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1145 Beauchamp Rd OPERATION PERMIT or nice use univ Davie County Health Department *CDP:File Number 175250.1 20 210 Hospital Street P.O.Box 848 County,110 Number.. Mocksville, NC 27028 .Evaluated._Foc, NEW Phone:336-753.6780 Fax:336-753-1680 Township: Applicant: Philip Williams Property owner. Jane Whitaker Address: 1222 Beauchamp Rd Address: 176 New Hampshire Court City: Advance City: Mocksville State/Zip: NC 27028 State2ip: NC 27028 Phone#: (336)940-5970 Phone#: Property Location & Site Information Address/Road#: Subdivision: Jane Whitaker Property Phase: Lot: 3 Beauchamp Road Advance7 NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East, right on Baltimore Rd. left on Beauchamp property on right between, 1163 and #of Bedrooms: 3 1129 #of People: 'Water Supply: SEMI-PUBLIC 'IP Issued by. 2140-Nations,Robert 'System Classification/Description: TYPE II A CONY SYSTEM(SINGLE-FAMILY 011480 GPO OR LESS)' *CA issued by: 2140-Nations,Robert Saprolite System? QYes QNo Design Flow: 3 6 0 'Distribution Type: DUAL ALTERNATING FIELDS Pump Required? QYes QNo Soil Application Rate: 0 - a 'Pro-Treatment: Drain field r.Ninification Field 6 0 0 Sq.ft. *System Type: INFILTRATOROUICK4STANDARD rain Lines a Installer. Jamie Bames Total Trench Length: 2 0 0 ft. Certification#: Trench Spacing: _ 9 Inches O.C. Feet O.C. *EH S: 2140-Nations,Robert Trench Width: _ 3 Inches •Feet Date: 0 1 / 0 8 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 14 Inches Approval$Status,: �! v Maximum Tren6h'Depth '3 6 Inches ®`Approve}d D 'Disapproved Maximum Soil Cover. 2 4 Inches CDP File Number 175250 - 1 County iD Number: Septic Tank Manufacturer. Let. Long: STB: Gallons: Installer. Date: / / Certification#: *EHS: *Filter Brand: ST Marker ❑ Yes ❑ No Date: O Yes 11No Approval status ❑ Yes O No ❑ Approve ❑'aDisapprve� Reinforced Tank: Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: / / Date: Risersealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) v- Approval~Status Reinforced Tank: O Yes ❑ No =`❑ Approved❑,Disapproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line Pipe Size: inch diameter Installer Pie Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: / Approved fittings [IYes ❑ No APR to' ,v"I WetUs qj x ss a ❑Approved a§ Isapproved Pump Requirement Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chan: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-vatve ❑ Yes ❑ NoApproval Status PVC Unions ElYes El No ❑'Approved❑ Disapproved Vent Hole ❑ Yes ❑ No i Anti-siphon Hole El Yes ❑ No CDP File Number 175250- 1 County ID Number: Electric Equipment NEMA Box or Equivalent ❑ YeS El Installer. Box 12 inches Above Grade 11 Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No J / =Activation Method: . Date: Alarm'Audible ❑ Yes; El No Approval Status Approved tisapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State AQet �— � Date of Issue: 0 1 0 $ a B 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for Sewage Treatment and Disposal,15A'NCAC 18A.1900 et,Seq.,and all condition's of the Improvement Permft and Construction Authorization.This property is served by.a TYPE IlA Sewage Septic system. Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria < Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator. NIA Reporting Frequency By Certified Operator.NIA Rule.1.961 requiresthat a Type IV and V septic.systems designed for a home/business owner,must maintain a valid contract with a public management entitywikh a certified operatoror a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule.1961,(2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an:Operation Permit for a system required to be,maintained by a public.or prorate management entlty,unless the system ownerand certified operator are the same..The contract shall require specific requirements for mintenance and operation,responsibilities of theowner systems operator;provisions that the contract shall be in effect for as long as the system is in use,and otherrequirementsforthe:continued properperformance ofthetystem. ftshaltalso tie a condition of the Operation Permit that subsequent owners of the systems execute such a contract. *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** ' OPERATION PERMIT 175250 - 1 Davie County Health Department CDP File Number: 210 Hospital Street po.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Dramin Drawing Type: Operation Permit Scale: . OON A k ft. 4r,'� - r .. I a 6t6 f t CONSTRUCTION For office use only Alirf'H0k1ZATION 'CDP Fite Number, 175250-1 °N Davie County Health Department County ID Number. 210 Hospital Street Evaluated For.= NEW P.O.Box'848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 1 a / 0 3 / a 0 1 9 Applicant: Philip Williams Property Owner. Jane Whitaker Address: 1222 Beauchamp Rd Address: 176 New Hampshire Court CRy: Advance CRy: Mocksville State/Zip: NC 27028 State2ip: NC 27028 Phone#: (336)940-5970 Phone#: Property Location & Site Information r dress/Road M Subdivision: Jane Whitaker Property Phase: Lot: 3 eauchamp Road dvance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East, right on Baltimore Rd. left on Beauchamp property on right between, 1163 and 1129 #of Bedrooms: 3 #of People: 'Water Supply: SEMI-PUBLIC System Specifications Minimum Trench Depth: a 4 rDesignn ssification: Provisionally suitable Inches Minimum Soil Cover. System? OYes ®No 1 a Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a Maximum Soil Cover: a 4 Inches "System Classification/Description: 'Distribution Type: DUAL ALTERNATING FIELDS TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 P OR LESS) Septic Tank: Gallons - f 'Proposed System: 25%REDUCTION 1-Piece: OYes @No Pump Required: OYes (E)No OMay Be Required NRrification Field 6 0 0 Sq.8. Pump Tank: Gallons No.Drain Lines a 1-Piece:OYes ONo Total Trench Length: a 0 0 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. 9 @Feet O.C. Dosing Volume: _ Gallons Trench Width: _ Inches 3 Feet Grease Trap: Gallons Aggregate Depth: inches PreTreatment: ONSF OTS-1 OTS-II SepticTank Installer Grade,Level Required: 01 011 0111 OIV Dann I of Z CDP File Number 175250- 1 County ID Nuriber. T ❑ Open Pump System Sheet Repair System Required:@YeS ONO ONo, but has Available Space rDesign System Trench Spacing: Q Inches O. . ification;. Provisionally Suitable 9 Feet O.C. Trench Width: Q Inches w: 3 6 0 — : Feet Aggregate Depth: Soil Application Rate: 0 - 2 inches `r Minimum Trench Depth: 2 4 "System Classification/Description: Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 2 Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 8 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches Na. Drain Lines "Distribution Type: DUAL ALTERNATING FIELDS 5 TotaiTrench Length: 6 � � ft. Pump Required: OYes ONo OMay Be Required Pre Treatment: ONSF OTS-I OTS-II .Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater system,Construction shall bevaltd for a person equal to the period of validity of the Improvement Permit not to exceed five years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)}if the installation has not been completed during the period of validity of the Construction Permit,the information submitted in thsapplication fora permit or Construction Authorization is found to have been incorrect falsified or changed,or the site is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance;monitoring,reporting and repair Applicant/Legal Reps.Signature Required? OYes ONo Applicant/Legal Reps.Signature: Date: _ . *Issued By: 2140-Nations,Robert Date of Issue: - 1 a , 0 3 .1 0 1 4 Authorized State Agent: Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 175250- 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 1 a / 0 3 / a 0 1 4 Q inch Drawing Drawing Type: Construction Authorization Scale: . pBlock Q N/A t off .- -CL- - .... L- am .,......,,.. .W .-..._ Iry � U r �j Grr i E 1 i � f I i 1 0 i t I G► , APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMITWe C Davie County Environmental Health P.O.Box 848/210 Hospital Street 4 b Nlocksville,NC 27028 a (336)753-6780/Fax(336)753-1680 U �`,veab Application For: ❑Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) Both ``� �Lec Type of Application: ❑New System ❑Repair to Existing System X'Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed c 1t Contact Personghi do W i( W V\S Billing Address 1 Home Phone -9 O- O City/State/ZIP L O (.r Business Phone (ca- gn- 495 Name on Permit/ATC if Different than Above t{y3S Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:0 Site Plan ❑Plat(to scale) (Permit is valid for 60 mon)hs with site lan,no expiration with complete plat.) Owner's Name _,.Mae fA�'1 t}Y��i C� Phone Number r- Owner's Address City/State/Zip Property Address If y'7 Q1x MP City AAWK ICti Lot Size at S acre-5 Tax'PIN# Subdivision Name(if a Ii able) Section/L.ot# D' ctions To �" Site: I 'Mar uaa_c If the answer to any of the fol owing 4ucstiomTis`ryes",supporting documentation must be attached. Are there any existing wastewater systems on the site? 8'Yes❑No Does the site contain jurisdictional wetlands? OYes QNo flo` srb N 4 Are there any easements or right-of-ways on the site? ❑Yes 8No Is the site subject to approval by another public agency? Oyes ZNo n�� v Will wastewater other than domestic sewage be generated? ❑Yes 13No VV77�� Ti IF RESIDENCE FILL OUT THE BOX BELOW #People _L1_ #Bedrooms 3 #Bathrooms 5,s Garden Tub/Whirlpool❑Yes No Basement:eYes []No Basement Plumbing: ZYes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ZConventional []Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ,County/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes /No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permigs)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to_determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locatin flagg}n Astaking the house/facility location,proposed well location and the location of any other amenities. Pro e o Site Revisit Charge p rty oner's or owner's legal representative signature Date(s): ClientNotification Date: Date EHS: Sign given ❑Yes ONo Account# L! Revised 11/06 Invoice# i i BEq��NgMP � f R. 1621 ROgD PA QED Lj i (I �4 1 1 1/2" w 4g <S 1 NIP 1 5 <6 x ; T BAR 1 i 53' 41 0 1 ✓ r C2 v�f 3/4" i EIP °= LOT 2 bo s ' I 5,100 ACRES rN PART OF D.B. 311 PG. 261 r141 t co i I � N 2 ELSIE B. v ,00 D.B. 128 i LOT'3 �• � - 2.506 ACRES T PART OF D.B. 311 PG. 261 00 81'P \ DECK SCREENED PORCH 12 x 12 H 19-9 x 12 1 TFx 5'r Z'8•x5r Z'Fx5r TFx 3'r 54'x5r Te•x 5 Z' T8•x 51• TFx VF I�--O -�I T F x 6'F LAUNDRY x 1 r ® x E, Ul K-IN CLOSET M 100 KITCHEN 9-1 x 1 9D'CEIUNG Q MASTER BEDROOM - TFx6'F z v0'COUNG 2 CAR GARAGE "" 116 II-� x 13 U 0 14 x 16-6 unEN I I b I I IOW VANITY 10 I I MASTER BATH ISLAND m i36X846 W F CEIUNG23-I1 x 21-1 - m 0 a CAB REF11 x 13 4 r4'x6'F aa=== SHOWER F m Z'4•x6'F x 2'8'x6'8• =s 40•CEIUNG '� CLOSET O o = FAMILY ROOM wA a 4F CEIUNG 5'Px6'F 4 >r r•Fx6•F =_ 20-1 x 16 O a - rt b � BATH No zr Z Fx6.8• BEDROOM No3 1 CAR GARAGE ATT ACCESS uDSET 9FCENJNG b 5Fx6F 12-8 x 12-1 b 22-1 x 13-4 5'Fx6'F ZrASr rrx5'r COVERED PORC 1 BEDROOM No2 9'FCUUNG Z'Fx5'r 12-11x12 r6-xrr ----------------- 5'4'x5'Z- MAIN FLOOR PLAN 54•x5'r HEATED AREA: 1886 SQ FT GARAGE AREA: 550 SQ FT SCREENED PORCH AREA: 144 SQ FT GU�S7-G,t�O CA8IaTQ�r�IPAN�� q�1haJt,cern DECK AREA: 231 SQ FT J FRONT PORCH AREA: 116 SQ FT P M sq Si yN .1 =-------- r U r r r r r n n I� I „I II II DECK n II SCREENED II _ I III ABOVE a PORCH I� Q n d ABOVE tl I 'll u u I, II II ' ilii I II II STEPS TO GRADE II II ' AS REQUIRED ii I ii I II II ' II II ___________ "1-4: I ,__r_ _n __ii______________________________________S.I.yi`2.------------- U-----------------q4•T-5.2.----_______1 _________________________________________________________________________-- 7!'x6'6 .___________________________________________________________________ ______________�_ . .---------------------------- ___________________ _________ ________________________________________________________ __________ O O � Z EXERCISE ROOM b 6 ' SHowER ++ b 22-1 X 12-10 GARAGE ABOVE a zrT ' i N j b r is_iszistzi_z_z_,¢p . _____________________Tifte—s`__________—___—___5—_rv_s,__—__ ____QQzzzzzzz _ _________---- -- -------------------------- --_u N Z 2 CAR GARAGE Q "" RECREATION R00 b � b - ___ ___� , __-__- r r }+r •---------------------------• ' •------------ r i ,x. �=4=c c c c c c cam.. a i 19-4 X 15-3 ; 19114' : 299 ------------- i M w w b' GARAGE ABOVE - - - - - ---- - -- -- -- ; --------------------------------------------------- FRONT PORCHb ---------------------------i------------ ABOVE -- r , r ___________________________________ _____________________________________________________________________FOOTING FOR STEPS'; TO GRADE AS REQUIRED BASEMENT PLAN ' - ---------------------------------------- HEATED AREA: 825 SQ FT GARAGE/STORAGE AREA: 1072 SQ FT T 129 146w147 106 6 I 156 a, 133�J � 107 , 1721 •.nn I "ti137 170 157 X112 X115 i g 2�180i�53 trd�13 ', X141 1155 kv",17 9'. /1 .8 ' 1336 15143 1831 127 t7t1 tom' I�x1'79 1339` - 114, 121 �187�1 �y 1220 19Ci.7 27 249X4711<46 179 1276 12061, 20 I ( 1P461124 B`1b3 f-152 v! 447 , 187f! 1317' 1222142 - ' + 1162' 137 „' 155 g 3 110 r 12'45 . 1210 - 1 i + .- 1136 �. c t32r r 106 118 172 1259, , 19261120129 .r x'144 � '+ 126r��'Z% V",+~° 8122• �119-�t122 1�39g,t: 1 t%4-132/ �128L.108, 155,.145 1129' X10 112 125 144 150 116�� 382t 131 �. 106 ' � , , 1 1827 11087 � 113 4 X147 150 �10�87 10�u�09 �106� X12'6„ f 1, ! X328 X1881 ,. 114 Pr, r£ 334. 123 1721 i '84811 w..x»119 123.. 363 299 t 273,32611 j X198°201 -- d11p1128129, ,1 12 965 124+ 118 107 133 155 k yy 4� #1t^- 119 a` 127. 111 M, I € (' 137 7"+120�t �t08' � � - 182 140_ 7` X129 125 ' t22�190.p1 r "r107T118�4i129 1z .�,6IL133 1231117 104't Q128 ;112 1752 _145��132• ,.828-124'1 128e1 . .. 129 '673 +, 'E All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out Pri rated:N ov 12 2014 S of the use or Inability to use the GIS data provided by this website. + VICINITY MAP JEREMY L. KEATON, PLS 1283 MAIN CHURCH ROAD MOCKSVILLE, NC 27028 (336) 909-3864 A I hereby certify that I am the owner of the property shown and described hereon, which is located in the county of Davie that I hereby adopt this plan of subdivision with my free consent, established minimum building setback lines and dedicoted all streets, alleys, walks, parks and other sites and easements to public or private use as noted. Furthermore, I herby dedicate all sanitary sewer and water lines to the County of Daive. Date Owner APpR�X. COCA TIO/� pF _ APpR�X. �OCATI E/P _ I �N �F R/W E/P � 3/4",., J I EIP �I�� I 40.12' TIE I I I I I I I I I JAMES C. & CONNIE W. I BAILEY I I D.B. 320 PG. 853 I I I I I I � I � � � _ � �, � � � ' w � y _ r--------� � � 0 I � 0 Z I I I I I ROY F. & GAIL S I WRIGHT D.B. 132 PG. 748 I I I �� 1/2" NIP SET AT BENT T—BAR eEA��NAMP l2 � R' � 621 NAIL SET AT BENT T—BAR LOT 1 5.006 ACRES PART OF D.B. 311 PG. 261 __ � \ \ APPROX. LOCATION \ OF BAILEY CREEK � I 1/2•' NIP SET AT BENT 3/4" EIP I S 04'08 49 W I 81.08 TIE I—'— — — — — — — — _ 3�4.. IEIP I I I I I�� ------------------------------ L \ 3/4" EIP ROY F. & GAIL S WRIGHT D.B. 140 PG. 800 Registerd Land Surveyor, Number l3 N / W� � ►E ' S D.B. 311 PG. 261 ROAD ?A �ED LOT 2 5.100 ACRES PART OF D.B. 311 PG. 261 Icertify to one or more of the following as indicoted by an X: I _____ a That the plat is of a survey that creates a subdivision of land within the area of a county or municipality that has an ordinance that regulates parcels of land; b That this plat is of a survey that is located in such portion of a county or municipality tiiat I is unregularted as to an ordnance that regulates parcels of land; c That this lat is of a surve of an exisin arcel or arcels of land• W • P Y 9 P P . d, That this plat is of a survey of another category, such as the recombination of existing parcels, a court—ordered survey or other exception to the definition of a subdivision; That the information available to this surveyor is such that I am unable to make a e. dertermination to the best of my professional ability as to provisions contained in a through d. above. Signature Surveyor Registration Number t �4 � J ��2� NIP I, __________________, certify that this plat was drawn under my supervision from an actual survey made under my supervision (deed description recorded in Book _______, page _______ ); that the boundaries not surveyed are clearly indicated as drawn from information found in Book _ , Page ______, that the ration of precision as calculated is 1: 20,000 ; that this plat was prepored in accordance with G. S. 47-30 as amended, Witness my original signature, registration number and seal this ___________day of _______________, A.D. 2014 Surveyor, Registration Number L-4487 � — — — — — — — — — — — — — — — —� �PRE�IMI�IARY �—---------------� ��s <S �6 \ �9p�p .\ \ R�.�' <O ty i-� T EBAR v�� F/�o c�ToN �� Fjp �F F�,',_� \ ^� � � �.�� .ho' �.. \ �, `�_ -+� y�� ,�h �/� ,; � 3 4 ` `� � � �_. EIP n �9p�p Rp�, C OC� �O N pF R � rn � � co � n ;n " N ^ � ELSIE B. WHITAKER Z � D.B. 128 PG. 236 3 LOT 3 ;,� 2.506 ACRES � PART OF D.B. 311 PG. 261 0 � — � � 3/4" 11'12��W � � � � � EIP S 82� 3�4» I 145.79 EIP I I N 88'16'04"W I 50. 00' I I I I DONNIE R. & ANGIE K. I I SIMMONS D.B. 789 PG. 801 I I I I J I� � � � � I LEGEND: EIP EXISTING IRON PIN I NIP NEW IRON PIN • POINT I E/P EDGE OF PAVEMENT S.R. STATE ROAD � p.g. DEED BOOK R��n/ RIGHT OF WAY This plat is subject to any easements, agreements or right of ways prior to the date of this plat. No NCGS Monuments within 2,000' of this property. REVIEW OFFICER'S CERTIFICATE I, ___________________________, Review Officer of Davie County, certify that the map or plat to which this certificaton is affixed meets all statutory requirements for recording. Review Officer Date 100 0 100 200 300 GRAPHIC SCALE - FEET F, _,..... i•.-r'<'7+'!,. � ..::.r'-gi4';ta'.,r;t ti: :::'.c, siw�-M,`r 4 rr'.� ��,r..r.{y.�., ,-•:;a '+�:m :.cam. _ a o2-. -� w.", ..v. - -.. ,. .r.. DAVIE COUNTY HEALTH DEPARTMENT AA IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NTE** This improvement permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. AN AUTHORIZATION FDR"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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME _ Pa`-) t,) W��\P�e� PROPERTY ADDRESS P�Gt I t CL= 7d�6 DATE LOCATION �b �`c. \ \�441NIZ �° •��- On A il L A F ', tp. SUBDIVISION NAME 1 /77 haubtOT v ER BEC./BLOCK NUMBER nn RESIDENTAL SPECIFICATION: BUILDING TYPE 0 ccr # BEDROOMS r) # BATHS d. # OCCUPANTS _I GARBAGE DISPOSAL: Ye /No .. .COMMERCIAL SPECIFICATION:,FtACILITY•TYpE # PEOPLE # PEOPLE/SHIFT ,v' # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE OATER SAY . DESIGN WASTEWATER FLOW (GPD) ` ,fib ,NEW SITE V REPAIR SITE 9 SYSTEM 5PECIFICATIONS: TANK SIIE Otd {r,GAL. PUMP TAM 6i 5 DRENCH WIDTH y�_ ROCK DEPTH LINEAR FT. 460 OTHER ;Ak 011 � REOUIRED SITE MODIFICATIONS/CONDITIONS: f ***THIS PERMIT IS SUBJECT TO REVOCATION.IF SITE PLANSOR THE INTENDED USE CHANE. YOUR WA$TERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 0 Yy Q � l , IMPROVEMENT PERMIT BY t1 ti **CONTACT A REPRESENTATIVE OF THE DAVIE HEALTH DEPARTMENT FOR.FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:�-1:30 P.M. ON TMjMTY Y OF-INSTALLf�TION, TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYST INST D•BY t A N1 Owe e AUTHORIZATION NO. O !) Z3 OPERATION PERMIT BY `+ DATE 4 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. I DCHD 10/95 -�1 ► „ "� a+ Davie County Health °Department 1/xd ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 00 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION d (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the'Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should to presented to the Davie County Building Inspections Office when applying for.Building Permits.*** •;, a er AUTHOR IZATION-NLPXR � a D1 '. y'�y '9 !� v 030 x�� o NAME ON IMPROVEMENT PERMIT (It,different than above) SITE LOCATIQN =c COMMENTS/CXITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM 4 ** MO'TICE*H THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ' ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95. J. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER �j t5 Davie County Health Department U Environmental Health Section P. O. Box 665 JUL 2 4 1995 Mocksville, NC 27028 v Im 0VECHEALTH STH I0N 1. Application/Permit Requested Byw// �¢ p Mailing Address 1163 64�CIIV 14 ►4 � PX. Home Phone 99�XZ52SJl Business Phone 2. Name on Permit if Different than Above 3. Application for: CY General Evaluation ❑Septic Tank Installation Permit 4. System to Serve: Douse Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑�Basement/Plumbing No. of People Q�Basement/No Plumbing No.of Bedrooms Q"Washing Machine No.of Bathrooms FDishwasher Dwelling Dimensions 1396 -rV fAOSli�f ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No.of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: S Public ❑ Private ❑ Community 8. Property Dimensions 10 /9t� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2 No If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: 6p* This is to certify that the information provided is correct to the best of my knowledge,and I understand I am responsible for all charges incurred from this application. ATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I WN the property. ❑ 2. I DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation //� NAME !�/�i �jYlr DATE EVALUATED 7_7//S_ ADDRESS PROPERTY SIZE AOc:!� -'i4C �J / PROPOSED FACIILTY ��usr LOCATION OF SITE Zn .�,-Y,✓!!� Water Supply: On-Site Well _ Community Public t✓� Evaluation By: Auger Boring Pit C�_ Cut FACTORS1 2 3 4 Landscape position L Sloe z HORIZON I DEPTH Texture groupL S G Consistence Structure MineralogX HORIZON II DEPTH OA d 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: a ve EVALUATED BY: '0?k11 LONG-TERM ACCEPT CE RATE: OTHER(S) PRESENT: REMARKS: LEGEN 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-Vl---y 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 3C-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 wateP 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(01-901 � I . ■■■■■■■■■MMiiMMM■MM■■EH■■■■nM■i■MEMH■H . ■M■EHE■■u ■ ■■■■■■■■■■■■■ S■OM■■■MMMM■■■ME■O■■OM■■M■sssMEl■MMEM■■Ei■■ ■■MMNMMHMM■M■■■■■■■ /■/ ss■■Mst■E■ns■ ■moiiiiiiiiiiiiiCCCCCCCCCCCCaiiiiiiiiiiiiiiiisiiCiiiCsiiiiiCC°Coo0■mC■■■=■■n■■■■■mons■■ a ■ ■ ■■ ■■■■ ■■/■■■■■■■ ■/■■■■■■■■■■■■■■■■■■■■■■HM■a■■■■■■■■■■■■■■■■■■■■■■CE■■■■M■■ CM ■Ci ■C■ ■/C■■/■■■■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.N.■.... ■/■■■ ■■■ ■■ CE ■ ■ .Immimimillu.■ ■■■■■■■■EM■■■■■M■■■EM■■Mi■MM■■■EMa■■MEM■�■■MM■■C■■ENCmin C ■ ■■C ■ ■■■■■■■/■■■■■■■ ■CCC CCC CC CCCisII1 0w 0M MCEMMMOCCCEOCESCM10A mommommossCsnsCs=sC=MIS oso s osCsso=momnmomnnssm ■■■■O■■■SEES■■■M■O■sCMNM■■■s■OEs■M■ ■E■■■�■■■■■■■■■■■■ ■■■ ■■ ■■■/ ■■■■■■/■■■moommummom■■■No ■ ■■■■■■■■■■■■■■n■■■■■/■■i■■■a■■■�■■■■Ct■■■CCCC osuosomisis sin■o _�C■CsiiMOMMENEEN 0iC CCCCCCCCCCCC■�Cs�CCCCCCCCCCCNC■CCCCCCmsn■NE� C■ CC ■ ■C■C■C■C■C■C■C■C■C■CC■■CC■■C■CC■C■■C■C■CECCMC■ECnCC■CECa■ ■■■_■■C■ C C ■ CMO/soon■■■■■C■■■ ol ■ / C■ n�oC ■CCCCCC MMM■MO■M■EMM■M■H ■■■■iC ■■■■■■■■■ mommoommmomsnnmONECCCmnmCCNo ■■■■ ■ ■/MEN ■■■■ ■MM■■■■■■■■■■■■N■■■■■■■ ■■■■■NEM Cso p ■ ■ CCCCCCCCCCCC ONE ■■■■■■■■■■/■H■■■■■■■��■■■■ ■■■C■■■■■■ _ ■■■■■M/■M■■■■■ ■■■NMii■iM■M■MM■■■MMM■MMl�M■ECMM■ ■Moon ■EEEE■EM■ME■M 11111119111:1 ■■■■■■■■■■■■H■■'CCCCCCCms ■ ■■CCCCCCCCmon CmnCCCCCCCCCC■M■■MnOME■■�� v !! 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BOX 665 t i MOCKSVILLE.N.C. 27028 PHONE:(704)634-5985 July 28, 1995 Daniel L. Whitaker 1163 Beauchamp Rd. Advance, KC 27006 ' Re: Site Evaluation Beauchamp Road/5+ Acre Tract r Dear Mr. Whitaker: As requested, a representative from this office visited the aforementioned site on July 27, 1995. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr. , R.S. Environmental Health Section i RH/wd Enclosure