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136 Everhart RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002002 Billed To: Homeworks Custom Builders Reference Name: Aaron Elwood red 10-I te-a t Tax PIN/EH #: 5767-27-8210. HC -B Subdivision Info: Location/Address: Everhart Rd -2702$ Proposed Facility: Residence Property Size: 1 acre ATC Number: 2980 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). 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 WASTEWATE C T UCTION VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: _ Date: Z( CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion sh1 in 'cate the system described on Improvement/Operation Permit has been installed in compliance with Article 1 of .S. hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be to en a a g grantee that the system will function satisfactorily for any given period of time. a Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: &�2j Ido DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section /�Id—/6--16 ,P. O. Boz 848/210 Hospital Streetl Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002002 Tax PIN/EH #: 5767-27-8210 Billed To: Homeworks Custom Builders Subdivision Info: Reference Name: Aaron Elwood Location/Address: Everhart Rd -27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2980 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a 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 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 2f #People y7 #Bedrooms %-? #Baths 2 Dishwasher: Garbage Disposal: ❑ Washing Machine: 710' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size L Type Water Supply--Ak%"esign Wastewater Flow (GPD)YZ.2 Site: NewO/Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width�� Rock Depth 1zLinear Ft.c� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact are County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p. . to 1:30 .m. on the day of ins llation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: 1/6/ DCHD 05/99 (Revised) 1 CT 4 '('PCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 I (336)751-8760 *.I-t,IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed t-tbdYlSl. &1 (eS AL)STIM, UylLp"LILs Contact Person JOCGPL0,SV—`( Mailing Address �Vy[�� lY �� Home Phone q� City/State/ZIP Q3'VQ-:Yj5(30Q0 h)C= J -79 r l -y Business Phone 3](6b 2. Name on Permit/ATC if Different than Above Mailing Address 732 812cyieW8u W jT- 3. Application For:4Site Evaluation 4. System to Service: -ZHOUSe Mobile Home 5. If Residence: # People" City/State/Zip Le -L.1 t5V,1.a 0C- 2-7023 ❑ Improvement Permit/ATCI Both ❑ Business 11 Industry 11 Other # Bedrooms 3 # Bathrooms r2— dishwasher ❑ Garbage Disposal Washing Machine II Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People It Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City H'Well II Community o. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes %ti -Kb If yes, what type? ***Id1PORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFOILNIA170N REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: ( Aey— Tax Office PIN: # 5 7 (� )'Z-7 &I 10 Property Address: Road Name E'V<-a fl &aT 2D_ City/Zip { t+1me5u I we &fit^ If in a Subdivision provide information, as follows: Name: WRI'T'E DIRECTIONS (from Mockm,ille) to 111ZOPE IN: X57ori t09 •412 �� Or,J TOE �( o �It-1 T_ ! Section: Block: Lot: Date Property Flagged: ( b This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I nm responsible jar all charges ineurrerl from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmcnl to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE 1013A, SIGNATURE L'l` THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Rcvisit Charge Datc(s): Client Notification Date: EIIS: Account No. q� Invoice No. T v (359 (7.39A) , A) 1038 co _...._ N • �r 503 (340) C 6 7845 co Iso 314 339 (1.57A) 7754 (261) 1773 ACP . 350 97.7.1 " 3668 7644 ca• - �o (200)( 370) (284) 165 - - - - EVERHART-RD_.. _ - _ --SR._1.810 150 N 48 J 3620 APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Account #: 990002002 Tax PIN/EH #: 5767-27-8210 Billed To: Homeworks Custom Builders Subdivision Info: Reference Name: Location/Address: Everhart Rd -27028 _ Proposed Facility: Residence Property Size: 1 acre Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring ► / Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence yi Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION D LONG-TERM ACCEPTANCE RATEi L SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: O OTHER(S) PRESENT: 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 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 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 05/99 (Revised) ■E■■■E■ ■sE■O■■ ■E■■E\■ MONOMER mass ■ ■ ■moss■■■■■ ■■■m■■m■■■ ■■■■E■E■E■ ■E■■EE■■■■ ■N■E■E■ES■ ■ ■■NE■ ■EN■■ ■ENE■ NOOSE ■■SE■ ■ENE■ ■■■E■ ■ ■ ■EE■ ■EE■ ■OS■ ■OE■ ■OO■ ■E■■ ■O■■ ■OE■ ■