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1571 County Line Rd (2)DAVIE COUNTY HEALTH DEPARTMENT ' ' ' � ' Environmentol Heolth Section �� ^ � � � a P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)?51-8760 Account #: 990001301 Billed To: Patrick Brooks Reference Name: Proposed Facility: RESIDENCE IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5800-06-3373 Subdivision Info: Location/Address: County Line Road-28634 Property Size: 1.7 ACRES ATC Number: 2506 **NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 _ Dishwasher: � Garbage Disposal: ❑ #People �l-' _ #Bedrooms � #Baths � 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 Other: Required Site Modifications/Conditions: �� ` i GAL. Trench Width � Rock Depth J�_ Linear Ft.� IMPROVEMENT/OPERATiON PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G" BELOW F�NISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 130 p.m. on the day of installation. Telephone # is (33G)751-8760.**** Environmental Health Specialist's Signature: �'��!/ Date: �/ �I (� DCHD OS/99 (Revised) � �� Account #: 990001301 Billed To: Patrick Brooks Reference Name: Proposed Facility: RESIDENCE ATC Number: 2506 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5800-06-3373 Subdivision Info: Location/Address: County Line Road-28634 Property Size: 1.7 ACRES 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). 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 WASTEWATE ONSTRUCTION IS VALID FOR PERIOD OF FIVE YEARS. , Environmental Health Specialist's Signature: � � � �J`/ > Date: � ;�`U� CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletion 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 tem will function satisfactorily for any given period of time. . � ��,1'3 X�� 1°/YG� Septic System Installed By: �� / Environmental Health Specialist's Signature :_�� Date: f`'� "' � ��/ DCHD OS/99 (Revised) . APPLICATION FOR SITE EVAWATION/IMPROVEMFM PERMIT & ATC I' Oavie County Health Department En vironmenta/ He�a/th Se�ction . P.O. Box 848/210 iiospital Street � Mocksville, NC 27028 :1� (336) �'�g—�9��D . � �_�- � � f�L� �'� 2L�� e:� ___ ... � ***I1�ORT�EATT*** �HI3 APPLECi@1TION �� Pli�SSED UNI.ESS ALL THE REQUIRED INFORt�TION a3 PROVID�D. Refer *:o t.'�e INH'ORMATION BULLETIN for instructions. 1. Name to be Hilled Mailinq 1►ddreas City/State/2IP 2. Nama on P�rmit/1►TC i! Dilforant than Contaat Porsoa �� _ go� phono 33(� ?51 �5°��O Busineas Phone _ � (I/ _r �> ( � �� Mailinq ]lddress ��_ City/Stato,�Zip � /�I I j� 3. Application For: 4,�3ite Enaluation ❑ Impronement Permit/ATC ❑ Both a. sYet� to so�co: ❑ House �Mobile 8ome 0 Business 0 Industry ❑ Other 5. xf Residence: � People � t Bedrooms � i Sathrooms „�� ishMashar ❑ Garbaqa Diaposai �1'iPashin4 Hachino 6. I! Husiaoss/Iadustry/Othar: Spacify typa ❑ Hasameat/Plumbinq O Sasement/No Plumbing ; Paople � Sisska # Co�dea � Sho�rors � Urinals � fPater Coolers IF FOOD3ERVICE: # 3est8 LStimBtAd Water U9tige (qallons por day) �. Type of xater supply: �County/City ❑ Well ❑ Commtuiity e. Do you anticipate additions or eapansions of the facility t6is system is intended to serve? 0'l'es �No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. ,rropertyDimensions: /L ��C Taz Oftice PIN: # ��' � � ' ��1� Property Address: Road Name � � � City/Zip � If In a Subdivision provide information, as follows: Na�me: Sectior: Block: Lot: WRITE DIREGTIONS (trom Mceksville) to PROPERTY: � �a �x l ��v - � 2 � ' �2r� �2 ol� �� -�m _ �� 5 I�l1L� �/2�1 � D� �'DU��.1 LlN� ,�'� Date Property Flagged: ��oi� �� This is to certify t6at the iafor�nation provided is correct to the 6est of my knowledge. I anderstand that aay permit(s) issue� hereafter are subject to suspeasion or revocation, if the site plans or intended use chaage, or if the information submitted in this app`ication is falsified or c6anged I, also, understand that I am responsible jor all charges incurred from this applicatlon. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described properiy located ia Davie County and owned by to conduct all testfng roced res as necessary to determine the site suitability � ,�/( DATE J UU SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR STI'E PLAN (Include all of the following: Ezisting and proposed property liues and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) � Site Revisit Charge , Date(s): � Client Notification Date: I EHS: J , �l ACCOUOt IiO. �� u�' �/� � I_�� Iavoice No. �.� -� `-� - - - � i i.; �`"' 8 4 4.8 � � . ,: _ . � . 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X ."-� . ,� �� i � '�� "_� � � m rt � � ';� d, 16. 5 A c. � ��' � 366.3 g6 673.2 C0 L�3 , � g�$ Q �, s r- 5 3 0. 6 4 =_ � 4 �`° � � 16.5AC. r — �g f� .. ,�� If #`"�c'� r�t's,� � 541.2 � � ,, - � �'� � � � � _ � ' ' - �, � �' S.R . � 3�``� '�� '',� . . � __ �,� _ . ,, � �- �� ' ' �;� . . � i �, �� `r �� `� ' �i�q=� . �� •539.88 � 8 �` �4 'k..� � �� .�'. /_ y ,� i � ` gd , � � � s � ��.w;. + � wp ` r��t � � �� ' �'�t , ' s . - � � .��aG Y�7 1,, � � ��!a. r ^'a,c . �;�"'�A�i e '� � Q .� � a �: � a . . ,� �'�q � 5 � }E" :i � �L .-'1�1 � t,� • f x �,� ' . L� r' ,{�}� ,� ] �}',I �T `�. . � n� � �"- � � .,� �'.? ,t � r � ' � . � . . ::�w � �,� .. - . . :, � k°' � =' . . to.�. . � ' �� " ' , , v . . � . . �� , �� , F _ � � N°RT� DAVIE COUNT r= � F _ _ �� ` �� s, �� -� ; ; - � r, - � /i �' S'�; ✓�,..e _ TAX MAI SCALE' 1��= 400 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT, SoiUSite Evaluation APPLICANT' S NAME � � � PROPOSED FACILITY _�� SUBDIVISION Water Supply: Evaluation By: On-Site Well '� Community Auger Boring �� Pit DATE EVALUATED ?�� PROPERTY SIZE � �� ROAD NAME w� 1�"K .l��, Public � Cut HORIZON IV DEPTH Texture group Consistence � LONG-TERM ACCEPTANCE RATE: REMARKS: OTHER(S) PRESENT: LEGEND � Landscape Position R- Ridge S- Shoulder L- Lineaz 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 - Granulaz ABK - Angulaz 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 - 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 - gaUday/ft2 DCHD (01 •90) - 4 i ■ ■�t�e■ ■��■■■ ■��■■ ■�■��■ ■t��■ ■�■■ ■��■ ■�■■ ■■�■ ■■ ■ ■ ■ ■ ■ ■ ■��■■ ■��■ ■■��■ ■��■ ■��■■ ■■t�■ ■■��■ ■�■�■ ■��■ ■��■■ i ■ ■ ■ ■ ■ ■ � ■■ ■�■■��■�■ ■��■��■ ■�■■��■■ ■�■��■■■ ■��■��■ ■��■��■■ ■�■■��■ ■�■■��■�■ ■��■��■■■ ■��■ ■��■�■ ■��■ ■��■■ ■■��■ ■��■e■ ■��■■■ ■■ ■ ■ ■��■ ■�■■�■ ■■ ■■■�■ ■�■�■ ■��■ ■��■ ■■■�■ ■�■�■ ■��■ ■■��■ ■■■�■ ■■��■ ■■■�■ ■