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. "
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` System Type.;_ � (�V1�� .T.Manufacturer�'�..� Tank Date�� Tank Size�(� �
Pump Tank Size / Bedrooms:�_
System Installed By���_� c '7(,_Installer# Date: � �J�
GPS Coordinate: ` �
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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 .
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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.
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- 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# _{��
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REMAlNING PROPERTY 0� NO'j3�36'S/5��E � � � y • . _
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ITTE � � �Q°3�'�� �tE � :---��AIL 5�T'A� 'fHE BASE OF A
AND WIFE NEYJ )RON PIPE SET 2 0 ' ' "- .-_x Z'� '.72 -�.
A NEW LOT CORNER '-'�-----___ -�-y /� TWO FEEi"7A11 SOLl� IRON�S
I��Rh�A JEAN TRIVI�'TE � �.00� � c�w,RF����� X---�_:__x____�'� . -
DEED BOOK 15Q, PAGE 831 -
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Afl data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implieci
warranties of inerchantability or fitness for a particular use. 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
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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).
Site Rcvisit Charge
�� � �-� s� 9''�- ��-S�� Datc(s):
, Clicnt Notification llate:
,- �/
' EHS•
�1 �
Sign given�l Account No. '� / �O �
Revised DCI�D(07/99) Invoice No. � � � g v
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� ' ` .� • ' ' '� � 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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