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1014 Farmington Rdr' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003318 Tax PIN/EH #: 5841-66-3692 Billed To: Lowell Livengood Subdivision Info: Reference Name: Location/Address: Farmington Rd -27028 Proposed Facility Residence Property Size: see map ATC Number: 3842 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 WASTEWATER COASMUTIONIS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � IU // 7 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 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 system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: ,- % Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003318 Billed To: Lowell Livengood Reference Name: Proposed Facility Residence Tax PIN/EH #: 5841-66-3692 Subdivision Info: oe g-,2-3- �y Location/Address: Farmington Rd -27028 Property Size: see map ATC Number: 3842 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 #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 Design Wastewater Flow (GPD) Site: New,;-'-f'Repair ❑ System Specifications: Tank SizV,,I44,//r1 & GAL. Pump Tank n GAL. Trench Width��`�Rock Depth � � Linear Ft. Other: 4u � i '–v , Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** Environmental Health Specialist's Signature: Date:dP DCHD 05/99 (Revised) C [E D APPI Q k - 4 2004 �u ���ppV1EC00 FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 *ttJHPMTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed L© We- 'l_ L 1: k r V r N 4 A P c7 Mailing Address ASO Z:n /1 R jI !S )—,9Ad City/State/ZIP u i bS L e /V• e- 2. 2. Name on Permit/ATC if Different than Above a 700 Mailing Address Contact Person L0we1-1 T L i ue-ACx n d Home Phone ?415'— 3 % :5 / Business Phone City/State/Zip 3. Application For: P115ite Evaluation ❑ Improvement Permit/ATC LI Both 4. System to Service: P Hoousse' 13 Mobile Home ❑ Business El Industry 11 Other 5. Type system requested: Lai Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ,- # Bedrooms _ # Bathrooms _ 9Dishwasher []Garbage Disposal WII� aching Machine ❑Basement/Plumbingasement/No Plumbing 7. If Business/Industry /Other verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: #��See/ats Estimated Water Usage (gallons per day) 8. Type of water supply: Ud'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yesi o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 0 k Ll X 0 X 1/e x !V) a N WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #�5 a'�f l (9 6 3 Property Address: Road Name Q- ih( /�' LP - 11 Fa r n I req ' 011 City/Zip 0 i YIN e $rookcfiG^Ol j If in a Subdivision provide information, as follows: • I at 5 �- /,V\ 'f ru N 7 c5 -t" Ll) e - ?q is e Name: Section: Block: Lot: Date home corners flagged: This is to certify that the information 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 intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I ani responsible for all charges incurred from this application. 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 the site suitability. DATE SIGNATURE /ftyC.-� .t . 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). Sign given_ Revised DCHD (05/03 0 .i- I� �I v �I Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. 3 '� 7 7 lZ tia 4 v", V 5, Nq 10, 'M W MIR "T "'iz'i'MI",%��, W AA h 20 4 W M4, R5 iip, R, �V Wo ................il� VK e Lo 209 T-7 ............ Yt,\1 g mg y arlgj �w El ll� (2.03A) gtpp� 3692 RT 41— ova G in, 909 vffi JBIMMIM G, a r£ a4 Q 1 0- M FNV� lull a 4DRE g, IN Nil wjpo v 4 Al f RAM StOw-mm", M Y 7, 4:1 40 my-- fi 15 ll • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003318 Billed To: Lowell Livengood Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5841-66-3692 Subdivision Info: Location/Address: Farmington Rd -27028 Property Size: see map,,Date Evaluated:/ Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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: ` EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: /I�� l Yc�r : . /c :lit' LEGEND 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 AMA 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) ■ ■ ■ ■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■t■■■■■■trot■■■■■■■■ ■■■■■■t■■t■■■■■■t■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■ ■ ■ ■