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154 Flat Rock Rdt • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002506 Tax PIN/EH #: 5735-77-6257 Billed To: Jason Magallanes Subdivision Info: Reference Name: ATC Number: 3532 Location/Address: 154 Flatrock Road -27028 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 WASTEWATERgTRUCTION IS VALID FOR A PERIOD OF F VE YEARS. Environmental Health Specialist's Signature: Date: 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 a antee that the system will function satisfactorily for any given period of time. P" Septic System Installed By: P Y Environmental Health Specialist's Signature: AoG I 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 M 990002506 Billed To: Jason Magallanes Reference Name: Proposed Facility: Residence Tax PIN/EH M 5735-77-6257 Subdivision Info: Location/Address: 154 Flatrock Road -27028 Property Size: see map ATC Number: 3532 **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. 11�Residential Specification: Building Type M T#People 1 #Bedrooms ',? #Baths _ Dishwasher: 0Garbage Disposal: ❑ Washing Machine: 21"" 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) Sz?&/ e). Site: New Repair ❑ System Specifications: Tank Sizeeae GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �—?6 "Rock Depth %V f'Linear FtkFOe 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.**** 1 -I Environmental Health Specialist's Signature: �' // Date: DCHD 05/99 (Revised) < APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Q 2 E Environmental Health Section ©v P.O. Box 848/210 Hospital Street Mocksville, NC 27028 1Ro�av1tpNyF`LjH (336)'151-8760 EP1y n kl , E -S _,—*'*-IMPORTANT*** THIS APPLICATI CANNOT BE PROCESSED UNLESS AM THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Addree City/State/ZIP 2. Name on Permit/ATC if Different than Mailing Address 3. Application For: 4. System to Service 5• If Residence: Contact Person /Ltdsr2 /- Home Phone L,)5 r -- -911V Business Phone 402 - City/$ta a/Zip to Evaluation ❑ Improveme3 t C) 1 ❑ Both ❑ House Ergo—bile Home ❑ Business ❑ Industry ❑ Other # People _ It Bedrooms 3 It Bathrooms 2- U U Dishwasher U Garbage Disposal , 14-Vashing Machine ❑ Basement/Plumbing Ia Basement/No Plumbing 6. If Business/Industry/Other: Specify type It Commodes # Showers It Urinals # People It Sinks # Water Coolers IF FOODSERVICE: # Seats . Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well CI Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 4 4-PIo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBb11TTED by the client with TIIIS APPLICATION. Property Dimensions: ,� `�='L-/� WRITE DIRECTIONS (from Mo6svillc) to PROPE'RTY: Tax Office PIN: Property Address: Road Name City/Zip /lo.oh il/�. ZzDZ,S' If in a Subdivision provide information, as follows: Name: ] % Section: Block: Lot: Date Property Flagged: 1 l l t 0 2�— 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 frunn this application. 1, 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 THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 1� � 1 A / /1 Da te(s): EHS: Account No. Revised DCHD (07/99) o/ ✓ Invoice No. `� f C /n -v ROPO Q�oefooa� FLP iko ,x011 'A i o, � J -prTBJV" Xj0NAL No.1JEA-11X17 �S �-' pP�G • \5 p0� OA ? N 03• A9 °eo AREA = 2.189 ACRES Persimmon tree UA N Q Ir new 5 iron 1716.00 THOMAS E. PARSLEY D.B. 151 PG. 720 (533) (6.42A) 6257 . DAVIE COUNTY HEALTH DEPARTMENT • Landscape position Environmental Health Section Sloe % Soil/Site Evaluation HORIZON I DEPTH APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002506 Tax PIN/EH #: 5735-77-6257 Billed To: Jason Nogallones Subdivision Info: Reference Name: Location/Address: 154 Flatrock Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut Mineralogyi HORIZON III DEPTH FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group TC4 T6TF- Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence { Structure Mineralogyi 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 c , SITE CLASSIFICATION: �D J�WW7� EVALUATION BY: T6hyL LONG-TERM ACCEPTANCE RATE: �l OTHER(S) PRESENT: REMARKS: 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 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) ■ ■ ■ ■ ■ ■■■■IMI■■■■■■►:i■■■■■■■■■�■■■■■■■■■ ■■■■I■■■■■■■III■■■■■■■■■■■■■■■■■■■■ ■■■/■■■■■■■►iii■■■■■■■■■■■■■■■■■■■■■ Mr ■■■■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■M■■M■■EM■■■MM■ ■EN■E■ ■ME■M■ ■■OMEN ■ENNE■ ■■■■■■ ■■MME■ ■E■EM■ ■ ■ ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 November 21, 2002 Mr. Jason Nogallones 154 Flatrock Road Mocksville, NC 27028 Re: Site Evaluation/ Flatrock Road Tax Office Pin : #5735-77-6257 Dear Client(s): As requested, a representative from this office visited the aforementioned site on November 19, 2002. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, A ea &. 4 ;V 'IlAaA. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 1y P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 AER/MIT IMPROVEMENT/OPERATION -7 Account #: 990002506 Tax PIN/EH #: 5735-77-6257 Billed To: Jason Magallanes Subdivision Info: Reference Name: Location/Address: 154 Flatrock Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3532 **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 /// , /1 4 #PeopIZ 1 #Bedrooms ',-? #Baths;_ Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: JEr"' 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/ GAL. Pump Tank Other: Required Site Modifications/Conditions: e� GAL. Trench Width -?Z "'Rock Depth .4 Linear Ft1?ZY1 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.**** FL4 1r/✓C y t✓ Environmental Health Specialist's Signature: bl: /Z Date: f ✓/ DCHD 05/99 (Revised)