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154 Hearthside LnAccount #: 990002195 Billed To: Jeff Crisco Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5769-21-5016.JC Subdivision Info: Location/Address: Heatherside Drive -27028 Property Size: 10 acres ATC Number: 3167 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 WA O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: /� O 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 aken as a guarantee that the system will function satisfactorily for any given period of time. � - /6S �10 l� ,y1b .--�-y V u,tz Septic System Installed By: 1� Environmental Health Specialist's Signature: //� Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT 4 ' Environmental Health Section Q Co a-" • P. O. Boa 848/210 Hospital Street I J Mocksville, NC 27028 &`� b (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002195 Tax PIN/EH #: 5769-21-5016.JC Billed To: Jeff Crisco —Al Subdivision Info: Reference Name: Location/Address: Heatherside Drive -27028 Proposed Facility: Residence Property Size: 10 acres ATC Number: 3167 **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. 14 Residential Specification: Building Type #People #Bedrooms N#Baths Dishwasher: X*, Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ CommercialSpecification: Facility Type #People #People/Shift #Seats Industrial Waste: El� ff //��TT Lot Size Type Water Supply O� � Design Wastewater Flow (GPD)''SOU Site: NewJO'' Repair ❑ System Specifications: Tank Size/UDU GAL. Pump Tank GAL. Trench Width t.� Rock Depth dr Iq Linear Ft -6 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: p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** r �L Environmental Health Specialist's Signature: / , Date: 6 w DCHD 05/99 ((Revised) dL S '• APPUCATION FOR SITE EVAWATION/IMPROVEMENT PERMIT & ATC D L5 Q • Davie County Health Department . ( Environmental Health Section P.O. Box 848/210 Hospital Street MR 8 2�_,D Mocksville, NC 27028 (336) 751-8760 ENUI pA�VIE COAL HEALTH ***nWCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Hamm to be Billed I [- E� � l_ 1'� �S CCS Contact Parson Kms, /e Swl c eel�Q e� Mailing Address _RS�TT V 11 Rome Phone City/State/ZIP "nC (CSU 1 1 (t (j L U 20 Business Phone 7 $7 I - �y 2. Mas» on Permit/ATC if Different than Above Mailing Address City/State/Zip r e.I l c¢_Sftil 3. Application For: ."ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. Systen to service: douse ❑ Mobile Rome ❑ Business ❑ Industry ❑ Other 5. If Residence: i People # Bedrooms L s Bathrooms .� J3-Dish,mober ❑ Garbage Disposal ArWashing Machine ❑ Basement/Plumbing ❑ Basenent/No Plumbing 6. If Business/2ndustry/Other: Specify type # People # Sinks # Comsiodes # showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Eatimated Water Usage (gallons per day) 7. Type of Mater supply: 0 County/City ell ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ 'Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensiods: IC •a Cge 5' _ 4T WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 6'7 (o y Z I so l J C M?.0 P - - 1hP'c'( '7 1 Property Address: Road Name peas l s; do 2A:1✓V_ city/zip n 1Z CoQrJ.4i 2c2 If in a Subdivision provide information, as follows: Pas' - 4a t Name; u t 1 'S�: 1.. i t -)*y Co + 6 '� 6Z a eat �f e e//1ew Fla s Section: Block: Lot: Dante Property > agge 1: M19 9C4 S= 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 1, also, understand that I ant responsible for all charges Incurred frons 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 ;� I� I D Z SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the allowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 64/02- e.', EJ."'dr �- gi S b 1* P vt lJ•t' (�2 2�_ — t`cy-O' t'_ -s we - s Revised DCHD (07199) Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. C g Invoice No. 3 • ,--•• ori. � *' nQCY ... A '•4 7 t Wf ot4 v /• ;, a. F n n y v S Cid`• �: ,� r l 41, S :•+y 1' . ^ Fs+{ tiiw, .y; M,°°i�}j.;' "ti ,i E ,:. 3. 406 V 66.4 ,8 A,c� 1 Al - , l ; �.. '"far 1 OA! ` V 1 3A ,c 16 bY3:5 N, 8 ?' 6tM 36 4 v 820.3 66 *,, C4` 9q 4.2.5 Ac 5 2 c 183.34 i $ � 34A 29 15 Loi , ,• • Q , ' CD 73 ;'�7AC, 2.OIA` 6�y k 2 l�f-8o 2 zj S, 5.4 S ac `.1° w 2 A 318 ° ?' w D o O 8.7 ., t4605$�5. :'S0 t _ Ac) i DAVIE COUNTY HEALTH DEPARTMENT • - - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002195 Billed To: Jeff Crisco Reference Name: Proposed Facility: Residence Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5769-21-5016 Subdivision Info: Location/Address: Heatherside Drive -27028 10 acres Date Evaluated: -3 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 '2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH'i ci 4k Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure f0 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION L2 162 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: %/� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: i' ; ► I %tV*11 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) It to YY ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09.40.06 Mocksvilie, NC 27028 Phone #: (336)751-8760 March 20, 2002 Jeff Crisco 854 Valley Road Mocksville, NC 27028 Tax Office Pin: # 57 69-21-5016 Dear Client(s): As requested, a representative from this office visited the aforementioned site on March 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, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df