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486 Howardtown Rd DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 V��)6 Account #: 989900605 Tax PIN/EH#: 5860-20-2133.01 Billed To: Shannon Smith Subdivision Info: Reference Name: Location/Address: Howardtown 9d -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3436 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 CONSTTR�UCCTIO/N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: '�� /7 —6�3 3 4(6o rti S CERTIFICATE OF COMPLETION C2 **NOTE** The issuance of this Certificate o Co pl ion shall indica ystem described on Improvement/Operation Permit has been installed in compliance 'th i le11 of G.S. ap 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in N W Y taken as a ar n that the system will function satisfactorily for any given period of time. I ! hl �r d '70 ox Septic System Installed By: Environmental Health Specialist's Signature:� Date: �s~ DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • _ - . Environmental Health Section d' . ' P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900605 Tax PIN/EH#: 5860-20-2133.01 Billed To: Shannon Smith Subdivision Info: Reference Name: Location/Address: Howardtown Circle-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3436 **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 #People #Bedrooms, #Baths Dishwasher: 21Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbingel!r--� Commercial Specification: Facility Type #People #People/Shift #Seeats Industrial Waste: ❑ Lot Size611KType Water Supply Design Wastewater Flow(GPD) —40e Site: New;2---Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width cJiU Rock Depth Linear Fu. ' Other: 1,�� u� X" Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- PPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a r r tat ve of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:0 m.t :3 p.m on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: i � ` Date: `/ ?� DCHD 05/99(Revised) Mai 15 03 09n38a davie county envhealth 336 751 6786 P. I. APPLICAT110N FOR SITE EVALUMION/IMPROVEMENT PERMITS ATC Davie County Health Department E•nvlmnmellta/NeOIM SeC6017 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-5760 ±+*IMPORTANT*** THIS APPLICATION CANNOT 3E PROCESSED UNLESS ALL TAE REQUIRED NFORMATIOI IS PROYIDBD. ReZer to the SNFORttATION BULLETIN for instructions. .—.1. Waaw to be Bille ,� �COntaCt pers0a 'n-o nom.__ ' . .. (�.Nailing Address all _ L.l.. �nbme v City/stats/ZZt' l�o)V •� Phone —2. xasns on PecuitIXTC it Dittorent then Above ^` Mailing Address _ City/state/ILD 1-7% Application For: tis Fvaluation Improvement Permit/ATC Both ✓-4.." ayotam to service. HouD Xcbile Home Business Induatty Other ,r.5. If Residence, I People _ _ x Bedrooms I Bathrooms 3 - �..• Dia hvrasher azba a Dia�;oaa2 cashing NaCaiae Bassmsatjvluc+bta3 - easement/Wo aiwri�ing 6. if Business/Industry/Ctners %pecity type _ M vaoPlo s Bink. I Ccamwdes # :,howra #.urinals _- # Hater Coolers IF FOODOURYICEr # Seat:: Estimated Water Usage (psilone per day) __ y7. Type of water supplys County/City Well Community tea. Do you anticipate additions or etpansions of the facility this system h intended to serve? Yes No Ifyes'what type? ***IAIPORT(NP**CLIEN'±'S MUSTCOMPLETETHE REQV1RL'D PROPERTY INFOItD1A'rI0N REQUES•1'BU t1FLOW. Hither a FLAT or SI TE PLAN muSPDESUDMITTED by tt:a clitnt with THIS APPLICATION. --Property Dinienslons:—f Q-----7 1PL+3 _ W RITE DIRECTIONS(from Mock%ille)to PROPL IM: tax Office PIN: 4 �rroperty Address: Road Hume_•• �C�y , t%N-_` O�^►� t�J �7 citylzIp — T If In a Subdivision provide infurmt tion.as follows: _ Name Section: _ Block: __•� Lot: —Date hoinecornerstlagLed:!____._� _ pas is to certify that the Information provided is correct to the best of my knowledge. I understand that any perutit(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,artderstand tkarl aur rdspunidblejor all charges incurred fi qin this appllration. T,hereby,give consent to the Authorized Representative of the Daviu County HeaNir Mpartmcnt to enter upon above described prmpe rty located in Dmie County and owned by_ ^� W eouducttall testing procedures as ecessary to determine the site suitability. ✓ �. DATE —&D • TII1S AREA MAY BE USED FOR DRANVI.NG YOUR SITE PLAN(Include all of the following: Esistiug and propused property lines acd dimensions, struAttres, setbacks, and septic locations). _ Site Revisit Charge Client Notification Datc: EIIS: Sign given_ Account No. Revised DCITD(07199) Invoice No. AIPPLICAFOR SITE EVALUATIONAMPROVEM PIi2911%fog Oepez(ee-7 Davie County Health Department L� Environmental Health Section nP.O. Box 848 — 4 I (�/ '�q;' Mocksville,NC 27028 C4I / I _ ?5-(.5'D v (704)634-8760 YIRONIAUffAL HtWn 1 ��t DAYiE 001I ****IMPORTANT**** THIS APPLICATION CANNOT BE ALL THE REQUIRED INFORMATION IS PROVIDED. C ) 1. Name to be Billed N o n1 v Mc-�L Contact Person Sq+9NrJW SMS{�„ 1 ,y+, 15:L S ?-�/- 3 A&7 Mailing Address VD J C_at, jsu C�, 0,'tQ e e Horne Phone 7 5'1 -S d 5 t) City/State/Zip �Q C. � D 2-� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip, 3. Application For: lute Evaluation ,Improve nt Permit&ATC ❑ Both 4. System to Serve: Q' House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. if Residence: # People �_ # Bedrooms ✓ # Bathrooms 25 XDishwasher ❑ Garbage Disposal Washing Machine .Sasement/Plumbing Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: ❑ County/City Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes '\A No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: eS S,/ GL. f0y2ue I WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # - !. - - 1 10Ntj -07 G?00000o41 Jglsi Property Address: Road Name ,44 o�„ bk,-d 'b cc,N &. �” 1 OV DA01 - ✓ /✓✓ City/Zip F'lDL1dQ,i& �C -2aa-k \ I If in Subdivision provide information,as follows: 1 1 — - J�v /��w•ud�Jcd�✓ Name: I I C r�C��. a J�✓ � Section: Lot #: I I 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. I,also,understand that I am responsible for all charges incurred from this application. I,hereby,give consent to the AuthorizedRep ntative of the Davie County Health Department to enter upon above described property located in Davie County and owned by 1 e JNt6-' t�0 luct all testing procedures as necessary to determine the site suitability. DATE (!5—'1_ S SIGNATURE Revised DCHD(06-96) - • sr•� �. a" , 'fix,.; ��` • � a,.. 8IBJ42 .52 '• • T 660 My � .: 310 �. i w. 8.2 Ac V Y . FIN. t 5 Ac. a :, • w .y t:9�4� ..1644, . I 5.4,6k. .¢9.4. N S03 s . n 11.75 AC.4; (0` � 6 Ac �- .. - )5 7 4 4 - `11' ` . . 2x 01 9 5 Ac v (15.64 343.13 �- ♦' +� 2• (28.75 Ac) 4 79.64Ac I V 6 to 2— • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME�/%moi°, DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME / w,r�i�119 Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring « Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% �- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group 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 SITE CLASSIFICATION: IDS EVALUATION BY: W,5�- LONG-TERM ACCEPTANCE RATE: 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 Mois 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(01-90)