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248 Dalton Rd (2), DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section " P. O. Boa 848/210 Hospital Street � Mocksvitle, NC 27028 (336)751-8760 Account #�: 990001609 Billed To: Jimmy Cowan Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH ##: 5757-19-0454 Subdivision Info: Location/Address: Dalton Road-27028 Property Size: 1/2 acre + ATC Number: 2753 **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 /07/f' #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 L D Design Wastewater Flow (GPD) � � Site: New � Repair ❑ System Specifications: Tank Size,l�p�j GAL. Pump Tank Other: Required Site Modifications/Conditions: i GAL. Trench Width c�C�� Rock Depth �� Linear Ft.o�� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G L° 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 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** �/�-�� ,� � �oc� ��'tn � _ Environmental Health Specialist's Signature: DCHD OS/99 (Revised) � r Date: � `� � d )� Account #: 990001609 Billed To: Jimmy Cowan Reference Name: Proposed Facility: Residence ATC Number: 2753 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5757-19-0454 Subdivision Info: Location/Address: Dalton Road-27028 Property Size: 1/2 acre + AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � � I**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �.�� Date: ��'-_`�/� `�� CERTIFICATE OF COMPLETION **NOTE** The 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 s will function satisfactorily for any given period of time. l Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) Date: /�'`� v� � �� \ -,� � ��"�� _;,,oJV ,�'1J" ��APPUCATION F013 SlTE EI�ALUATION/lf�1PR00�E11iEM' P�IthilTi &/�i�C � Q�� ' Davie County Health Department , • � �,,, � (� � Environmenta/ Hea/tfi Secfion U.f�- \_,� P.O. Box 848/210 Hospital S�reet n P�'" MOCICsville� NC 27028 l. �t'1 (336) 751-8760 � �� .I� _,��._t'I-T_�-- _ _ l`� � �� ENVIRO«h7ENTAt HFbI7H ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INEOR2�TION IS PROVIDED. Refer to the INFOR2�TION BULLETIN tor instructions. 1. Name to be Billed Mailing Addreas City/State/ZZP 2. Name oa Permit/ATC if DiF£erent than Above Mailing Addresa �a� �JL � Contact Peraon � //¢ )( .f J��/ ,(;(_/ /U/ / � l_J Home Phone � � �� `9 ��'(�LIJ �% � �/ � � � r�� (� � Businesa Phone �((� �P') �/ City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC � Both a. syHt� to se=vice: 0 House Cd Mobile Home ❑ Business 0 Industry ❑ Other s. =f Residence: � People � � Bedrooms � # Bathrooms _� � DishMa�er lJ Garbaqe Disposal C� Washing Machine O Hasement/Plumbing ❑ Banement/No Plumbinq 6. Zf Huainesa/Induatzy/Other: SpeciPy type B People N Sinka M Commodes A Shoxern � Urinnls # Water Coolora IF FOODSERVICE : # Seats Estima.ted Water Usage (qallona per a�y> �. Type of water supply: � County/City ❑ Well ❑ Community e. Do you anticipate additions or capansions of thc facility this system is intended to servc? 0 Ycs yl No / If ycs, what typc? ***IMPORTANT*** CLIENTS MUST COMPLETETI�E REQUIRED PROPERTY INFORMATION REQUCSTI'sD BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED bv the clicnt witt� TIIIS APPLICATION. Property Dimensions: ��2 - � dC�l�. Tax Office PIN: # ,� /.� !� QUy•5�`'l" Property Address: Road Name �(J(,Z� ).� c;ty�Z;p �r��it.tv�J,h �7U� lf in a Subdivision provide informalion, as follows: Name: Section: Block: Lot: WRITE DIRGCTIONS (from Alocksvillc) to PROYL;R'I'7': ��' Q i�l Gf K.. l -� .1�� S � h C2C� J�,1 �-vr� 2c� Date Property Flagged: 3 'a-O� This is to certify that the information provided is correct to the best of my knotivledge. I understand thAt any permit(s) issucd hercafter are subject to suspension or revocation, if the site plans or inteaded use cLange, or if the information su6mitted in this application is lalsified or changed. I, also, understand lhat I am re.rponsible for a11 charges incurred fronr lhis application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described propetty located in Davie County and owned by to conduct alt testing procedures as necessary to detennine the site suitability. � DATE 3' o�-d � SIGNATUR THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN clude all the following: Eaisting and proposcJ property lines and dimensions, structures, setbacks, and septic locations). Site Revisit C�arge Da tc(s): Client I+Iotification Datc: EHS• Revised DCHD (07/99) Account No. /� � Invoice No. � ✓ e SOZ lo��'i'' 90Z9 4 �ZZ � � � �,�Z \�� l6`'�l \`� � � � � �n � M �'o 9t�Z � � �,6 \ • Z£Z �5�� : O � `d �L6'£ v, . M � f�5t�06�L5L5 � ��000000sr Z£6 9B�' �,�,Z LZ80 �0£6 �/OL6'E 6�� / � , 0 DAVIE COUNTY HEALTH DEPARTMENT - . Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001609 Billed To: Jimmy Cowan Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5757-19-0454 Subdivision Info: Location/Address: Dalton Road-27028 Property Size: 1/2 acre + Date Evaluated: �-/�- jj/ Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit HORIZON III DEPTH Texture group ('nncictPn[�r SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RA REMARKS: Public � Cut EVALUATION BY: 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 - Sil[y clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C- Clay Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 - gaUday/ft2 DC�ID OS/99 (Revised) ■�■ iii ■■■ iii iii ■■■ ■■■ ■■��■ ■��■ ■��■ ■�■■■ ■��■�■■■ ■■��■�■ ■��■ ■■■��■■ ■��■��■ ■■�■��■ ■��■�■�■ ■��■�■■�■■■L9% ■■■■�■■��■■■■ ■��■ ■■�■��■■�■■�■ ■��■��■�■ �...... .... ...... .... ............. ............. ■■��■■��■��■ ■��■■■■�■��■ ■��■��■■ ■��■■■��■■ ■■■�■��■�■�■ ■��■■��■■ ■■��■��■�■■ ■■��■■�■��■ ■■��■��■■�■■ ■��■��■��■ ■��■■��■■�■ ■�■��■��■�■ ■■�■■�■�■�■�■ ■��■�■��■��■ ■■�■■■��■��■ ■��■■��■■�■■ ■■■■�■�■�■�■■ ■��■ ■��■ ■■■■ ii ■■ i iii iii ■�■ ■�■ ■�■ ■�■ ■��■■ ■■■�■ ■�■�■ ■�■�■ ■��■ ■�■■■ ■■�■■ ■■�■■ ■■��■ �.... .... ..... ..... ■■■■ ■■��■■ ■��■ ■�■�� ■�■■ ■�■■�■ ■■■■�■ ■��■�� ■�■v■�■ ■�■��■ ■�■■■■■ ■■��■ ■��■��■ ■��■ ■■�■■�■ ■��■�■ ■�■�■�■ ■�■�■�■ ■��■�■ ■��■��■ ■��■■■ ■��o■■ ■■�■�■■ ■ ■��■■��■��■■ ■�■��■■��■■ ■�■■��u■�■�■ ■�■■��■■■ o�■■�■��■■�■ ■■■■�■■�■�■■■■ ■■■��■��■■��■ ■��■ ■�■��■■■ ■o■■��■��■�■■ ■■■��■��■�■■ ■■�■��■��■��■ ■■��■ ■■��■�■■ ■�■�■��■��■�■■��■�■■��■��■ ■�■�■■��■��■��w■��■��■ ■��■■��■��■■■��■■■��■■■� ■��■��■�e��■■�■■��■��■� ■■■■��■■��■■�■��■■�■■��■■ ■■�■��■■�■��■��■■��■�■��■�■■ ■■■■■��■■��■��■■��■■■■■■■■�■ ■��■■�■■��■�■■��■■��■■��■�■ ■�■�■■�■■�■■�■■�■■■��■■ ■■��■��■■�■■��■��■■■��■��■�■ ■■■��■■��■��■■■��■��■■�■ ■■��■■��■�■��■■��■■■ ■■■■��■�■■��■■■��■��■■■ ■�■■��■��■�■■��■■��■��■■■■ ■■��■■�■��■■��■■■■�■��■■ ■��■■�■�■■��■■��■■�■��■��■ e�■�■■�■■■�■��■��■■��■��■■ ■■■■�■■�■■�■��■��■�■��■��■■ ■■��■■��■■■■■��■��■■��■ ■■■�■�.��■■■■��■■��■�■��■■�■ ■■■■■�iJ■�■■��■��■■■�■�■�■�■�■ ■�■�■■�■�■��■■■��■■��■■■ ■��■■��■��.��■�■�■■��■��■ ��■�■��■■�■■��■■■��■�■■ ��ii�=:7��■■��■■��■��■�■�■■ ■■■■��1�■��■�■��■■■�■��■��■ ■■■■■�I�■��■�■■��■■■��■��■��■ ■��■■I��■■�■�■■��■�■��■ C:::: i'j: C C::: �:::::: �i:::::: � ......, ......................... .....►. ......................... :::==:a■■��■■�■■■�■��■�■■��a ■■�■��■��■��■��■■��■�■ ■■�■��■■■��■■■■��■��■ ■�■��■��■��■��■�■■■■■■��■ ■�■�■■ ■�■�■■ ■��■■ ■��■�■ ■■■��■ ■■�■�■ ■■�■�■ _■��■■ ■�■�■ ■■��■ ■��■■■ ■■■��■ ■��■■ ■ ■■■��■ ■■■■�■ ■��■ ■■■■■■�■■■ ■■■■��■■■ ■��■■�■ ■��■�■ ■■■■��■ ■��■■■■■ ■��■�t��■ ■■■■■��■ ■��■��■ ■��■■■■��■ ■■■■��■�■ ■■■■■��■�■ ■■■■■��■■