ln pd ��� ��
� DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
, • P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003305 Tax PIN/EH#: 5789-19-8021
Billed To: Joe Everett Subdivision Info:
Reference Name: Location/Address: Sowers Lane-27006
Proposed Facility Residence Property Size: 2+acres
ATC Number: 3831
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 CONSTRUCTION S VALID FOR A PERIOD OF FIVE YEARS.
;
Environmental Health Specialist's Signature: Date: �,���f
CERTIFICATE OF COMPLETION
**NOTE** 'The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article ha ter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in e taken as a guarantee t system will function satisfactorily for any
given period of time.
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Septic System Installed By:, � (/ � /�
Environmental Health Specialist's Signature: Date: !�"�U L�Y
DCHD OS/99(Revised)
, DAVIE COUNTY HEALTH DEPARTMENT �� �-I a „ d ��/
. Environmental Health Section
'. P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
• ' (336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003305 Tax PIN/EH#: 5789-19-8021
Billed To: Joe Everett Subdivision Info:
Reference Name: Location/Address: Sowers Lane-27006
Proposed Facility Residence Property Size: 2+acres
ATC Number: 3831
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � �L #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� Type Water Supply�� Design Wastewater Flow(GPD) �J�rJ Site: Ne� Repair❑
System Specifications: Tank Siz��GAL. Pump Tank GAL. Trench Width� Rock Depth���Linear Ft.3D�
Other:
Required Site Modifications/Conditions:
I1�IPROVEI�IENT/OPERATION PERMtT LAYOUT- APPROVED EFFLUENT FILTER: RISER(S)IF G`�BELOW
FINISHED GRADE. ****NOTICE: Con *�a++��±+.+ e Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or�p � n the of installation. Telephone#is(33G)751-8760.****
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Environmental Health Specialist's Signature: � �`• Date:
DCHD OS/99(Revised)
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O , ` 2 6 ,�D�p� A TION FDav'e County Health'ADepartme�PERMIT&ATC
�v Environmenta/Hea/th Section
P���pl.t� P.O. Box 848/210 Hospital Street
v\RONMESCp����S1 Mocksville, NC 27028
E� pP� (336)751-8760
IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
� 1. Name to be Billed J�_� /L� . �V ���"� .� (� Contact Person �jl�, �(r�rC�T]
—rTr— -T—
Mailing AddreBs '� � ��' ^.('�r�r��-�T� �� Home Phone ���—��.J�
City/State/ZIP ���]C1CS✓/��� �.�_��/ U�-�Susineas Phone
�
2. Name on Permit/ATC if Diffarent than Above
Mailing Addresa City/State/Zip
3. Application For�Site Evaluation ❑ Improvement Permit/ATC � Both
4. syatem to services l� House ❑ Mobile Home ❑ Businass ❑ Industry ❑ Other
5. Type syatem requeated: � Conventional ❑ conventional modified ❑ innovative
6. if Residence: # Paople �--- # Bedrooms --3 # Bathrooms 2—
❑Diahwasher ❑(iarbage Disposal �Washing Machine ❑Hasement/Plumbing ❑Basement/No Plwabing
7. If Buainesa/Induatry /Othar: verify type # People # Sinks
# Commodea _� # Showers �i # Urinals # Water Coolers
IF FOODSERVICE: _ # Seats Estiittated Watex' Usage (gallons per day)
s. Type of water aupplya �County/City O Well � Community
9. Do you anticipate additiona or expansions of the facility this system is intended to serve? Ga'�Yes ❑No
) r ! _ /� / l
If yes,�vhat type? bU'�1Y�S�l� [�y,? ►,^7" V� ��r T� (S/les�.�a-r_ . S r n � �F G O��r'�/Q c�C�,l
***IMPORTANT�**CLIENTS�1UST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST ItE SUBMlTTED by the clicnt with THIS APPLICATION.
Property Dimensions: �",7pYt�X t r�'tCr�tJta �llLVc� WRITE DIRECTIONS(from Moc sville)to PROPERTY:
t (,4 ,�,�S,��p �L/ �..�.�G]rOt'S
Tax Office PIN: # ,� 7�I� j� t�0.Z� �'
Property Address: Road Name cSOW�P�'a I.-c. �� Y 1'� "/ i'G.0�S F.�,�iD rd7� ��j�
City/Zip .�- 7 d C� �/ scr�.,c.'-ev' � �C.,v1� r"R�'h-1 7 'r cC w��
If in a Subdivision provide information,as follows: ` �r� � '�• �i V�I
Name: ci 1' i d't c"��t �"T G (r$�r� l 1 Llus'i=
Section: Block: Lot: Date l�ome corners tlagged: / ��- � -" a �
This is to eertify 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 intended use change,or if the information
submitted in this application is falsiGed or changed. I,a[so,iu:derstand tl:at I am responsible for all cliarges incurred from
Ntis application. I,hereby,give consent to the Authorized Representative of the Davie County Health Depa• ment �
to enter upon above described property located in Davie County and owned by�� r ,p=. �
to conduct all testing procedures as necessary to determine the site suitability.
DATE �" �- lv ` U / 5IGNATURE ,
THIS AREA MAY BE USED FOR DRA,WING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
__- ..� Date(s):
Client Notification Date:
� ��'
��n' � EH5:
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Sign given � �' ""� Account No. � � � S
Revised DC D(OS/03 Invoice Na / �`
� � Dav�ie County,North Carolina Spatial Data Explorer Page 1 of 2
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• Land Unit/Type:G800000054 :/AC � Creeks and River
• Deed BooWPage:00315!0073 E911 Addresses
• County ID:G800000054
� Deed Date:1999/09/27 � Fire Departments
• Account Number.75524000 • Sales Price:$0.00 � Schools
� PlN:5789198021 • PropertyAddress: DCBW L8y@C;
• Legal 1:28.118 AC HWY 801 000212 000212 LN --- -
• Owner Name:WADE GAYE SOWERS • County Zoning:R-A
• OwnedAddress 1:WADE GAYE SOWERS • Census Code: MAP CUI'I'eIl
• Owner/Address 2:WADE SHELBA HENRY JR • City Code:
• Owner/Address 3:PO BOX 133 • Fire District: This map is prepared fo
inventory of real properl
• City,State Zip:ADVANCE,NC 27006-0000 • Flood Zone:ZONE X within this jurisdiction,a
compiled from recorded
• Land Value:$140,150.00 • Flood Community.�370308 plats,and other public r
• Buildrng Value:$122,460.00 � Flood Panel:0100 C and data.Users of this i
hereby notified that the
� Out Building/Extra Features Value:$0.00 • Flood Map Date:12-17-1993 aforementioned public F
• Assessed Value:$262,610.00 • Soil:PaD information sources shc
http://66.208.132.254/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=Clk&Left=15783... 7/19/2004
� � � DAVIE COUNT'Y AEALTH DEPARTMENT
-� Environmental Health Section
� , , . Soil/Site Evaluadon
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003305 Tax PIN/EH#: 5789-19-8021
Billed To: Joe Everett Subdivision Info:
Reference Name: : Location/Address: Sowers Lane-27006J
Proposed Facility: Residence Property Size: 2+acres Date Evaluated: 71J0%�
Water Supply: On-Site Well Community Public �
Evaluation By: Auger Boring �/ Pit Cut
FACTORS 1 2 3 4 S 6 7
Landsca e osition L
Slo % �
HORIZON I DEPTH �� c/
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH r�� �
Texture rou
Consistence .'l
Structure
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY: C✓�
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-Tenace 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-Tliickness 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 OSl99(Revised)
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