The URL can be used to link to this page

139 Indian Hills Rd (2)a Account #: 990004142 Billed To: Ronald Jones Reference Name: Proposed Facility: Residence ATC Number: 4529 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH M 5778-09-4336.05 Subdivision Info: Jones Estate Lot # 5 Location/Address: Indian Hills Drive -27006 Property Size: see map 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 §ewpke Treaynent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUj2TJON I V LID FOR A PERIOD OF FIVE YEARS. S Environmental Health Specialist's Signature:D�te: CERTIFICATE OF CO **NOTE** The issuance of this Certificate of Completion shall indicate 119C ri d has been installed in compliance with Article 11 of G.S. Chauli ITt o .1 Disposal Systems," but shall in NO WAY be taken as a guar t given period of time. S e -j�) - &&X S01,1p e,90- 0,=, - SH, c Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) �ir7iry ,-ZO4 L3 v Improvement/Operation Permit I "Sewage Treatment and I function satisfactorily for any Date: .. DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street �. Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004142 Tax PIN/EH #: 5778-09-4336.05 Billed To: Ronald Jones Subdivision Info: Jones Estate Lot # 5 Reference Name: Location/Address: Indian Hills Drive -27006 Proposed Facility: Residence Property Size: see map ATC Number: 4529 **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 #People #Bedrooms #BathsQ3 Dishwasher.-/!54 Garbage Disposal: ❑ Washing Machine: wlo/ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �20 Design Wastewater Flow (GPD) Site: New ❑ Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: GAL. Trench Widthl_�� Rock Depth Linear Ft.�kfp Required Site Modifications/Conditions: accented SystemsNnay olsa he use5d IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW FINISHED qRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system betwe n 8:30 a.m. to 9:30 a.m. o p.m. to 1: n the day of installation! Telephone # is (336)751-8760.**** P,,p LAA Environmental Health Specialist's Signature: DCHD 05/99 (Revised) A, 2,1pe. 11 OCT 13 2006 R'Aug DA EALiN ITE EVALUATION/IMPROVEMENT PERMIT )avie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751=8786 Voth Application For: [Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) & ATC ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed RContact Person Billing Address 6 Home Phone 33 6 - 9/ T- `i P 0 City/State/ZIP , G Business Phone 33 6 JO i Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Permit is vplid for 60 months `nth site plan, no expirationwi c mplete plat.) T Street Address .-rN "'if �SKGI'- City / t/QW C Tax PIN# Subdivision Name S ctio//n/Lot# Lot Size Directions/To Site: / � .P 9/7r- • Lvh u S Date House/Facility Corners Flagged MAP bvt 6 A)e If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes Digo Does the site contain jurisdictional wetlands? ❑Yes cryo Are there any easements or right-of-ways on the site? ❑ Yes E7No Is the site subject to approval by another public agency? ❑Yes EVo Will wastewater othet than domestic sewage be generated? ❑Yes e'No 1-F .KESIDENCE FILL OUT THE BOX BELOW # People 12, # Bedrooms T # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement:❑Yes CJI o Basement Plumbing: ❑Yes MNb IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: peonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: e'C ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes CC1 0� If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections determine com lliance with applicable laws and rules on the above described property located in Davie County and owned by /i U `t L—t/H �101111Z ) 16yl� 2V 0 IYt.S--0 Prop6rty owner's or owner's lega r presentative signature ate t Sign given L�1'Yes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account #L' Invoice# I a 4 i i e Y R0, 'St 18:9 i (, h0 RV ViLLS p� XV 245 . N * A •_ _ � ��> N IAN L1,.SRD i �W. 544A), , Z, 6l n C 22a o0 (� 2,7 112 51A) $ t 1376 4336 3585 r4 g r 5:1 60 f � GnB2 �s 10 � Q _ z ^4001 UP U /� , APPLICANT INFORMATION Account #: 990004142 Billed To: Ronald Jones Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-09-4336 Subdivision Info: Jones Estate Lot # 5 Location/Address: Indian Hills Drive -27006 Property Size: see map Date Evaluated: ffj1.2p 44 On -Site Well Community Auger Boring Pit Public 4' Cut FACTORS 1: 2 3 4 5 6 7 Landscape position Slope % b % HORIZON I DEPTH Texture group Consistence Structure Mineralogy - HORIZON II DEPTH f«»' Texture group' Consistence T Structure i 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: Q� EVALUATION BY: T`fPi_l� y . 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 sandSL 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 .ON4I T ,N 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 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 05105 (Revised) ■■■■■■■■■■■■■s■■■■■■■■■■■■■■sae■ s■■■w■■■ee��l:�e.■■■■■■■■■■■■■■■■ ■e■■e■■■e■■■sea■■e■■■■■■a■■�■■■■■r�■■�■■■■■■■■■■■■■■■■■■■■■■■■■■a■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■rig■■■a■■wee■■■■■■■■■■■■■■■■■e■■■■■■■■■■■ ■■■■■■■■■e■■■■■e.■e■■e■I■■■■■■■■1111■■■■■■■■e■■■■■■■■■■■■■■■■e■■■■■■ EMMONS�' liiiiiiiiiiiieiiiiiiiiiiil�l ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ -- Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Improvement Permit October 20, 2006 Ronald G. Jones 168 Cedar Hill Lane Advance, NC 27006 Re: Indian Hills Jones Estate: 5778094336.05 Dear Mr. Jones, This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. System To Serve: C Wastewater Design Flow(GPD): `/U CValid: Z5 Years ❑No Expiration System Type: ❑Conventional Accepted 01nnovative ❑Alternative ❑Other Site Modifications/Permit Conditions: Environmental Health i.p.letter 7/06 As stated in Date