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1628 Hwy 601S"Pttee's.Ir. DAVIE COUNTY HEALTH DEPARTMENT Name: Environmental Health Section PROPERTY INFORMATION D ' U j i { P.O. Box 848 ` Directions to property: ) t�''� L'I3 Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN :# SYSTEM CONSTRUCTION - - AUTHORIZATION NO: 002721 A Road Name: �Y I wt Zip: J(1271 **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. (IncomplianceWith-Article, l l �)f G.S. Qutptq 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) I V ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. HEMETAlAHSENVIRONP ; IALISTy DAT ISSU D RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No tc COMMERCIAL SPECIFICATION: FACILITY TYPE PEOPLE 1-1# PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes o�o LOT SIZE TYPE WATER SUPPLY VDESIGN WASTEWATER FLOW (GPD) � NEW SITE REPAIR SITE /r SYSTEM SPECIFICATIONS: TANK SIZE _____GAL. PUMP TANK GAL. TRENCH WIDTH t( ROCK DEPTH /17- LINEAR Fr.��_r. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ' �-�= t �� 1-/'��`� iC � `I t=om+ VEUT 51 (,-CU'iv, C7 m h la :1 t%�- IMPROVEMENT PERMIT LAYOUT Pop. . t.. t►J4 . ..f� V- N: As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT VO I SYSTEM INSTALLED BY: R PMAI IUl �CIS X f.Vdl-0 LZ 7 30 v_ 40' ; .v c c a� o A IZKfvx1 s � -AUTHORIZATION NO. Z7'z I OPERA11 IT BY: 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 02/02 (Revised) , ,!P; te&-s4 DAVIE COUNTY HEALTH DEPARTMENT L Environmental Health Section PROPERTY INFORMATION. P.O. Box 848 DirediongI6 property: ImoMocksville, NC 27028 Subdivision Name: Phone #: 336-75J,8766 Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Ta ,Office AUTHORIZATION NO: 002721 A Road Name: zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section pri8r to issuance of any Building Pen -nits. This FonrdAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article. I I of G.S. Cbaptpr 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONOE'NTA HEAL H SPECIALIST DAT ISSU D RESIDENTIAL SPECIFICATION: BUILDING TYPE #BEDROOMS #'BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #1 PEOPLE ' #P'EOPLEISHIFr_ #SEATS_ INDUSTRIAL WASTE: Yes orco LOT SIZE TYPE WATER SUPPLY A -WI WDESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE —GAL. PUMP TANK ----GALi, TRENCH WIDTH i ii ROCK DEPTH —ILL LINEAR Fr. ') OTHER — REQUIRED SITE MODIFICATIONS/CONDITIONS: L: (7NS s IMPROVEMENT PERMIT LAYOUT L 1 211 I-LoJC L1 V FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. O�7 FIE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT ^ SYSTEM INSTATLEDB'Y: RRMJ3 bo L e AUTHORIZATION NO. Z7 Z I OPERAII`0IT BY: AAV DATE: o "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 T� EATMENT AND DISPOSAL SYSTEMS',", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERI-OROF TIME. DOM 02M (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)7.51-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000811 Tax PIN/EH #: 5747-02-6382 Billed To: P.D. Allen Subdivision Info: Reference Name: P.D. Allen Location/Address: Hwy. 601 S.-27028 Proposed Facility: Business Property Size: 1.40 Ac. **NOTE* i�iib?n v8m0ent/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 __!y #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply _ Design Wastewater Flow (GPD) 149!! Site: New Repair ❑ System Specifications: Tank Size%DDD GAL. Pump Tank GAL. Trench Width —,� Rock Depth _tL Linear Ft,&2: Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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 #: 990000811 Tax PIN/EH #: 5747-02-6382 Billed To: P.D. Allen Subdivision Info: Reference Name: P.D. Allen Location/Address: Hwy. 601 S.-27028 rroposea i-acmty: business ATC Number. 2830 Size: 1.40 AC. 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, ion .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA R ONSTRUCTION IS VALID FO A PERIOD OF FIVE 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 as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: `� V . APPLICATION FON SITE EVAURTIONJIMPROVEMEW PERMIT A AT • J _ Davis County Health Department 9.0. Box 968/210 Hospital Street C,) Mockoville, VC 21029 (336) 751-6760 [E @ O IE OCT 71999 +**rilPQRTIIN?*** THIS "I?LICATICN CSIO T ZZ PW=SMM UML1188 AM THZ RZQUIMM UMTM 210H I8 IMOMIDZD. Rater to the IM TMlITION BULZZ21H for instructions. 1. Maas to be allied�- "c�'��` content s�ereon wiling Address _ - �, 0A �Jesx� `�� . mom Nwm a.`6`A- tzo z I city/stawalp W -c. �;'I o d �S ftel"es phone s. Mase CIA :emit/= is Ditterent than Above 14041iAg bddress City/state/sip z_ _ �p e. Antiaawon res: SPS 4:c —..- "`uaticn %�%31,7J Improvement Bermit/11TC O Both 4. systea to sesioet 0 House 0 Mobile Home a. It Residences # woople !t-11fusiness 0 Industry 0 other • Bedrooms ! Bathrooms 0 Diebxashes 0 Gasbags Disposal 0 hashing Maobise 0 aasement/plumbing 0 sasesant/Vo ILmbing i. tt awinass/fndmsstsy/Otlsar: speaity two S\,00 f *copies A # sinks ,, Commodes / showers 4 Dsiaals b ! Rates coolers I* 1OOD93AYICZs (1 Seats Zatimated Nater Usage (gallons p w "T) 7. Type of Rater supply: VCounty/City 0 well 0 Community 6. Do you anticipate additions or expansions of the htwty tbb system Is Intended to serve? O Yes 0 No U yes, what type?. ***IMPORTANT*** CUENM MOST CDMPLETBTHE REQUIRED PROPERTY INFORMATION REQUESTED BELDW. Either a PLAT or SITE PLAN MUSTBESUBlkIrM by the client with THIS APPLCATION. Frroperty almenslonss JTaz 0111ce PIN: Property Address Road Name (oD \, CLty/Zlpc9eS� U in a Subdivision provide information, as follows: Name: Sections Blocks Loh WRITE 9IREC`nONS (tcom MotWile) to PROPERTY: Date Property Flaggedt This Is to cerilk that the Inbrmatiou provided Is correct to the but of my knowledge. I understand that any permit(s) biped bereatler are subject to suspension or revocation, It the site pians or intended sse change, or if the information submitted in ibis application Is Wiled or ebsuged. 1, silo, understand shag I ant responsible for all charges incurred ji om chis sppUcadou. I, hereby, give consent to the Authorized Representative of the Davie Canty Health Department to enter upon above described property located In Davie County and owned by 2LP.� ��r~ to conduct all testing procedum as necessary to deterutlan the site suitability. nn AA - DATE ) b - "1— gal SIGN KfURE j� � �J.XXstM THIS AREA MAY BE USED FOR DRAVMG YOUR 6137. PLAN (Include sit of the following: Existing and proposed property Uses sail dimensions, structure, setbacks, and septic locations). Revised DCHD (07/99) l Site Revisit Charge I Date(s): Client Notification Date: `EAS: Account No. z �1836�� INDEXED ON 5747.13 ' Gn132 7 This map is for PERC TEST and BUILDING PERMIT purposes only. The Davie County ^mom Tax Administrator's Office assumes no liability for any information contained on this map f e (207) 252 COUNTY -ID: K509OA1102XA GnC2 (L36A) /1.46AJ October 07,19991:39 PM N 7172 Parcel Identification Number 5131 5747-02-6382 APPLICANT INFORMATION Account #: 990000811 Billed To: P.D. Allen Reference Name: P.D. Allen Proposed Facility: Business Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5747-02-6382 Subdivision Info: Location/Address: Hwy. 601 S.-27028 Property Size: 1:40 Ac. Date Evaluated:8— On-Site Well Community. Auger Boring ►l Pit Public i Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: • L REMARKS: EVALUATION BY: 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 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 ois VFR - Very friable FR - Friable FI - Firm VF1- 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 Mineraloev 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) Landscape position HORIZON I DEPTH Texture group Consistence _19NAMWAMM-12 "N Fr HORIZON 11 DEPTH M"Wrolimi Consistence tiii►-+_ii ��A�---® Texture group Consistence MEMME -. Mineralogy HORIZON IV DEPTH Texture group W.972. ii,nWINEEN-IMMEN-- Consistence - SOIL WETNESS ve SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: • L REMARKS: EVALUATION BY: 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 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 ois VFR - Very friable FR - Friable FI - Firm VF1- 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 Mineraloev 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) DAME UOUNTY.HEALTH. DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 October 29, 1999 P.D. Allen 204 Bean Road Mocksville, NC 27028 Re: Site Evaluation/Hwy. 601 S. Tax Office PIN: #5747-02-6382 Dear Mr. Allen: As requested, a representative from this office visited the aforementioned site on October 28, 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 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 Clint Dorman, Environmental Health Specialist CD/mp Enclosure(s) VIE COUNTY HEALTH .DEPARTMENT Environmental Health Section r 2QQ� PO Box 848/210 Hospital Street Mocksville, NC 27028 H Phone: (336)751-8760 - TE WASTEWATER CERTIFICATION FOR DWELLING One) REPLACEMENT ❑ REMODELING V' RECONNECTION ❑ Name: Phone Number: 336' ��`�� (Home) Mailing Address: 336- "751- /130c) (Work) Detailed Directions To Site: tO 1 '5. Q `� '►^► ► «4 cs n r,` .�) b� 5; ��` Property Address: Please Fill In The Following Information About The Existing Dwel ing ( t09 Name System Installed Under: �. ,1-0.11 �X b Type Of Dwelling: AtSi -s15 Date System Installed(Month/Day/Year): :9 q -Zdy Number Of Bedrooms: 0 Number Of People: Is The Dwelling Currently Vacant? Yes ❑ Nom" If Yes, For How Long? Any Known Problems? Yes ❑ No If Yes, Explain: Please Fill In The Following Information About The New Dwelling: �J S 1Zc '' /I Type Of Dwelling: sas r E'1 Q- S -S `701G � � Number Of People: Requested By: �• (�' 4 Date Requested: (Signature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Fl Comments: 1z&1'< _y�sv 1"j ��` 1!�� 1"VE!• ) +��'i2d:3.,;, Environmental Health Specialist s.--...--..-�/ Date V '"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 ❑ # 007401W Amount: $ 100, C% Dater'// -fib Paid By: Received By: --ry Account #: 0' Invoice #:� l