Loading...
176 Knight LnHEALTH DEPARTMENT RELEASE Davie County Health Department r 210 Hospital Street P.O. Box 848; Mocksville NC 27028'. Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Chris McNaught Address: 2306 Dover Place City: High Point State2ip: NC 27265 Phone #: (336) 209-3777 For Office Use Only *CDP File Number 199907-1 5880035692 County ID Number: Evaluated For: HDRNVWC PERMIT VAUD 0 a/ 1 1/ a 0 a :1 UNTIL Property Owner: Jeff Jones Address: City: State0p: Phone m 176 Knight Lane Advance NC 27006 Property Location & Site Information Address 176 Knight Lane Subdivision: Phase: Lot: Road# Advance, NC 27006 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms 3 It of People: Hwy 158 east, right onto Hwy 801 S. dight on Comatzer Rd. Knight Lane on right 'Water Supply: NIA Basement: Fil Yes ❑ No 'Proposed Improvement: Pool Type of Business: Total sq. Footage: No. Of Employees: Any portion of the pool must be no less than 15 from any part of the septic system 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? OYes ONo Applicant/Legal Reps. Signature; *Issued BY: 2140 -Nations, Robert *Date: *Date of Issue: 0 a% 1 1/ 2 0 1 6 Authorized State Age' **Site Plan /D rawin gattached.** ''` @Hand Drawing OimportDrawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street 5880035692 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 .a ;/ 11/ 2 0 1 6 Q Inch Scale: QBlock Q N/A CDP File Number: 199907 -1 Health Department Release 3 Saw: goco Phone: (336) - 753 - 6780 N Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Detailed Directions To Site: Property Address: Fax: (336) - 753-1680 Number3% �?0 % % (Home) 2 ('Work) Address 7%i �0- 09 - Please Fill In The Following In-,fo��rmation About The EXISTING Facility: Name System Installed Under: �. eW V 0 NNS Type Of Facility: 404sb Date System Installed (Month/Date/Year): 0 (0 Number Of Bedrooms:_Number Of People: Is The Facility Currently Vacant? Yes (0 If Yes, For How Long? Any Known Problems? Yes �. o If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �G�e�u h • i� ���'�pi / Number Of Bedrooms: Number of People *Pool Size: A i1' 3 Garage Size: Other: n Requested By i Date Requested: 11z- ignature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee Payment: rated) that the on-site wastewater system will function properly for any given period of time. Money Order # Paid By: Received By:_ Account #: Invoice #: —r 4b .�4v tz . QUI = ,. � C 7i 7,699 >1 I ova Q W(A 64 0 Cge . 011 66C) 9 ,.:.�.� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848!210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002433 Billed To: Jeff Jones Reference Name: Tax PIN/EH #: Subdivision Info: Location/Address: I -7G Knight Lane -27006 ATC Number: 4365 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 WASTE TER CTI IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign A Date: j2q)ow ,, , CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operati6n 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. Q f Septic System Installed By:Yt/Q�jJr-�'� V Environmental Health Specialist's Signature : _ A�z / Date: DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002433 Billed To: Jeff Jones Reference Name: Tax PIN/EH #: Subdivision Info: Location/Address: 5880-03-6370 1-76 Knight Lane -27006 ATC Number: 4365 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 WASTEW TERCTIJ IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign Date: q P 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. 1( Septic System Installed By:Yr'/Q,�f1r�� C4 df� Environmental Health Specialist's Signature: / Date: DCHD 05/99 (Revised) t • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002433 Billed To: Jeff Jones Reference Name: Tax PIN/EH #: Subdivision Info: Location/Address: 5880-03-6370 1-76 Knight Lane -27006 ATC Number: 4365 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 WASTEW TERCTIJ IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign Date: q P 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. 1( Septic System Installed By:Yr'/Q,�f1r�� C4 df� Environmental Health Specialist's Signature: / Date: DCHD 05/99 (Revised) .I] DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section " P. O. Boa 848/210 Hospital Street = Mocksville, NC 27028 (336)751-8760 1�1 "Qq IMPROVEMENT/OPERATION PERMIT Account #: 990002433 Tax PIN/EH #: 5880-03-6370 Billed To: Jeff Jones Subdivision Info: Reference Name: Location/Address: Knight Lane -27006 Proposed Facility: Residence Property Size: 15.03 **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 HDG #People _ #Bedrooms Ll #Baths 3 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Commercial Specification: Facility Type #People Basement w/Plumbing: 0"� Basement/No Plumbing: ❑ #People/Sh3ft #Seats Industrial Waste: ❑ Lot Size _ '} Type Water Supply WEU— Wastewater Flow (GPD) qaQ Site: New 0 Repair ❑ �r System Specifications: Tank Size /XO GAL. Pump Tank GAL. Trench Wic-t dth �;l Rock Depth 12—" Linear Ft.qC0 ��STQII�L�TIOn� i�r`�11 As state 15A NCAA 1$A.1969(5� Other: acce t . S stems ma alcn hp usp Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFF ENT FILTER RISENO it �` BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie C ty Health Department for al spection 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 in tallation. Telephone # is (336)751-8760.**** Environmental DCHD 05/99 (Revised) •DRtd� I l_..ti'�C-S l �' Date: r �1 )010 M '� s1 • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health: Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 ement Permit ❑ Authorization To Construct(ATC) VBoth ***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 ll Ames- Contact Person v Billing Address 9 Home Phone O QIP City/State/ZIP %^P1 'Business Phone Name on Permit/ATC if Different than Above jv Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. 11, (Permit is valid for 60 months with site plan, no expiration with complete plat.) a Street Address L27 City :U)6 lac Tax PIN# p G Subdivision Name %/ . Section/Lot# Lot Size Directions To Site: (ne j N T J ( r�� = J,, a{E h +� _,�t/ �f'T- / /Cin J Date House/Facility Comers Flagged oSiGt{cd�S� t c%t,�folotitf nl-eoNI�?l1�7• veeslerHc1tea- If. the answer to any of the following questions is "yes", supporting doc iitation must be attached. Are there any existing wastewater systems on the site? (mss ❑No Does the site contain jurisdictional wetlands? ❑Yes fll�o Are there any easements or right-of-ways on the site? B'!�es ❑No Is the site subject to approval by another public agency? ❑Yes Cil Will wastewater other than domestic sewage be generated? ❑Yes 90 IF RESIDENCE FILL OUT THE BOX BELOW # People 5— # Bedrooms .� # Bathrooms Garden Tub/Whirlpool des ❑No Basement: j -T&s ❑No Basement Plumbing: Elfes ❑No 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: P1Conventional ❑Accepted ❑Innovative []Alternative ❑Other Water Supply Type: ❑. County/City Water /New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes B-90 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 to determine compliance with applicable laws and rules on the above described property located in Davie County and owned by til i/l/ �• A.1 A I aW Site Revisit Charge Property owner's fflers legal representative signature Date(s)-.' 3 Client Notification Date: _ Date EHS: Sign given []Yes ❑No Account # 33 Revised 2/06 1Invoice # 1 1-1 7 1 s te 41 i dq EZ t tt r � 1<�' � .,. - ; .� � ..���+R � .. a � 4 �`` �� � I �.� °�•`_' 4 � � a,:�, �'. �`�' � '^fir a+��r �� ��� yb. t say"' " 31 A M� Y" (�PR n i 1 r { 4', A �a ... 11A 1 FT V } i s ,*ate, � k.,; � .. ° § • °�. � < � �.�� rf' " e ,� �, � � 5" ® a w e"i` t ai } 'l 9 5 41 A r w�T��' �.•`°�s� �xiq���',g� .g�' �?. � �, �,, s. .{,Rµ•+7y�y �,�`.� �� 4 � ", �2" m a'��"' � v'�. - � � { ti.# .. � �1.'� .. '"b,r'�: ,�X fit,!' �� �,'+: • 1� RFs^ �� •� ri �iaCe - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002433 Tax PIN/EH #: 5880-03-6370 Billed To: Jeff Jones Subdivision Info: Reference Name: Location/Address: Knight Lane -270066 Proposed Facility: Residence Property Size: 15.03 Date Evaluated: J �� Water Supply: On -Site Well Community / Public Evaluation By: Auger Boring Pit ✓ �,h Ip� C`t • • ®®®®�� Landscape position HORIZON I DEPTH Texture group Consistencemmm� �. .., is •��®■� Mineralogy HORIZON II DEPTH WORM Consistence Consistence mum= Mineralogy Rm= HORIZON IV DEPTH Texture group Consistence Mineralogy SOIL WETNESS law 1 .11 54W 0 W1521 . • ,. • • • • ��o��©moa CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: 0 • �� REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 MQisi VFR - Very friable FR - Friable FI - Firm „ VFI - Very firm EFI - Extremely firm met - 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 NOW 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) ■■■■■■■■■■■■■■■■■■■rye■■■■■■►■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■ ■■■■■■■■■■■■■■■■■■■■■■■nen■■■■■■■■■■■e■■■■■■■■■■■■■e■■■■■■■■■■■■■■■ e■■■■■■■■■■■■e■■■■■■■■n■■■■pie■■■■■■■■■■�■e■■■■■■■■■e■■a■■■■■■■■e■■ MENNENMEMNONENZN=i ' EMMONSMEMMiiiiiNEN MEi■■iiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■`■�■■■■■■■■■■■■■■ori■■■■■■■■■■■■■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■SEEN ■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■ ■■■e■■■■■See■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■SSSS■■■■■■e■■■■■■■e■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■SSSS■■■■e■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■SSSS■■■■■■e■■■■■■■■■■■■■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■e■■■■■■See ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 March 29, 2006 Jeff Jones PO Box 2012 Advance, NC 27006 Re: 15.03 Acre Tract/Knight Lane Tax PIN# 5880036370 Dear Client(s): As requested, a representative from this office visited the above site March 27, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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. Improvement Permit System To Serve: -P�S`-ceoCe— Wastewater Design Flow: (� System Type: 21onventional ❑Accepted ❑Innovative ❑Alternative ❑Other System Location: -� ®� � T��, Valid: Years ❑No Expiration Site Modifications/Permit Conditions: loco CAA X'J ps-i.p.letter 2/06