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1142 Gladstone RdAccount #: 990002452 Billed To: Edward Mays Reference Name: ATC Number: 3311 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5735-75-4759 Subdivision Info: v /Nz, Location/Address: Gladstone Road -27014 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 WASTEW;== FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: -�,`zq Z UN.NM 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 I 1 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: r 115 /Oo U Environmental Health Specialist's Signature: y I Date: DCHD 05/99 (Revised) Account #: 990002452 Billed To: Edward Mays Reference Name: Proposed Facility: House DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT e6/-I1._oz Ci"S Tax PIN/EH #: 55}}735-75-4759 Subdivision Info: 1�'117Z Location/Address: Gladstone Road -27014 Property Size: .85 Acre **NOTES* ThMisb)emprovement/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 #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 ❑ t System Specifications: Tank Size /DIAD GAL. Pump Tank GAL. Trench Width V Rock Depth Linear Ft. ip Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISIIED 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: L' DCHD 05/99 (Revised) . • • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department Environmental Health Section uW2 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH oavIE lE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed acluiaJ mRY S Contact Person y Mailing Address �t� 1 7 Z. at Home Phone 33G �-EJ , 4- 2—L- 0 P City/State/ZIP Cpyl e e nqe e ML- Z:tl 1$ Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ate Evaluation City/State/Zip 41- w z JZes,- ❑ mprovement Permit/ATC [I Both 4. System to Service: So'Touse ❑Mobile Home El ❑ Industry 11Other 5. If Residence: # People Z. # Bedrooms 3 # Bathrooms Lell5i'shwasher 11 Garbage Disposal 6l"Washing Machine LI Basement/Plumbing 17 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: "ounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. to S 13 Property Dimensions: 2 I IX I Ito X Z. 11 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 57 3S'- 7 5—+ -7 S" C) Cc31 Y1tip��yued-��:�eJ 4- %�o�s� ►�*� Property Address: Road Names City/Zip t^vyJlevv-4.- If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: C1 - I t. - D Z This is to certify that the information provided is correct to the best of my knowledge. 1 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 to conduct all testing procedures as necessary to determine the site suitabili DATE I- / G - a 2- SIGNATURE Y 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) [�T's I IJ rT Site Revisit Charge Date(s): Client Notification Date: EHS: Account No.0 !d 5Z Invoice No. 3/ S2 V'a W �- 3'D�(e (5.91 A) I J , 6191 222 s i o , 109 9957) ,t 1:68 A 108 43, N • 00 8023 CO I 0')(2.22A) } 4052 9979 C-0N (1.30A) rn F o (1.06A) 2987 F co 1925 172 100 I IW W 4 S 1118 100 rn 103 149 75 173 N 7874 0 97 135 © E E r N 88 91 -P N 7863 • No N 6860 cv • • 67'7 8759 U' 9737 1 00 4759 N 6 2736 � 3736 o C) ` • o r, .1 • O • • • OI 1 8111 - 77 100 A 111 i 176 SR 1119 F--- - - W __All 5 1 V fV 4 5 3 (165) 41 119 100 10 6 0 100 100 :? 00 g3 6547 --� � � ti • I 356- o C � • • I • � 856 rt „l (1.88A) I D 9521 3'� 1 — 7503 W � NNS > IC31 a 0419 1416 M r 10 2414 Ic:) W X42 2p NI 3482 6 i o 65 35 26 C) g6 2 C) 112 � O APPLICANT INFORMATION Account #: 990002452 Billed To: Edward Mays Reference Name: Proposed Facility: House Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5735-75-4759 Subdivision Info: Location/Address: Gladstone Road -27014 Property Size: .85 Acre Date Evaluated: , -y 2 On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope %ge HORIZON I DEPTH t Texture group Consistence Structure Mineralogy HORIZON II DEPTH y Texture group Consistence Structure iG Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION V� LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscape Position EVALUATION BY: X14�/ OTHER(S) PRESENT: 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 k - Very friable CONSISTENCE FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S - Sticky VS - Very Sticky SP - Slightly plastic P - Plastic VP - Very plastic M - Massive CR - Crumb GR - Granular ABK - Angular blocky blocky PL - Platy PR - Prismatic In inches inches :on - Thickness and inches from land surface table), U(unsuitable) aches from land surface to free water or inches from land surface to soil colors with chroma 2 or less S(suitable), PS (provisionally suitable), U(unsuitable) Ln acceptance rate - gal/day/ft2 ■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■ ■ ■ ■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■ ■■■■■ ■■■■■ ■E■■■ September 30, 2002 Edward Mays Box 172 Cooleemee, NC 27014 Re: Site Evaluation/ Gladstone Road Tax Office Pin #5735-75-4759 Dear Client(s): As requested, a representative from this office visited the aforementioned site on September 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, �il.�•t��L�ld Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df