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3521 Hwy 801S1 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003815 Tax PIN/EH #: 5788-11-2168 Billed To: Travis Young Subdivision Info: Reference Name: Location/Address: NC Highway 801-27006 Proposed Facility: Residence Property Size: see map ATC Number: 4538 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 CONST U TIO IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: O ' /-3/ 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. ;t O7 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) I Date: G , r 10 L -f —/ DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section ' P. O. Boa 848/210 Hospital Street ` Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003815 Tax PIN/EH M 5788-11-2168 Billed To: Travis Young Subdivision Info: Reference Name: Location/Address: NC Highway 801-27006 Proposed Facility: Residence Property Size: see map ATC Number: 4538 **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. 1/ L Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply d.0 Design Wastewater Flow (GPD) c 4vSef Site: New Repair ❑ System Specifications: Tank Siz��& GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width4/ Rock Depth 1,9 Linear Ft,.?d-O 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: - A/ DCHD 05/99 (Revised) e FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section J P 0. Box 848/210 Hospital Street 111���JJJ Mocksville, NC 27028 (336) 751-8760 ** IMPORT '`PHIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED IN TION IS PROVIDED. Refertothe INFORMATION BULLETIN for instructions. 1. Name to be Billed -r/2 A4 i 5' l/ O k/ hl G e Contact Person Mailing Address 353,5 ►o! c lawV ��� u . Home Phone �c�o City/State/ZIP Q 0 VAI cj Nr 271 0 �_ Business Phone ?3 &—"398 / 8 -17 3 3 2. Name on Permit/ATC if Different than AboveS-A IYU A Z 461' /l Mailing Address City/State/Zip �/ 1/ 6t O & 3. Application For: Lh Site Evaluation [Improvement Permit/ATC ❑ Both 4. System to Service: R/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative I 6. If Residence: # People # Bedrooms # Bathrooms 2 Z dDishwasher ❑Garbage Disposal I Washing Machine ❑Basement/Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers # Urinals # People ❑Basement/No Plumbing # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT"°** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: :SZFG PLAT WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 5—] 881 17, 1 (o R V 5 H V& (o y %ASS" ' To w C "wy 610 Property Address: Road Name t4 C F1 VQ t: H V✓ y gOI NyrirN Tob4/4121' City/zip yq 4 Cl , n1 L 2 70Z8 A O Jq G' 1-\1 C P)2A 12 -t If in a Subdivision provide information, as follows: i's Ota( 9 t G W T A)= ?r tp4cpos v A- U 1 St o W 0T- i► FYI0T14\r "�aU►�1G) Name: /W O= t2Y L v "Tr l ASS I A) CSA t27'Ft2 Section: Block: Lot: Date home corners flagged: 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 front 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 1 ' 0, S to conduct all testing procedures as necessary to determine the site suitability. DATE I 7,I6//0 SIGNATURE N J ( n THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the mllowin 1 Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge . 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Pa;D001 s! ;D4; (anlns o ;o s! ;D!d s!q4 ;041 'q :puo! ;o slaoJDd s9;oln69l ;Dq; 93uou!PUO UD soy ;Dq; (;!lod!o!unw Jo (;unoo o ;o DOJD eq; q;!M puo! 40 uo!s!n!pgns o 90;09:3 4041 (Onlns D ;o s! ;DId s!q; ;Dq_ D Jo ® 'snq; pa;o3!pu! so 6u!Mollo; aq; ;o auo o; (411-193 'Z92- 1 '10kO JnS PUD -1 iDuo!ssa;oJd 'auo;S yaW 96JO00 ON1a-line 80 'S033 'NOIld080038 803 1 JOgwnN u0!;Drisl6ey (en1R auo}S •8 a6JoaO .�� t-,8nS Z9 L2 -1 , (� I S a: 610�SS�'��� O`> dwD.,S Jo iDaS l9 82! * 900Z ° v ' JagwaoaG ic ADP L sl" loss puo Jagwnu uo1lDJ4s!63J 'a JnlDU61S 1 DU 161 Jo 6w ssauI IM •PsPuawD so 0£ -Lb 'S'0 qi!M ao4DPJo03D ul pe,c:ald sDM told slgi :Dqt :000101/1 sl POtDlnolo3 so uo!s!oald ;o oi1DJ aqt ;Dqt � 86Dd X008 ul puno; uo!towlo;u! wo1; uMDJP so patD3!pul FI mala 010 pa6anins tou salJDPUnog 944 1041 :(19410) (•Die ' -; a6Dd * - 4008 ul POPJO0aJ uo„ dilosep POOP) UDIalnJadns Fw JOPUn appw �OA.9S lDnt3o UD woJ; ao!slnJadns ALL Jepun UMDJP sDM toad s!qt :DLit 641tJao 'aUotS :Jago8 O6Joa9 'I APPLICANT INFORMATION Account #: 990003815 Billed To: Travis Young Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5788-11-2168 Subdivision Info: Location/Address: NC Highway 801-27006 Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope % HORIZON I DEPTH r <i Texture group Consistence t- /- Structure 7r. - Mineralogy 'If,/ HORIZON II DEPTH Texture group Consistence r - Structure 54 el - 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 L. L SITE CLASSIFICATION: G EVALUATION BY: 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 3ICL - Silty clay loam SIL - Silty loam CL - Clay loam . SCL - Sandy clay loam . SC = Sandy clay SIC -Silty clay C - Clay STENCE Moist VFR Very friable " FR - Friable FI - Firm VFI Very firm EFI Extremely firm 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 No c 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 Cl f t' S(itablIl 'tabl) U( 't bl asst tca ion - su e) PS( , provtsiona y sm e , unsui a e) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■.■■.■■■■■■■c.■■■�■NOON■■■■■■NN■■■■■■■■■■■N■■NN■N■ ■■.■■■.■■■■■■■■.■■■■■■■■■■■.■■■eO■■■■O■O■■■■■■■■■NON■N■■■Ott■■■■■■ ■■■■■■.■.■.■■■■■■■■■■■■■■■■■■■■■.■■■■■■■E■NN■■N■■NNN■■NN■■■N■■NON■ ■■■■■■■■■r■■■■■■■��.■.■■■■■■.■■■■■.■■■■■■■■■■■■■■���■■■■■■■■■■NONE ■■■■NOON■■E■■.■■.■■.■■■N■■■■■■■■■N■■■EON■■■■■■■■■■■■■■■■■■■■■■■■■■ NONE ■■■■■■■■■■■■■■■■■■■.■■■.■..■■■■■■■.■..■s■■■■■■■■■■EON■■■■■N■■■■■■■ ■■■■■■■■■■NON■■■N■■N■■NNNEN■■N■■■■■■N■■■■■■■■■■■.E■■■■■■■..■.■■■ Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 MnrLevilla WV.. 97/129 December 22, 2005 Travis Young 3535 NC Highway 801 S Advance, NC 27006 Re: Site Evaluation/NC Highway 801 Tax Office PIN: #5788-11-2168 Dear Client(s): As requested, a representative from our office visited the aforementioned site on December 21, 2005. Based on the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, it was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement/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