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373 Allen Rd . , '' -• � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATiO1�T PERMTT t�cct�unt #: 990005503 ` T�x P��€i�H#: G30000008203 Billc��'o: Carolina Mobile Home Senrice ,, . �uk7�i�i:.,iari iri#a .. R��eE��r�ce {�afne: Gerald Trivitte . , LocaiioniAdi����ss: Allen Road-27028 , f'ropc�s�;i9 F;�ciEity: Residence l�ra��rty Siz�:: 1.89 Ac . . a�TC N��ibgr: 6004 . ., . .. **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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 auy given period of time. " /1� ���y � ` System Type.;_ � (�V1�� .T.Manufacturer�'�..� Tank Date�� Tank Size�(� � Pump Tank Size / Bedrooms:�_ System Installed By���_� c '7(,_Installer# Date: � �J� GPS Coordinate: ` � , . � ; � C � � _ � \ ti �� 1 �� � � S � � .� � \En ._ ` 6 rL� S� � �1 Environtnental Health Specialist � Date: �. 1 2�� . i . DCHD 11/06(Revised) . . . � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMTT Account #: 990005503 TaxPIN/EH#: G30000008203 Billed To: Carolina Mobile Home Service Subdivision Info: Address: 113 �ostall Drive Location/Address: Allen Road-27028 City: Mocksville Property Size: 1.89 Ac Reference Name: Gerald Trivitte Proposed Facilit�: Residence ` ~ **NOTE* This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: CdNew ❑Repair OExpansion Permit Valid for: [�5 Years ❑No Expiration , Residential SpeciCcations: #Bedrooms�#Bathrooms�#People � Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type � #People #Seats Square Footage(or Dimensions of Facility) , Design Flow(GPD):�v Type of Water Supply: ❑County/City �.Well ❑Community Well • Site Modifications/Permit Conditions: S stem T e LTAR Initial o Re air ^�=z �, ` Site Plan . �3,a`��� `�,*,�,., � �—�o r�"' ' ��. �a� ') . ��� � A� �� - �a�� 5,:� ��� �,,� �� � - � � � `f� �5'� ��' w� � � � I Environmental Health Specialist �.i..�,L . � Date l�2 � i.p.11-06 / DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 ' (336)753-6780/Fax#(336)753-1680 - - AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accr�u�t #: 990005503 � �"�x F�l�€.�EN#: G30000008203 �iflc,�€Tc.�: Carolina Mobile Home Service ... � S��E��i�i:.,ior� 1r���� . ; : � . . Refer�E�c� {��r��e:: Gerald Trivitte : :; : � '. t�acationrA��r��s:� Allen Road-27028 . : �'ropc�s�;c9 F���,ility: Residence . ., . �: �fa��rly�S�ix.�:: 1.89 Ac , . a�TC Nurnbe3': 6004 ' , . � _ . Site Type: �iew ❑Repair ❑Expansion **NOTE** This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior tp issuance of any building permit(s),(in compliance with Article 11 of G:S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specitications: #Bedrooms .3 #Bathrooms�_#People 3 Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size 1.��'taC � Type of Water Supply: ❑County/City �Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��(� Tank Size IccaO GAL.Pump Tank / GAL. Trench Width 36" Max.Trench Depth '��r• Rock Depth�� Linear Ft.�/c Zt�uG�7�ti � Site M difications/Conditions/Other: Contact the Davie County Environmeatal Health Section for final inspection of this system between 8:30=9:30a.m.on the da of installation. Tele hone# 336 751-8760. � � � f � � �r � La � � 1 . ' �-�`' C �� � � ��� � r F :� ��� ��- `�� ��'� � ��o� w�`�Q� � , - Environmental Health Specialist � �, Date: � , f _ DCHD 11/06(Revised) . - ' . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33�753-6780/Fax(336)753-1680 Application For: ❑Site Evaluation/Improvement Permit ❑Authori7ation To Construct(ATC7 Both Type of Application:�New System ❑Repair to Existing System ❑Expansion/Modification of Existing stem or Facility •'�'IMPORTAN�'"t THIS AF'PLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Rcfcr to thc INFORMAT[ON BULLETIN for inswctions. APPLICANT INFORMATION NametobeBilled �!'01fNa iytab�l` v/�v�'c�r�icC ContactPersonsl��rw�y�C� Billing Addcess - u Home Phone � City/State/ZIP S..I ,� .L 2 O Z Business Phone"7$2• /L 1 Name on PermitlATC if Different than Above co, r'�J' e. Mailing Address i City/StatelZip ,, PROPERTY INFORMATION *Date House✓�acili Corncrs F!a cd" ••��-2:`,..��^ NOTE: A sarvey plat or site plan musf accompany this application. Included:�f Site Plan ❑Plat(to scaYe) (Pemut y'�valid for 60 months with site plan,no eacpiratioo with complete plat) Owner'sName�.to„le,� T,e.u�c, PhoneNumber Owner's Address City/State/Zip/�'1�'srlC,. ��- ,/� Property Address�� /�1,�... Ru� Ciry(�o G�GS�•ll� N L LotSize �.�_�j TaxPIN#57243�iC�SS9 �3�ba���z�3 Subdivision Name(if applicable) Section/Lot# �D'rections T Site: (�D� rt er�0-y ����, R✓1 �Q�r��,Y 7H.�k...: /u u,..� �.�N� �ss Ari�— ►�► If the answer to any of the following questions is"yes",supporting documentatio must be attached. � �� � Are there any existing wastewater systems on the site? CYes� , Does the Site Cpntain juri�diFtipnat w�uands? o�Y o Are there any easementsbr right-of-ways on the site? F�Yes ONo Is the site subject to approval by another public agency? ❑Yes CT�Io Will wastewater other than domestic sewage be generated? ❑Yes� IF RESIDENCE FjLL OUT THE BOX BELOW #People '3 #Bedrooms '3_ #Bathrooms�_ Garden Tub/Whirlpool�'Yes ❑No Basement:❑Yes o Basement Plumbing: ❑Yes�No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Bui(ding #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per dayj (Attach documentation of simi[az facility water consumptionJ FOODSERVICE ONLY: #Seats Type systemrequested: �IConventional �Accepted '�Innovative �Altemative�Other .� Water Supply Type:�County/City Water f�New Well ❑Existing Well ❑Communiry Well Do you anticipate additions or expansions of the facility this system is intendcd to scrve?0 Yes C�No If yes,what type7 This is to cectify that the information provided on this applicatiou is true and correct to the best of my knowledge. I uuderstand that any permit(s)or ATC(s)issued hereaftet are subject to suspension or revocation if the site is altered,the intended use c6anges,or if the information submitted in this applicauon is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Departrnent to conduct necessary inspectioos to determine compliance with applicable ]aws and rutes. I understand that I am responsible for the proper identiScation and[abeling of property Iiaes and corners and l�ng an ' g o�staldng the house/facility location,proposed well location and the locadon of any other arnenities. ,.KI�� Property owner's or owner's legal representative signature Site Revisit Chazge Date(s): `�'j(i'�� C(icnt Notification Date: Date EHS: Sign given ❑Yes ONo Account# �/�`�� Revised 11/06 Invoice# _{�� ���f1�7� ,QAj� ����' C�P�-g1��� �� � Q,,,�1 5�t293��SSS � . � :�,a � , ��� � � - �. • � � �� I /-OLD CAft AXt£ FOUh1D NEAF2 • �' � � ,!, THE NtIRE FENCE CORNER POST REMAlNING PROPERTY 0� NO'j3�36'S/5��E � � � y • . _ BI�LY W• i 1V1 1' �lo•O��\t�td�} �e\,Q /� . � " . ITTE � � �Q°3�'�� �tE � :---��AIL 5�T'A� 'fHE BASE OF A AND WIFE NEYJ )RON PIPE SET 2 0 ' ' "- .-_x Z'� '.72 -�. 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All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. � , .; , � . . DAVIE COUNTY HEALTH DEPARTMENT , .' '• ''' ' Environmental Health Section �� C��/ ' " ' . ' P.O.Boz 848/210 Hospital Street / /._, /�` �� Mocksville,NC 27028 6 � (33G)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002769 Tax PIN/EH#: 5729-38-4183 Billed To: Gerald Trivette Subdivision Info: Reference Name: Location/Address: Allen Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3472 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 / �� Type Water Supply� Design Wastewater Flow(GPD)�<� Site: New�Repair❑ �, .. System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft�t�a Other: Required Site Modifications/Conditions: Ih'IPROVEI�1ENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 "BELOW FIN1SIiED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C►)751-87C,0.**** U � Environmental Health Specialist's Signature: Date: �� � ��� DCHD OS/99(Revised) � � � , • �y ,/ . . . � . • � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990002769 Tax PIN/EH#: 5729-38-4183 Billed To: Gerald Trivette Subdivision Info: Reference Name: Location/Address: Allen Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3472 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). T'his 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 CONSTRU TION 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 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) , , . ry .F� .S s . .� � � � � � LICATION FOR SITE EVALUATION/IMPRUVEMENT PERMIT&ATC Davie County Health Department D 3 20d3 Environmenta/Hea/th Section •1 ��p� 2 P.O. Box 848/210 Hospital Street � Mocksville, NC 27028 n NS�� (336)751-8760 rJ�ROP�,n� 11N� ***I AN'1'*** THIS APPLICATION CANNOT BE PROQESSED UNLESS ALL THE REQUIRED FORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Silled (�� � 1 (�` �, Contact Person ��q�� ��,�/(�Q Mailing Address'7�( /`t�/Pn ��� Home Phone 1.��� L�`7 O�`7T7� � City/State/ZIP �(�^��/'{IC()�r�, �!Q r�Q Business Phone W3�/ ��7����(.J 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip ���� � , 3. Application For: Site Evaluation� Improvement Permit/ATC oth 4. syate/m� to service: House ' �Mobile Hom Business Industry Other � 1 1—� 0 1 g� S�G/'^ 1. C.�h tl[/1�.an•uQ. 5. If Residence: # People � # Bedrooms �� # Bathrooms � Dishwasher' Garbaga Disposal Washing Machine Basement/Plumbing Basement/No Plumbing 6. If Susiness/Industry/Other: Specify type # People # Sinks # Commodes # Showera # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City Well Community a. Do you anticipatc additions or expansions of tl�c facility tl�is system is intended to scrvc? Ycs l�io If yes,what type? ***IMPORTANT'`**CLIENTS MUST COMPLETE TfIE REQUIRED PROPERTY INFORMATION REQU�STED BEL011�. Either a PLAT or SITE PLAN MUST BE SU6MITTLD Uy the client with T11IS APPLICATION. P• erty Dimensions: ��-'�'�-'n�—'�'�j`j� WI2ITE llIR�CTIONS(from Mocksvillc�to PROPGRT�': axOfficePlN: # S�� / �� ��p � �-w� l D/�!ur'n bes� e �l'ld'1'S�� � � � . � � �!`uc�i�YtC La�t�� s /t0l`dK, � I� ���� Property Address: Road Name t?v� Lf l+'lr � UY� c�tyiz�p 'I�� a hU r se na S�c,r� � If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date home corners flagged: -�-- �� This is to certify ttiat the information provided is correct to the best of my knowledge. I undcrstand tl�at any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the iuformation submitted in this application is falsified or changed. I,also, trnderstai:d t/iat I am respo�:siGle for all c%Rrges i�icur•red fi�ovi t/iis applicatio�r. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessa�y to deterinine the site suitability. DATE S- o�-'J` O � SIGNATURE 9����. /��(i���tJITG THIS AREA MAY BE USED FOR DRAWING YOUR SITL PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 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' � i . ,; '� . , , : . // / /o����� �/Oi%�� � /;, � > ';,- iv ,;�///���jj/�/ %/�/ :,, !�„ , ' //�///r/% �G%i ///po �;_ .. , . , ,,,,.,,,,,,,, _ 'a j%///////�/%///������� . ;„ . �� - ;; - ��� , i ////iiii��ii/i��ir//i y��/%///%r �%/ ,. '��. '� „ ',' /// , ' �' . . '�' �;, �' _ yi,��/ . � � i/�/%/ r Oio�///%/�iG�%/�� ; . . � ' . . : _: .,,-,_.. '� �'. ' i_oij , ' oi% �� s� �' _ .. . �,. ._.�. /a�i/%�//Diaaaiii�yy„�����,�, ,� � �,,�__ ��.�-.�,� � ��;, ,,,,�:� £ . � . � i � ' ` .� • ' ' '� � DAVIE COUNTY HEALTH DEPARTMENT - ' � � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002769 Tax PIN/EH#: 5729-38-4183 Billed To: Gerald Trivette Subdivision Info: Reference Name: Location/Address: Allen Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: ��� Water Supply: On-Site Well Community Public /� Evaluation By: Auger Boring Pit Cut 1�IJ /2//3//Z FACTORS 1 2 3 4 5 6 7 Landsca e osition L Slo e% 3� HORIZON I DEPTH >� �/ Texture rou �L .S� G C Consistence '� Structure �y Mineralo /,j HORIZON II DEPTH ' ' Texture rou Consistence r 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 y� SITE CLASSIFICATION: EVALUATION BY: 4`' 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 Mineralo�v 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 OS/99(Revised) ■������■�����■�■�������■��■�����\�■■������■����������������������■ ■�������������■�����������■������■��/�������������\�������������\■ ■�������������������������������������������������������/�������■ ■�������������■���\�����■������■ ■■��������■���■■���\���������■�■ ■����������������■����������������■������■���■■■������■�������■■�■ ■����������\�■�����■�■�■��■■���■���■�■��■�������■�������\��������■ ■������■������������������/������■■�������������■�����■����������■ ■�������������������������■��������������■��������������■���\����■ ■����■���■��■������■�■�■��■■■����■�■�■■���■����■�■��■�■■���������■ ■���������■�����■��■����■���■��■��■��■��������������■������■�����■ ■�������\�■���������������■����■ ■��������/���������������������■ ■�����������������■��������■��������������\■�����\■���■������■��■ ■��■�■■■�■����■�������\�����■������■��■��■���������■����������■��■ 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