Loading...
995 Howell RdDAVIE COUNTY HEALTH DEPARTMENT NP Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900595 Tax PIN/EH #: 5823-63-7211.000EP Billed To: John Shelton Subdivision Info: Reference Name: John Shelton Location/Address: Howell Road -27028 Proposed Facility: Residence Property Size: 4.76 Acres ATC Number: 2056 **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 � 9 #People #Bedrooms Kj!- #Baths :V -- Dishwasher: 21"' Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply P l( Design Wastewater Flow (GPD) Site: Site: New 0 Repair ❑ System Specifications: Tank Size,&� GAL. Pump Tank GAL. Trench Width,.Z Rock Depth -M Linear Ft. °VD7> Other:CI(/ 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.**** Environmental Health Specialist's Signature: 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 Account #: 989900595 Tax PIN/EH #: 5823-63-7211.000EP Billed To: John Shelton Subdivision Info: Reference Name: John Shelton Location/Address: Howell Road -27028 Proposed Facility: Residence Property Size: 4.76 Acres ATC' 4ttmber: 2056 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OFF FIVE YEARS. Environmental Health Specialist's Signature:i 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 as a guarantee that the system will function satisfactorily for any given period of time. 1 dL.;j- j5 `�' o, OD' Qp' Septic System Installed By: Environmental Health Specialist's Signature : n DCHD 05/99 (Revised) APPLICATION FOR SIZE EVALUATION/111PROVEAAENf PERMI 11 Q �( b _ Davie County Health Department Envlronmenfal Health SeWon O. Box 848/210 Hospital Street %m 1 1999 Mocksville, NC 27028 1336) 751-87 VNIRONMENTAL HEALTH f� a DAVIE COUNTY * * * IIKPORTANT* * * THIS APPLICATION CUNM BE PIM INFORMATION IS PROVIDED. ccRefer to the IUMPI 1T 1. Name to be Billed tD k IV•�J Bailing Address %76' City/state/ZIP2-70,22 a. Name on Permit/ASC if Different than Above D UNLESS ALL TIL REQUIRED BULLETIN for instructions. Contact Person Home Phone Business Phone Bailing Address City/state/Zip 3. l►pplioation For: WSite Evaluation ti G Improvement Permit/ATC Oth dG 4. system to service: 0 House IU3�Mobile Home 0 Business D Industry 0 Other s. If Residence: # People �# Bedrooms # Bathrooms W Dishwasher 0 Garbage Disposal 3'Nashing Machine 6. If Business/Industry/other: Specify type # Coa modes # showers 0 Basmait/Plumbing 0 Basement/No Plumbing # People # Sims # Urinals # Nater Coolers IF FOODSERVICE: Ii Seats Estimated stater Usage (gallons per day) 7. IYPe of water supply: 0 County/City 0 sell I 0 Community s. loo you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes "o If yes, what type. ***IMPIDRTANT*** CLIENTS A1UST CVJfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBAOTTED by the client with THIS APPLICATION. Property Dimensions: 7. 7Z0 Jc4, Tax Office PIN: # J� 3 'lo — %a I ProPeqyAdw s: Road Name tf D <I e City/Zip ��'�- /1�<<• a7o-z g If in a Subdivision provide Information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksvllle) to PROPERTY: fd /,& �.Gu .�i_ �R Id- .i A I t / i n At Date Property Flagged: a:qw This is to certify that the information provided is correct to the best of my knowledge. i understand that any permits) 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 ebanged. I, also, understand that I am responsible for all charges incurred frons this appUcation. 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 tability. DATELA-.�g SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07198) Account No, Invoice No. 153 L40 71,�'P ' MsB 11~h'B EnI3 �.... 1836 s�o w "' This map is for PERC TEST 211 0281 and BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office assumes no liability for any information contained on this map, F F.)M! MsC MSC 7270 aim COUNTY -ID: C300000126 June 01, 1999 1:22 PM MrC2 Parcel Identification Number �°° 5823-63-7211 DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: - 989900595 Billed To: John Shelton Reference Name: John Shelton Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5823-63-7211.000EP Subdivision Info: Location/Address: Howell Road -27028 57 Property Size: 4.78 Acres Date Evaluated: % Z ; Water Supply: On -Site Well I Community Public Evaluation By: Auger Boring f/ Pit Cut FACTORS I 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH C91 Texture rou G' Consistence - Structure 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 'P_ SITE CLASSIFICATION: 4X M tt.�4=2 -0v— -' LONG-TERM ACCEPTANCE RATE: REMARKS: t-( EVALUATION BY: ' A5 l/ 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 01 As 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 - Angu SBK - Subangular blocky PL - Platy PR - Prismatic MineraloaX 1:1, 2:i, 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 soi Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD (Revised 05/99) ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ i ■■ MEMO MEMO SOMEONE ■■ME■■■ ■MEMO■■ ■■EEE■■ ■E■■■■■ ■EEE■■■ ■E■■E■■ ■■MEMO■ ■■■■■E■ ■■E■■E■ ■■■■■■■ ■E■■■E■ i■■■■■■■■UMMOM■■ ■■■■■ME■MEMOM■E■ ■EM■■■■II■■■■■■■ ■■■■■■■■■■■■■U■ ■■■■■■a■■■■■■ ■ ■■M■■I■■■■■■■■■■ ■■■■I.M■■■■■■■■■■ ■■■rm■■■■■■■■■■■ O■■A■■■■■■■■■■■■ ■onMMMM■■M■MM■M■ ■ ■ ■M■MMMMMMM■■M■ ■MMM■MMMMMMMM■ ■■M■■■■■■■■■■■ ■■■■■■■■■■■■M■ ■■MM■■M■■■■■■■ ■■■■■■■■M■■■E■ ■M■■■■■■■MESE■ ■■■■■■■■■■■■■■ ■■■/■■■■■■■■■■ ■■■E■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■M■■M■■■■M■■ ■■■E■■■■■■■■■■ ■■MM■■■■■■■■■■ ■■■■■■■■■■M■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ UAMM■■■■■■■■M■ v3vMM■■■■■■■■■ ■■a■■■■■■■■■■■ ■■M■■■■■■■E■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■M■■■■ ■E■■MMEMM■E■EME■ ■EMMME■EMM■MME■■ ■■■■M■■ME■OMME■■ ■E■ME■■M■■MEM■E■ ■O■■ME■EM■■M■ME■ ■■M■EM■MMEM■■M■■ ■E■EMMUMEME■■E■ ■M■ME■ ■M■MEM■■ ■■MMM■MMM■MMM■M■ ■E■E■■ME■EMME■E■ NONE" ■MEMS■ ■EMM■■ ■E■■■■ ■E■■E■ ■■■■E■ ■■■■■■ ■EMEM■EMMEMEM■ ■EMOMME■M■MM■■ ■■M■MMEMMOME■■ ■EMEMEMEMEMME■ ■■MMEME■E■■E■ ■E■■M■EMEMMMMI ■EMM■M■■M■■M■■ ■■ ■ ■E■E■ ■E■■■ ■EM■■ ■OMMEME■EMEM■■M■ ■MM■■MMMMMEMMM■■ ■EMEMMEMM■■EMEM■ ■■MMEM■E■■EM■■M■ ■M■■■■■■■■■■MMM■ NUMEM■M■MM■■■M■■ ■MMEMM■M■M■M■M■■ ■w*•M■MMM■■MMMM■ ■M■M■M■■MM■■■■■■ ■M■■■■■■M■■■■M■■ ■■■■■■■■■■■■■■■■ ■■MMM■MMMMMMMMM■ ■■MM■MM■■■■■M■M■ ■■MM■M■MMM■M■M■■ ■EM■■■■■O■■■■■■■ ■■MMM■■■MM■M■M■■ ■■M■M■M■■■■■■■■■ ■■MM■M■■MM■MM■■■ ■EM■■■■■■■■■■MM■ ■E■■■■■■■■■■■■■■ ■M■■■■M■M■M■■M■■ ■■M■M■■■■■■■■M■■ ■■■■■■■■■■■■ ■■■■■■■■M■■■ ■OMMEMME■EMEME■ ■EEMME■■EMM■M■■ ■EMEME■■MEMEMM■ ■■MM■■MMMMM■■M■ ■■MM■MMEMMEMM■■ ■EM■MEMM■MEME■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■ June 21, 1999 John H. Shelton 995 Howell Road Mocksville, NC 27028 Re: Site Evaluation/Howell Road, 4.76 Acres Tax Office PIN: #5823-63-7211 Dear Client(s): As requested, a representative from this office visited the aforementioned site on June 18, 1999. 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 a modified, oversized 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 ofi~ If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s)