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845 Main Church Rd Lot 6 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • > P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT yoS3 Account #: 990003021 Tax PIN/EH#: 573949 Billed To: Tom Crowley Subdivision Info: Reference Name: Location/Address: Main Church Road-27208 Proposed Facility: Residence Property Size: 5 acres ATC Number: 3641 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of 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 H 60SC #People 3 #Bedrooms 2 #Baths 2 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: 13n: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Z ACR�� I ype Water Supply AAO—A,Design Wastewater Flow(GPD) 2Z40 Site: New Repair❑ Z f t System Specifications: Tank Size/©CO GAL. Pump Tank GAL. Trench Width Rock Depth 1Z• Linear Ft.-4p Other: 4 1�isveA :>na,J-&x 1��17a1 1. S ai ©.c. F-.t►J. Required Site Modifications/Conditions: ftp} Taj-o-,) C-Z-3TD09, CO FVo,�t.3-2- IMPROVEMENT/OPERATIONPE IT LAVOUT APPROVE^EFF U :'T FILTEI—RISE-R(S)I `BELOW FINISHED GRADE. ****NOTICE: ontact a representative of the Davie County Health Department for final ' spection of this system be een 8:30 a.m.to 9:30 a.m.o 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)75 -8760.**** - I PtE-1 i�-�rN beZ IL r V Environmental Health Specialist's Si e: Date: 'OA . 2 lfl, DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 z a S'3 Account #: 990003021 Tax PIN/EH#: 5739-49-4424— Billed To: Tom Crowley Subdivision Info: Reference Name: Location/Address: Main Church Road-27208 Proposed Facility: Residence Property Size: 5 acres ATC Number: 3641 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 CQNSTR O IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: IZ VV 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: Date: DCHD 05/99(Revised) 'LIGATION FOII SITE EVALUATION/IhIP110VEMENT I'GG111 C ;t: I Davie County Health Department Enviroamenta/Hea/t/1 SeCNOfl D P 2003 EC P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-87 6 0 ENVIREALTHDY TIiIS APPLICATION CANNOT B.V PROCESSE'D UNLESS ALL TIIL RINFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for inStrucol. ,w1 G" 1(' --4\ �d l3 1. Name to be Billed �Z"Y�+ ,v2 Contact Person _ /__-per HMG3T �/ Mailing Address r° 67 9 '/�"V+'�N CNv e1-1 home Phone City/State/'LIP !Ao6 k<L,i 1 - Z-IO Yti Business Phone — ------- _.... 1 2. Namo on Permit/ATC if Different than Above _ Mailing Address City/State/'Lip _ 3. Application For: Site Evaluation ❑ Improv nenL heinniL'/ATC ❑ Doth ea 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovaLivo 6. If Residence: It People 3 It Bedrooms •Y it Bathroom:, L hwasher E1GaAQ Disposal XKashing Machine ❑Basement/Plumbing ❑Basement/Ido Plumbing .7. If Business/Industry /Other: verify type It People It 'inkr, # Commodes It Showers It Urinals It WaL•er Cooler IF FOODSERVICE: It Seats Estimated Water Usage (gallon:: per day) _^ _ s. Type of water supply: ❑ County/City Well ❑ Community 9. Do you anticipate additions or expansions of the facility this systclll is ill(cll(led to serve? ❑ Yes �No If yes,what typC? ***IAIP0RT11tYT***CLIENTS AIUSTC0,41PLBTETHE Rr'LQUIRLD PROPERTY INFORMATION IZEQ11ESl I;ll BELOW. Either•a PLAT orSITE PLAN r11USTBESUI1A1I7TED by the client ivil,r'1'11IS APPLICATION. l Prolm-13,Dimensions: Sz t eC �o WRITE DIRECTIONS(li•olrl f ucliwille) to 1'l OPE'ltTY: 2ns3 'tax Office PIN: # r1� Property Address: Road Name /lam w C14✓nc1q CA.5p QC � fe City/Zip �,' e . Lack k Atili rwl f If in a Subdivision provide iill'ornlalioll,as follows: I,G L( -,t d e/X r-u'r (4A Namc Section: Block: Lot: Date !ionic corners!lagged: j L' This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlil(s) issued hereafter are subject to suspension 01-revocation,if the site plans or intended use change,Or if(lie information submitted in this application is falsified or changed. I,also, understand that I urn responsible for till charges incurr ed.lrum this application. I,hereb),,give consent to the Authorized Rcpresclltaliveof the I)avic�C oullt} I Ca1t11 1)cpa1-1111cul to enter upon above described property located in Davie County and owned by A,,,14 fi4,z vS 7 J 1 -�G 7f to conduct all testing procedures as necessary to dele•tlline the site suitability. DATE 1 63 SIGNATURE dy�- TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing:la proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge S4, 'e—✓'� Client Notification Date: y l EHS Sign given DAME L+0•f Account No. -30 2,l .ENVIRONMENTq!„HEALTE{ JUvised DCI-ID(05/03 .I:Ilvoice No. ��� 1 \ ug1 ;'� z<;y �€�C i / 1119�19 < ✓„� \` �,; \\� ` �yes 7 Jl 1 i, /// 3 ,�3 E a P+,,.•1 •ya, k'' .w.,„ s z<r r s. 111E33:33 JE33 3 / ya NNIMM y,/ii, 31Ef !Y J' F'�C r ! 3E33 3E k E%1 zV, ///////////,!4 a /- < � .r 3-rr NN..fH,,,. 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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 CQNSTR O IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: IZ VV 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: Date: DCHD 05/99(Revised) ' y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003021 Tax PIN/EH#: 5739-49-4124 Billed To: Tom Crowley Subdivision Info: Reference Name: Location/Address: Main Church Road-217208 Proposed Facility: Residence Property Size: 5 acres Date Evaluated: 1 SIJ 'D Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L. L- Slope% tk2o , HORIZON I DEPTH _k.6 O �+ Texture group L Consistence ' S Structure Mineralogy HORIZON II DEPTH Texture group Consistence to Structure Mineralogy HORIZON III DEPTH -t-! y Texture groupG-r� p k p Consistence $ �{ Structured _ le Mineralogy HORIZON IV DEPTH 4. o Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION CJS U S LONG-TERM ACCEPTANCE RATE J9.2-r7 O • .2 SITE CLASSIFICATION: S EVALUATION BY: P 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 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(unsbitable) 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) ■e■ee■■■■■■■ecce■■■■■ecce■■■■■■e■ecce■■■■■■■■■e'■■■■■■■■■■e■■■■■■■■ ■■■■■eee■■■■■e■■s■■■■eeee■■■■■eet�r■■eee■■■■■e■■■eeeee■e■■eeeeee■■■ ■■■■e■■eeee■■■■■■■■e■■■■■■�■■■■■ ■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■ ■■■ee■■■■e■■■e■■e■■■■■■eee■e■■eee■■■■eeee■eeee■■eeee■■■■■■■■eee■e■ ■■eeeee■■■ee■eee■i■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■ 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PROJECT X.1732503" / /SHEETS,I5,6,7 / atiy`