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1415 Junction RdHEALTH DEPARTMENT RELEASE d«,56 Davie County Health Department 219 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Micah D. Detweiler Address: 1415 Junction Road City: Mocksville State2ip: NC 27028 Phone # (717) 348-3706 For Office Use Only *CDP File Number 193867-1 County ID Number. Evaluated For: NEW PERMITVALID 0 6/ 0 4/ a 0 a 0 UNTIL: Property Owner. Micah D. Detweiler Address: 1415 Junction Road City: Mocksville State/Zip NC 27028 Phone#: (717)348-3706 r Property Location & Site Information Address 1415 Junction Road Subdivision: Phase: Lot Road# Mocksville NC 27028 SINGLE FAMILY Township: 'Structure: Directions of Bedrooms: 3 # of People: hwy 601,S. right on Hwy 801 right onMarginal Street. right on Junction Rd. from Cooleemee on the right 'Water Supply: EXISTING WELL Basement: FlYes Q No "Proposed Improvement: Type of Business: Total sq. Footage: No. Of Employees: Current septic system was installed for a 3 bedrrom home. Additional bathrooms will not affect this approval as its design is based on bedrooms. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? QYes ONo Applicant/Legal Reps. Signature; 'Date: *Issued By: 2140 -Nations, Robert Authorized State Agent: *Date of Issue: is 6/ 0 4/ 2 0 1 5 **Site Plan/Drawing attached.** (9Hand Drawing 01mport Drawing ((�X on5/AkI U (� ICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC date: Davie County Environmental Health C rl P.O. Box 848/210 Hospital Street i K R Mocksville, NC 27028 /9A (336)753-6780/ Fax (336) 753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Autho ' tion To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System xpansion/Modification of Existing System or Facility * **IA9ORTAN7* "THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION ✓ 1�n Name to be Billed MiC61 DPiVeller Contact PersonL, O yy� Billing Address Home Phone - City/State/ZIP ; 7 Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip - PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Permit is valid for 6Q months with site plan, no expiration with complete plat.) Owner's Name M i c a h Q, n e f:W e� lr f Phone Number - 70 Owner's Address I q l (:) 11 J, i ,irk _ R City/State/Zip Mac s ; 11, 2 702 $ Property Address Sa„c City Lot Size 6 Gcref Tax PIN# Subdivision Name(ifI 7�plicable) Section/Lot# ��/ ,, ///f n;i tinne Tn qhP.- HW / & _ AAI �%l 711f�/i/ioza;11a IMe answer to any of the following questions is `ryes", supporting documenT3bon must be attached. Are there any existing wastewater systems on the site? iii es ❑No Does the site contain jurisdictional wetlands? ❑Yes EA0 Are there any easements or right-of-ways on the site? ❑ es &6o Is the site subject to approval by another public agency? BlYes 0j10 Will wastewater other than domestic sewage be generated? ❑Yes SINo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 2_±_ # Bathrooms I -+I Garden Tub/Whirlpool ❑Yes ❑No Basement: Mies, NINo Basement Plumbing: ❑Yes 1dNo 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: N onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 9 County/City Water ❑ New Well ' 4xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? V No 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and lod flagging- or sttakin the house/facility location, proposed well location and the location of any other amenities. WQZ Property owner's of oN ner's epresentative signature Site Revisit Charge Date(s): -CL--d-201 5- Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account #� Invoice # CTAT 9PVIc` n�UN� s PrintedWay 06, 2015 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. i f ! . ' DAVM COUNTY HEALTH DEPARTM Environmental Health Section Soil/ Site Evaluation I APPLICANT INF RM TION iaakl D� I Water Supply:On- ite Well Community I Evaluation By: Aug r Boring / Pit ` j FACTORS fi 2 3 OPERTY INFORMATIO IL[ 6 V1Vef %DAl d. I Public Cut i I 'i I A 1 1 7 Landscape position Slope % I j HORIZON I DEPTH I Texture group j. G j Consistence j Structure Mineralogy HORIZON II DEPTH LlI I Texture groupj Consistence Structure Mineralogyi I I HORIZON III DEPTH Texture groupL I ' Consistence i Structure lc I I MineralogyI I HORIZON IV DEPTH I I Texture group Consistence Structure �. Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION t I LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: V f EVALUATI I N BY: LONG* TERM ACCEPTANC •'RATE: ��' OTHER(s) RESENT:, -e- RirMARxs: LEGEND Landscape cape Position ! R - Ridge S Shoulder ' _ L - Linear slope FS - Foot slope N - Nose slopei i CC - Concave slope CV - onvex slope T - Terrace FP-- Flood plain H I Head slope Texture S Sand LS - Loamy sand SL - Sandy loam L - Loam Si, Silt SICL - Silty clayloam SIL - Silty loam CL - Clay loam SCL -Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay Moist f I 41 VFR - Very friable FR - F'able FI - Firm VFI - Very firm REFI - Extremely firm ; NS - Non sticky SS -.Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slig tly plastic P - Plastic VP - Very plastic •I Structure Sc - Single grain M - Massive CR - Crumb GR - Granular f ABK - Ang lar blocky: SBK - Subangular blocky L - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed I Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thiclrnes i and inches from land surface i i Saprolite - S(suitable), U(unsu�table)• I 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 rovisionally suitable), U(unsuitable) i TTATI T .._ ----- #X DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation 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 B.S. Chapter 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME PROPERTY ADDRESS \J DATE, LOCATION 711111r VaN 0 SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE Ct� # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye PEOPLE/SHIFT J COMMERCIAL SPECIFICATION: FACILITY TYPE' # PEOPLE # PEOPLE/ # SEATS INDUSTRIAL WASTE Yes/No LOT SIZE "TYPE WATER RMY�4ESIGN WASTEWATER FLOW (GPD) (PC) NEW SITE REPAIR SITE GAL. ROCK DEPTH ,LINEAR FT. SYSTEM SPECIFICATIONS: TANK SIZE Gk. PUMP TANK TRENCH WIDTH OTHER ,REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS 1ABR .JECT TO REVOCATION IF SITE PLANS 0 THE INTENDED USE CHANGE. YOUR JR WA5TERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. tri IMPROVEMENT PERMIT,BY, **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION � THIS SYSTEM k4EN 8:30-9:30 A.M. OR 1iiO-1:30 P.M. ON THE DAY OF INSTALLATION. '-TELEPHQNE "634 �k. IS, (704) -8760. OPERATION PERMIT. SYSTEM INSTALLED BY A�A� \ e-+-�( Q? AUTHORIZATION NO. 0 3 -7 -7 OPERATION PERMIT DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF B.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 10/95 •. \ l a .Z/�� L-Xo $ ;: `„M DAVIE -COUNTY HEALTH DEPARTMENT . •�.- t: IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT"PERMIT a+ **NOTE** This improvement permit DOES NOT authorize the construction or, -installation of a septic tank system or any wastewater ...system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION oust 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) M Is� y �-�.J S PROPERTY ADDRESS " i V t� c 1 u t.1 a DATE j� 'b LOCATION J .sa;•�,.,,. �.y tt�c�.,rc�,', �i.,,c.`�*�aSt SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE.* # BEDROOMS 3 # BATHS # OCCUPANTS 6 GARBAGE DISPOSAL: Ye 400 COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE' # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE:' Yes/No LOT SIZE /, y c► ac, TYPE WATER SUPPLY . `?- DESIGN WASTEWATER FLOW (GPD) 3 0 NEW SITE REPAIR SITE � SYSTEM SPECIFICATIONS: TANK SIZE GAL PUMP,,JANI GAL. TRENCH WIDTH ✓ ROCK DEPTH LINEAR FT.- OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: i x .. is k =ov r IMPROVEMENT PERMIT BY .'.. **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION, OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. ,TELEPHONE # IS •(704)`634-8760. OPERATION PERMIT SYSTEM .INSTALLED BY / L Q? 9 q AUTHORIZATION NO. 3 OPERATION PERMIT 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 FLNJCTION SATISFACTOFILY FOR ANY GIVEN PERIOD OF TIME. J ' DCHD 10/95 h �,.- Davie County. Health Department d ENVIRONMENTAL HEALTH SECTION ' P.O. Box 665. Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIOdfr�;, (Issued in compliance with Article 11, of r/ G.S. Chapter 13OA, Wastewater Systems) ***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.*** 3 `AITTHDRIZATR NAME DATE 16 N Aa�� NAME ON IMPROVEMENT PERMIT (If different than above). SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM z t**NOTICE+** ?HIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FORA PERIOD OF FIVE (5) YEARS. ENVIR(WffAL HEALTH SPECIALISTS DATE DCHD 10/95 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME U� �_ Q ` S PHONE NUMBER �I y l t, ADDRESS L �U N Ctl t % SUBDIVISION NAME oC-'\"�\ S 14 k WQ `y �- LOT # DIRECTIONS TO S �A-N - ?-� ` o''^ i DATE SYSTEM INSTALLED 1 NAME SYSTEM INSTALLED UNDER — WW25Z TYPE FACILITY 6 ESQ' NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY ��Z� SPECIFY PROBLEM OCCURRING 4� v _ DATE REQUESTED {U - 9 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I erstand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93