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657 Crescent DrDAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001773 Tax PIN/EH #: 4797-89-1506 Billed To: Robert � Carrie Stroud Subdivision Info: Reference Name: Proposed Facility: Residence Location/Address: Crescent Drive-27028 Property Size: see map �TC N rnb�r: 2865 **N TE** �is mprovement/Operation Permit DOES NOT authorize the construction ofa 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type rn� #People -3 #Bedrooms 3 #Baths 2 Dishwasher: d Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply � Design Wastewater Flow (GPD) c3(pC� Site: New �Repair ❑ �' System Specifications: Tank Size �'�(�&AL. Pump Tank GAL. Trench Width �'�'� Rock Depth iZ ��Linear Ft. %� o�h�: 2�ST� g�coa t�x�S , l�srqc.� u�r,� aio.c. ;��. Required Site Modifications/Conditions: �S �� U-- (:N G�7��, ��(�%� �`� fl n•. t,�l�si1.. ,�� t o-'� . ._ _ , .— IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G�� BELOW FINISHED 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 1:30p��!on the day of installation. Telephone # is (33G)751-8760.**** � �� Environmental Health Specialist's Si DCHD OS/99 (Revised) � M.�c `r��l ��'rt-� 2�-I' � � �--� u��s �� i�m�-1 = 2��tT Date: y �� OZ �; J � ° �G�� —ifL�`' S DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001773 Billed To: Robert & Ca�'ie Stroud Reference Name: Proposed Facility: Residence p�. G- G -d� Tax PIN/EH #: 4797-89-1506 Subdivision Info: Location/Address: Crescent Drive�27028 Property Size: see map **N��'�iiibginprov8ement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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 �� '��+�1t�i #People � #Bedrooms 2 #Baths , Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #Peop(e/Shift #Seats Lot Size Type Water Supply��U— Design Wastewater Flow (GPD) Z�O Industrial Waste: � Site: New � Repair ❑ �� r System Specifications: Tank Size ��O�GAL. Pump Tank GAL. Trench Width �0 Rock Depth � Linear Ft:3z�� t och�: I �t�i�+ ��o� �oyc,, ��15%v.,�. v,Si�� p. e . w� �� . , � Required Site Modifications/Conditions: _��Sl A I,�- ��i C,��(Z .�� " 1,.��:l.l�� k� s�F IMPROVEMEIYT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF (`� BELOW FINISHED GRADE. **�**NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between $:30 a.m.�to 9:�30�.m. or 1 00 p.m. to 130 p.m. on the day of installation. Telephone # is (336)751-87G0.**** ^�'\ ��' . I�, t� � � � � T�a�`-� 2� �, �' \ �`�1 `1�� _ \ \ l �_. � �� /� `, �, J , �� _ ---- `� �C) �, ��/O, � �lon�� -��, � , �.� �12.' � ��„�, �� , �,� ` �I�J Environmental Health DCHD OS/99 � �. n,.1 �[c� 's � Date: �p � G� P� G�'�1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Account #: 990001773 Billed To: Robert 8� Carrie Stroud Reference Name: Proposed Facility: Residence ATC Number: 2865 Tax PIN/EH #: 4797-89-1506 Subdivision Info: Location/Address: Crescent Drive-27028 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEW ST N IS V LID FOR A PEWOD OF FI YEARS. Envuonmental Health Specialist's Signa e: Date: � J �% CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. f �� ;-� � S� � `S � � 3S �S� r Septic System Installed By: Environmental Health Specialist's Signature : S�/� I Date: �, DCHD OS/99 (Revised) - �„.�'', ^.'�' . r- r•� � D C��' � n 1 J�N 1. 2. ~ � L1GAT1011 F�R SITE EIrALUATION/IhiPitOVL-149CNT P�IigiiT & ATC Davie County Health Depa�tment � Lu�� Environmenla/ Hea/ti� Section P.O. Box 848/210 Hospitsl Street �N�P� y��At�H Mocksville, NC 27028 cOUN� (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS 11I�L THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BUI,LETIN ior instructions. Name to be Billed ��_ Q'� TI..U�Y1r�C ��C■r � Contact Pa=son �he.R� V� CG,rri � Mailing Addresa dJ'1 1`�lQ��e I(�./1C. Fiome Phone y�31 �'T'� O� ��i� City/State/ZIP / M�/) SV� �'� , /��• ��.�LY Husineas Phone /Q�—�iJ� �IF�tJO Nama on Permit/ATC i£ Different than Above M�;linq Add=esa City/3 te/Zip s. Appiication For: ls site Evaluation Improvement Permit/ATC Bo�h 4. Syatem to se=,.i�e: ❑ House !S Mobile Home ❑ Business 0 Industry ❑ Other s. IP Residence: � People _� i Bedrooms � � Bathrooms ' L] Diahwasher O Gasbage Diaposal Wwashing Machine fJ Hasement/Plumbing U Dasnment/No Plumbing 6. If Huaineas/Induatry/Other: Speci£y type $ People # 3inka # Commodea � Shoxera # Urinala # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay� 7. 7�pe of water supply: ❑ County/City hYWell ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? If ycs, what type? ❑ Yes L�i'!Yo ***IMPORTANT*** CLIENTS MUST CO6lPLET�TIIE RBQUIRID PROPERTY INFORMATION Rl:QUGS7'GU BELOW. Either a PLAT or SITE PLAN MUST BESUBb11TT'ED by the clicnt witl� THlS APPLICATION. Property Dimensions: S { � "'"�r� ax ottice Pllv: #�.1 rl �'1 �� -��— I� b 1� Property Address: Road Name �y�_SeAt,T lJlr� VL c;ryiz;p IUoC1�45Y� II� . N •G If in a Subdivision provide iaformation, as follows: Namc: Section: Block: Lot: WRITG DIRECI'IONS (from Nlocksvillc) to YROPLR'I'1': ��t�VV �.D ¢ �UF`3f' � �I OUG �'1C� • St"'o� ru i� CY�ert� `i�r . d� le�-�- S�ah� u�� II be iti -� Cu,r� on �4-h� h., fl o�. �i �Q�,�. Date Property Flagged: � � � / ° � This is to certify that the iaformation provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intcnded usc cLangc, or if the information submitted iu t6is application is talsified or changecL I, also, understand lhat I am responsiLle for all charges incurred frnm this app!%alion. I, t�creby, give consent to the Authorized Representative of tt�e Davic Cou ty IIcalth De �rtment to eater upon above describcd property located in Davie County and owned by O, L. ��Q.t.t,��w,e �ULLG� to coaduct all testing procedures as necessary to deterniine the site su' bility. � . 1 DATE � SIGNATURE , THIS A MAY BE USED FOR DRA.WING YOUR SITE PI.AN (Include all of the following: �aisting and proposed property lines and dimensions, structures, setbacks, and septic locations). �- �� 'l�� H ^�~ � .:-� ,�_ ��: '7' -��--.` �J , .,�.:��...� . �� ! �cF' . Revised DCi�D (07/99) �� Site Revisit C�argc Date(s) Client Notification Date: Zg�� -, 3 Account No. Invoice No. z3'2� �! `"�`�� s � � �-e- � 1 �-- � � � S . � � ' r'' � � 3 3 _f Z, �� . 5,,�, �' , � �,.L...�- .�k �� ? �/� �ip � c �a ., , , , . ' DAVIE COUNTY HEALTH DEPARTMENT ° • ' Environmental Health Section , Soi]/Site Evaluation � APPLICANT INFORMATION ACCount #: 990001773 Bil�ed To: Robert 8� Carrie Stroud Reference Name: Proposed FacilifS�: Residence Property Size Water Supply: Evaluation By: FACTORS Slope % HORIZON I DEPTH Texture group Consistence Structure II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence PROPERTY INFORMATION Tax PIN/EH #: 4797-89-1506 Subdivision Info: Location/Address: Crescent Drive-2 0 8 see map Date Evaluated: � Community Pit 2 3 4 SOIL WETNESS '� 3 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE D• .2 SITE CLASSIFICATION: �� LONG-TERM ACCEPTANCE RATE: � . � REMARKS: �AIA� 'v�G�`—�i P�� O� EVALUATION BY: ��-�`"�'— �+tlC�}�} -,'�N OTHER(S) PRESENT: _��o�'�-'�� ST�fI1i� +� (P � 2.�c.1�- D�� ,'� 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 _j 2r� NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic � � �� tructure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - An µlar locky SBK - Subangular blocky PL - Platy PR - Prismatic B v� MineraloEv „ _ p� 1:1, 2:1, Mixed �Si f��/� Notes �� D 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) � � i ■ �� ■■ ■■ �� ■■��■■ ■■��■■ ■��■�■ ■��■��■ ■��■■�■ ■■��i■ ■��■■■ ■■■��■■ ■es��e ■■��■■ ■■■■�■■ ■■■��■ ■■■��■ ■■�■�■� ■■�■�.■ ■■�� ■��■c■ ■�■■��i ��■� ■�s��v■ r<J��■ ��l��■ �■J■■■■ f��i�I�■■��■�■■■��■�■�■�■■■ l�%II�■■■��■■■■■�■■��■■�� ■��■■��■�■��■�■�■■■�■ ■//■■��■■�■�■��■■■��■��■■ ■�■■��■■�■�■■��■■■■■��■■ 1/��■�■■■��■�■��■��■■ %��■�■��■�■��■■�■■��■■ ■■�■■■��■■■�■■■�■�■■�■�■�■■ ■■�■■■��■�■�■■■�■��■■��■ ■■�■o��■�■��■■�■�■■■�� ■��■�■��■�■�■■�■■��■■ ■��\��■�■��■�■�■■�■�■�■��■ ■■�■■■■■■�■�■�■�■■■■�■�■��■ ■��■■■��e■■��■��■■■�■ ■■��■■■��■��■��■■■��■ ■��■■■�■■��■�■��■�■��■��■ ■■�■■��■�■�■�■■�s�■■��■■�■ i�iieiiii�iiiiii�iiiiii� ■■�■��■■■■��■■■�■■■■��■■�� ■■�■■��■■■��■■■■�■■��■�■ ■■��■�■■�■�■�■■�■��■■■ ■��■■■��■�■�■�■s�■��■�■�■ ■■��■��■e■��■■�■■�■��■■■ ■■��■�■�■�■��■�■��■��■■ i��s�a�-■:��e��■��■�� ■�►1�1��i��ICa��■■■■■■��■\'11 ■�11��■■�1�■��■■■��■�■r■■ ��rr�ii� .�i��ir��r�� ■■��■ ■■■�■ ■■��■ ■�■�■ ■��e ■■■�■ ■■■�■ ■■■�■ ■■■■■ ■■■■■ ■■■�■ ■�■�■ ■��■ ■�■�■ ■■■�■ ■�■■■ ■��■■ ■��■■ ■�■�■ ■��■ �� ■■■�Y�■ ■�■�■ ■ ■��■■ ■��■�■ ■��■��■ ■�■■■�■ ■�■■��■ ■■■�■�■ ■■■��■ ■��■�■ ■��■ ■��■ ■��■�■■ ■��■■■ ■��■■■■ ■�■■■■■ ■��■■�■ _ _ _ _____ _____ _ _ _ __ _ _ _.__ _ __ __ _ __ _ __ __ __ . __ _ - - — � . . . ,. - - � -• � ' ' �� ' , �,.�..,� ` � . � � � � � i � f � , I\ r I ,.a i I . 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