132 Greene Court Lot 6r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:
990001072
Tax PIN/EH #:
5841-05-1846
Billed To:
Donald Thompson
Subdivision Info:
Pudding Ridge Lot # 6
Reference Name:
Donald Thompson
Location/Address:
Green Court -27028f 3Z
Proposed Facility:
Residence
Property Size:
1.3 Acres
ATC Number: 2374
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 NS IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature ;7�Date: OD
f &-R-m 14 `I SC&I2,00h us
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 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
%4005j-
Septic System Installed By:
Environmental Health Specialist's
DCHD 05/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001072 Tax PIN/EH #: 5841-05-1846
Billed To: Donald Thompson Subdivision Info: Pudding Ridge Lot # 6
Reference Name: Donald Thompson Location/Address: Green Court -27028
Proposed Facility: Residence Property Size: 1.3 Acres
**NOTES* Thi bfmprovement/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� C) v#People #Bedrooms #Baths
Dishwasher: Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine: Basement w/Plumbing: 2"'-Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size I. FK�-�%� Type Water Supply CA�7Y Design Wastewater Flow (GPD) 1-16Q) Site: New Repair ❑
System Specifications: Tank SizeI� h GAL. Pump Tank GAL. Trench WidtL Rock Depth I Z-.'-' Linear Ft. 55-0'
Other: 3 "Do-C)P [So vas� n1 STgt� C -1 4--�s J O C•
Required Site Modifications/Conditions: 1 rJ STb'u' c)1 ci>� , -t-i� ) �� Of'F: 000szr vZg to C -X eGf, "Fcr's
IMPROVEMENT/OPERATION PERMIT LAYOUT - A'PPRC
FINISHED GRADE. ****NOTICE: Contact a esentative of
system between 8:30 a.m. to 9:30%m . or 1• p.m. to 1:30 .m on
A)
Iod'fo Fns- to 0
T
Enviromnen`1 Health
DCHD 05/99 (Revised)
;cialist's Signature:
►\ED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
th Davie County Health Department for final inspection of this
the day of installation. Telephone # is (336)751-8760.****
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Mar -15-00 03:12P Larew-Wood-Johnson 336 940 2098 f'•Ue
APPUCATM FGn SITE EVAMTION/itrlMMIENT PE nMfi & ATC D0
Davis County Hoal:h Department
Entrltatter. 7W/fe ribSect►art
P.O. sox 049/210 aonpital street WR 2 9
2000
Mackaeille, ttw 27030
(3313) 751-0760
•pezt o�rnert+�• sere AMICR210a ti9.'7= = Pzw=o= terse ram MW =QMUM LIM, MENTAL
HEALTH
to t�o/�IMr-M=(M 1; 11-171H for iaotrna ns. DE AE COUNTY
n"ZOMMICM re PROM D. t;o/�ler �tti
1. xsaa to be aLIU4 0 Zvi `A LQ Rf. /2UMP S ra®tact Qerem
A'al1Lnq Address 4.77 GoizeA) RnX Cr game phaas 709_193-,427
city/state/ase SNEi2Riltc FORb NCM67.3 meinaseLbaas 704 -R7/ -alto
2. :eggs on V""t/ASn U Disse a, seas Abe.+ S A m
t@slsinZ Address citr/atate/aio
Pr-aliaatioa 1'"t 0 Oita Walnxtion D 1Laproa=.zut: Perait/Mc 0 nodi
s. crat®a to servioel $(Cause 0 Vabile He= ❑ 2ucinaaa ❑ Industry ❑ other
is. It pasidancot tl Iteage �� a saftooms s Bathrooms
`Dishwasher O Qasbaes Disposal )(Wasting ltrzhino �rWs�t/82e p O MwwntAlo pluibinq
i. :e ^uataees/radustry/Otl+es, genLRT type R nsflpls # eLnke
$ ccsaadaa # chore= i Urinals Rater coolers
I? k"t1tE1fiMMCO: 0 seats gati-mat ed.'Matz-, Usago (ga22oae per and
7. .)MM Of Wags# supply: Csooty/city 11,7011 0 Camaanity
m. t10 yoII aatitipmto addittoas sspaasWa# of the taclllty tba syotenr !� latsac,ed to eervxY 0 Yes )(No
tf yes, what typos
aeelhfPORTANT**6 CIdRNT UEZTCOAIPLMEIIIE REQIlIIi V PrtOPEM WFORMAT10N UQUEffM
Ua06LOW. Ettiar
PWT er BIrM PLAN Al17191'3963I/AAIIITM b tae cltr.:t ve!b THIS APPLICATION.
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arty Dia:tasioae SX �4/x /6ax/6 S,r�YS CVIRI[ 6t Pfa�;jLCftQ S3 (them blxki9:fo/i�s PfA'JPSitTY:
TSx OM= PIN: S�`�is 5 /8 �/(. '40 _eAS :LrM-ilY\6to Y) �X fi
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F,,sty Addrewt Road Nems L.D%a 6 G2c�1 or
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Cltywo FmM1dam-J :27D.ig ,! f i\40 Q VhA A, CO V1f jk-
If In a Subdivhion provide lulbrmadoD, as 15011W.": � �G r �c c � (_ � Lo 1 lv
1t��te: PurD/D�aG 21�sE
ctirra C f 7 / \ Eloskt _ t•aa 6 Dztm Propzrty 1d1:-Msalt 3
xhln U to ccrlify that the hatlormatioa pravtdcd D corrcct to the bt.t crW l-s:=dcds a. I andetctead that any permit(#)
rsu-1 bsreafter are subject to tmspensloa or revocation, !ft:!* site plana or Intended =0 e0amgN or If tete Ioromation
eabmitted to thl: sppilcatioe to bbitled or e6cnged. 1, a!w, tanderttrnd rAct I e„ t ru orsltle jar ell ckarges (ncumrdffnat
abl- appllcadom I, hereby, give eonseet to tho Aatt:,;.lrcd Rcpreceetatfve of Me Ravla County H=Ilh Dcp3rtmeat
to es(:r cpn above dendbed property Ioested In Davle Ccat ly mad =n:d by C 7-^" : A-Ab4/'S d)
to co-adcat all traling procedures as necessary to dclermina 69 c:t cm3 r a b8 n� 0 WYti r, k3 S z 1 p i yam, V �L'! Ch
DATE 3 / a /r/t%o SIGNATIM tMA:
MM A=, A MAY BE USED FOR BRAWING YOUR Sr15E : LAN (Include all of the foilootag: Existing and proposed
limperty Race and dimensions, structures, setback-, mad rxptl: lotlora).
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Blta Revisit Charge
Date -3):
Cilcnt Notiticatton Dates
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Account No.
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NAME �cC'C '6
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well 4____ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position .L.
Sloe
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
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: EVALUATED BY://
LONG-TERM ACCEPTANCE RA
REMARKS: �/�
DCHD(01-901
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 :lay 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