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1099 Farmington Rd (2)DAVIE COUNTY HEALTH DEPARTMENT i Environmental Health Section -j) Zj ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000750 Tax PIN/EH #: 5841-57-6866 Billed To: Charles Jones Subdivision Info: Reference Name: Charles Jones Location/Address: 1099 Farmington Road -27028 Proposed Facility: Private Garage Property Size: 171'x/150 ATC Number: 2157 **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 4 r Q' #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 ❑ Repair ❑ System Specifications: Tank Size 0/0 GAL. Pump Tank GAL. Trench Width .1,/ "Rock Depth l� ( Linear FtA � Other: 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.**** r Environmental Health Specialist's Signature: 2� �U' Date: DCHD 05/99 (Revised) Account #: 990000750 Billed To: Charles Jones Reference Name: Charles Jones Proposed Facility: Private Garage ATC Number: 2157 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5841-57-6866 Subdivision Info: Location/Address: 1099 Farmington Road -27028 Property Size: 171'x 150 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 WASTE CONSTRUCTION IS VALID FOPERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: - Date: 4W2 14 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. �u F /yd Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r P- APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �5 Davie County Health Department D P[ � Envii unmenta/HealthSection PIBS P.O. Box 848/210 Hospital Street AUG 2 6 1999 X Mocksville, NC 27028 0 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BB PP.C=SSED UNLESS ALL THE'R$QUIRED INFORMATION IS PROVIDED. Refer to the INVORMATION BULLETIN for instructions. 1. Home to be billed G h ar l.P 5 G Tp ci S Contact "roan e a G'l� S Ta K -eS Mailing Address t/ 3 CQ R v ! �+ y S' 7- one phone 76 1-56't 3 City/state/EIp a-1 tit S Tc) I — 5 n `Y -N 14 'e- Business phone Z. Home on Permit/UTC if Different than Above Nailing Address City/state/nip s. Application For: 0 Site Evaluation 0 Improvement Permit/ATC 19 Both 4. system to service: 0 House ❑ Mobile Home ❑ Business 0 Industry )9 other S. If Residence: # People # Bedrooms # Bathrooms 0 Dishwasher 0 Garbage Disposal O hashing Machine O assament/plumbing O Baseaant/Ho Plumbing 6. If ewiness/industry/other: specify type /lWat e. # people # sinks # Commodes _I # showers # Urinals # hater Coolers IF FOODSERVICE: # Seats Estimated Yater Usage (gallons per day: 7. Type of Mater supply: (S County/City 0 Well 0. Do you anticipate additions or expansions of the facility this system Is intended to serve? If yes, what type? (I Community 0 Yes I&No ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: / 71 ' X // f-0 Tax Office PIN: # 4- 7 - G S'G G WRITE DIRECTIONS (from Mocksville) to PROPERTY: ,1 ye )5-01T ?o rK,l f 7 y Property Address: Road Name t o 4 T F &A *i i4f 7e AA %oa y re H ft r4, 7 u .c n d � 7' T City/zip m or- Ar v,'/%e 01 e - If in a Subdivision provide information, as follows: Name: Section: Block: Lot: d yo 2 1 1 M i'/1 S 40 fZ2 01-1 I -t -f1— aT imo I Pay wiT 4 /6717 ,3457- fotT Ge/�' o,��s R6v7y,r jlec% PAc Vrvsy. a0440fA s 1ogTF.#Arn,nyiGN Alf, Date Property Flagged: This is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit($) 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. 1, also, understand that I am responsible for all charges Incurred from this applicadom 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 • ,2 -f SIGNATURE 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). _ wcc1 �r Site Revisit Charge Date(s): �• �, o Client Notification Date: i u. x 3 �► 1 a 4r _ r EHS• �41 Account No. S� Revised DCHD (07/99) Invoice No. _ i .�' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000750 Tax PIN/EH #: 5841-57-6866 Billed To: Charles Jones Subdivision Info: Reference Name: Charles Jones Location/Address: 1099 Farmington R ad -27028 Proposed Facility: Private Garage Property Size: 171'x 150 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 Slope % 1;2 HORIZON I DEPTH 1- 4� r' Texture group -Irl- 52,141- 1 Consistence Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure IVL 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: r J !� IIa �, LONG-TERM ACCEPTANCE RATE: ' REMARKS: LEGEND EVALUATION BY: 9v4- 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) ■■SSM■■ ■■■mono ■■M■M■■ NEON■■■ MONSOON ■Mm■EM■ ■EMEMM■ ■■MM■■■ ■N■M■M■ ■M■E■■■ ■■MM■M■ ■■■■ME■ ■M■■■■■■M■ ■EMME■ENE■ ■■■■MNMMN■ ■■MEMO■■M■ ■MNEME■■■■ ■M■■M■■M■■ ■M■M■■M■E■ ■■MEMS■■■■ ■SEM■EMS■■ ■■MEMS■■■■ ■■■M■■■■M■ ■■■MM■■■E■ ■M■■■EE■M■ ■MM■M■■E■■ ■■M■■SSS■■ i i iii is OMENS ■■M■■ MESON ■■■M■ SENSE ■E■M■ ■M■■■ OMENS SOMME ■■N■■ ■■■E■ ■■■■■ ■E■M■ ENOZ MEMO MEMO ■EN■M■M■■ ■EM■ME■E■ ■EMEMM■■■ MENOMONEE ■ENO■■■■■ ■ENOMO■■■ ■■■■■EM■■ ■■■■MSN■■ ■■MM■■■■■ ■■■■■■M■■ ■NE■■E■■E■■■■ ■M■■■■■■■MM■■ ■EEM■■■■M■■■■ ■■M■■■■■M■■■■ ■■■M■■■■■■■■■ ■ME■■■E■MM■■■ ■■MM■M■M■■MM■ ■■■■■■■■■■■E■ ■■■MM■MN■■■■■ ■■■■MMM■■■■■■ ■M■■■■■■■■■■■ ■mFMMM■EE■■N■ ■■t■■E■■M■■E■ ■OMMEM■■■E■E■ ■ ■■M■■E■■■■MM■■■■ ■N■■■■■■■■■■M■■■ ■■■■■■■■■■■■EMM■ ■■M■■■■M■■■■■M■■ ■■■■■■■■■■■M■■■■ ■M■■■■■■M■M■■■■■ ■■M■MM■■■M■■■■M■ ■MM■■■■■■MEE■■■■ ■■■■■■■■■NMN■■■■ ■■M■■■■■ME■M■■■■ ■■M■M■■■M■■■M■■■ ■■■■EM■■EME■■M■■ ■MM■■E■ME■MEE■E■ ■■■M■■■■■■■■MMM■ ■■MMM■■ME■E■ ■■NEEM■MMM■■ ■EE■■MM■■■M■ ■■■MEEMME■E■ ■■■M■■■MMM■■ ■■MM■■■■■M■■ ■■■■■ME■■■M■ ■■■■■MM■■■M■ ■MMEEE■M■■■■ MEMO ■■