2162 Farmington RdHEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
- P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Tim Shore
Address: 2162 Farmington Road
City: Mocksville
State2ip: NC 27028
Phone #: (336) 998-0758
For Office Use Only
*CDP File Number 123525 -1
County ID Number:
valuated For: HDR/WWC
PERMIT VALID 1 0/ 0 1 / 2 0 1 8
UNTIL:
I—
Property Owner: Tim Shore
Address: 2162 Farmington Road
City: Mocksville
State2ip: NC 27028
Phone M (336) 998-0758
Property Location & Site Information
Address2162 Farmington Road Subdivision:
Road # Mocksville NC 27028
Township:
Directions
hwy 158, turn left onto Farmington Rd. go toward end property on left.
`Structure:
SINGLE FAMILY
# of Bedrooms- 3
'Water Supply: PUBLIC
Basement: n Yes ❑ No
'Proposed Improvement:
Horse Barn
# of People:
Phase: Lot
Type of Business:
Total sq. Footage: No. Of Employees:
elease Conditions
It is the responsibility of the owner to maintain a 5 foot minimum setback between the wastewater system and any part of the structure
foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? Oyes QNo
Applicant/Legal Reps. Signature;
*Issued By: 2244- Daywalt, Andrew
Authorized State Agent:
*Date: /
*Date of Issue: 1 0/ 0 1/ 2 0 1 3
**Site Plan/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
O Hand Drawing Olmport Drawing
0565 DAVIE COUNTY HEALTH DEPARTMENT
l e Environmental Health Section PROPERTY INFORMATION
•.�.�.Jli/� � Y: P.O. Box 848
Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: _�� Ii r .r7 %t.; l �/ Section: Lot:
AUTHORIZATION FOR
A�� A
WASTEWATER Tax Office PIN:# 3
SYSTEM CONSTRUCTION _ (�
Z Road Name:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
1 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION Q
C �'�'.r%� i' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTHSkCIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE f`7� # BEDROOMS; # BATHS OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILrrY TYPE # PEOPLE # PEOPLE/SHUT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 71'67! TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE I//REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH 1.-"<L LINEAR FT. �40
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACr A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 -1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
OPERATION PERMIT
ALLEDBY: �""��J1e' L&y%Y
iL!
goose
O J 1G jj/j7Z3 Co/�
AUTHORIZATION NO.OPERATION PERMIT BY: + A � A^M Atli, DATE:��
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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.
DCHD 05N6 (Revised)
Froc Gentiva 704 872 6320 09/13/2013 07:44 #126 P.001/002
.W " ..
Davie County Health Department
Q 6 ,.V'Cui IRRIvu'onmental Health Section
P.O. Box 818
210 Hospital Street
p CI Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: -7—,',,) S `7 u re_ Phone Number 336- S1 c1 E' 07S-9- (Home)
Mailing Address: 2_ Za Z Fc,rM:ti,•jcn ( 332- 5-75^ 6 /.s'tr (Work)
27uZe 7tv hort✓® yacf4e- l• n e��-
Detailed Directions To Site: W' -S4 Ao '1' go( 'Ic-,
L ,;jf �c.rn 12 �o�St i5 �L m:lc cry iZ
Property Address: (2d _ .Moc FJ1�: dc., Z7vZ£f
Please Fill In The Following Information About The EXISTING Facility: '6'�-_ (J 0(]_0 k1 X02
Name System Installed Under: �/ U 1'` 1 'P'�`'� Type Of Facility:
Date System Installed (Month/Date/Year): 7 Number Of Bedrooms: 3 Number Of People: 4
Is The Facility Currently Vacant? Yes No If Yes, For How Long?.
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: I7"rs" ( Orn Number Of Bedrooms: Number of People
Pool Size:
Garage Size: Other;
Requested By: � Date Requested: y-1.3-0
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check
Money Order #
Amount•$ Date:
Paid By: Received By:
Account #: Invoice i
h7a�Q��9
CD��1235�
A16L q/05_113
From:Gentiva
704 872 6320
70
09/13/2013 07:44
#126 P.002/002
a
AUTHORIZATION NO: 0565 DAVIE COUNTY HEALTH DEPARTMENT ! 30
r Environmental Health Section PROPERTY INFORMATION
Permitte'e's, P.O. Box 848
Name: ►1
� / %'• Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: _ Z-,1: 'T/V/".''o Section: Lot: _
" I AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Alk -Z'
Tax Office PIN:#�
Road Name: ' 120) 'k ' m%
A r%0�)'F
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
.% J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
jit:�i`�.•�'��' !� �, /��% /�% IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALT `SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
` * IMPROVEMENT AND OPERATION PERMITS
-Permittee's
Name:
Directions -to property: .rf.
-✓
PROPERTY INFORMATION
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
ffl ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�t •� ` . ' _ �f;?,:' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE /" # BEDROOMS •_�? # BATHS -tS # OCCUPANTS 4 _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS _ _ - INDUSTRIAL WASTE: Yes or No
LOT SIZE -///,( TYPE WATER SUPPLY (I DESIGN WASTEWATER FLOW (GPD) 0 NEW SITE ✓ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Z12 25 GAL. PUMP TANK GAL. TRENCH WIDTH-1-10� "' ROCK DEPTH �� / LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT \ I Y
SYSTE INSTALLED BY: YO
V-4 l`f/ �I /� j�q 7Z (o%
-Iooc>
�r
AUTHORIZATION NO. J�p� OPERATION PERMIT BY: �� I DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
x
Subdivision Name:
Section: Lot:
IMPROVEMENTPERMIT'
Tax Office PIN:#
Al 2
Road Name:_6"1`i y ' 1 t sir°i / 1 ` ' Lip:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
ffl ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�t •� ` . ' _ �f;?,:' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE /" # BEDROOMS •_�? # BATHS -tS # OCCUPANTS 4 _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS _ _ - INDUSTRIAL WASTE: Yes or No
LOT SIZE -///,( TYPE WATER SUPPLY (I DESIGN WASTEWATER FLOW (GPD) 0 NEW SITE ✓ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Z12 25 GAL. PUMP TANK GAL. TRENCH WIDTH-1-10� "' ROCK DEPTH �� / LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT \ I Y
SYSTE INSTALLED BY: YO
V-4 l`f/ �I /� j�q 7Z (o%
-Iooc>
�r
AUTHORIZATION NO. J�p� OPERATION PERMIT BY: �� I DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
• APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section�`�,
P. O. Box 848 /
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
/ / -s �1�/ALL THE REQUIRED INFORMATION, ISS PROVIDED. / /
1. Name to be Billed T �• h l 1 dSA— �V /t J one t Person
Q • �diS
Mailing Address T �_� �• (� Home Phone y 9(. '7
City/State/Zip ocks di 11 E . i e. a -;,q ;2 ,? Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address _
3. Application For:
4. System to Serve:
5. If Residence:
3"bishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
D' Site Evaluation
House ❑ Mobile Home
# People a
Er Garbage Disposal
Specify type _
# Showers
# Seats
City/State/Zip
❑ Improvement Permit & ATC ;7Both
❑ Business ❑ Industry ❑ Other
# Bedrooms 3 # Bathrooms a a•
Er Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
7. Type of water supply: County/City
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes 0 -'No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
,/ SUBMITTED WITH THIS APPLICATION.
Property Dimensions: %f ,4 /-s �C LEI . 6 � 12 25E s X513, 2,J WRITE DIRECTIONS (from
1 Mocksville) TO PROPERTY:
Tax Office PIN: # S v - - 1
1
Property Address: Road Name JCrX 1 P
1 '
City/Zip OC
1
If in Subdivision provide information, as follows: 1
O�
Name: 1
Section: Lot #: 1
1
1
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 am 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
as necessary to determin� he site suitability.
DATE SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 5-��✓ B/G,S
ADDRESS
PROPOSED FACIILTY 106Z
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE l.YiJiAE'
Water Supply:
On -Site Well _
Community
Public -4--"
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1 2
3 4
Landscape position
L.
Sloe R
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
"` g r-
Texture group
Consistence
,-
Structure
S /t
.�
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: /6
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: 2% //
OTHER(S) PRESENT:
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
S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt
SICL-Silty :lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V,_ -.-y 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
3C --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 -A
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