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153 Lower Place LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)75�-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 990002411 Bilied To: Jeanna Hendren Reference Name: Proposed Facility: Residence ��L� Tax PIN/EH #: 5778-29-5202 Subdivision Info: Location/Address: Clearwater Lane-27006 Property Size: 2 acres ATC mb r: 3248 **NOTE** is �mprovement/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). T'HIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE IN1'ENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People �_ #Bedrooms �� #Baths � Dishwasher�' Garbage Disposal: ❑ Washing Machines� Basement w/Plumbing: ❑ BasementlNo Plumbings�_ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size C Type Water Supply �/// Design Wastewater Flow (GPD) c�G'� Site: Ne�r Repair ❑ System Specifications: Tank Size� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width ��Rock Depth � 2 �Linear Ft. c�l� IlV1PROVEl�1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m.�p.m. on the day of installation. Telephone # is (33G)751-87G0.**** �y � Environmental Health Specialist's Signature: Date: ��!J 2- DCHD OS/99 (Revised) Account #: 990002411 Billed To: Jeanna Hendren Reference Name: ATC Number: 3248 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5778-29-5202 Subdivision Info: Location/Address: Clearwater Lane-27006 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 WASTEWAT CONSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS. Environmental Health Specialist's Signature: r Date: �'� .2 -tf'L CERTIFICATE OF COMPLETION **NOTE** 'I'he 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. b % �c � O .} U � � Septic S stem Installed By: YC/� Y Environmental Health Specialist's Signature : ��v �� v Date: �l � DCHD OS/99 (Revised) � . : • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER611T & AT Davie County Health Department � Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 1 2. D � � � D �� (i � � ZQ(�2 �:��_ / ***iMPORTANT*** THIS APPLICATION CANNOT BE PROGESSED UNLESS ALL THE REQU�F24�3 �`��I, INFORMATION IS PROVIDED. Refer to the INFORI�ITION BULLETIN for instructions. 1.,,, Name to be Billed(�eQ%jn� �en�r� � Contact Person V�� 1'- Mailing Address �� G� � ►� �Ci • Fiome Phone � q Z - 1 � s % city/state/z=P _ j�OCI�SVl II C, NC .�70af-3 Business Phone �µU — r]o'Z-� � Namo on Permit/ATC if Different than Above �I rne� ��anna �Y� Mailing Address (J� /city/state/zip 3. Application For. p Site Evaluation ❑ Improvement Permit/ATC la'Both 4. System to service: 11YHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _�1-'_ # Bedrooms 3 # Bathrooms � A,F�Dishrrasher fl Garbage Disposal (�+�Washing Machine CI Basement/Plumbinq 1i,1'Basement/No Plumbing 6. If IIusiness/Industry/Other: Specify type # People # Sinks # Commodes N Showors # Urinals N Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (galions per day) 7. Typc� of water supply: ❑ County/City UYWell ❑ Community e. Do you anticipatc additions or cxps►nsions of thc facility tliis systcm is intendcd to scrvc? If ycs, what type? ❑ vcs r�-f�o ***lMPORTANT*** CLIENTS MUST COMPLETCTHE REQUIRCD PRQPERTY INrORMATION REQUGS7'ED I3CLOW. �ithcr a PLAT or SIT� PC,AN MUST IIESUBMI7TED by thc client with THIS APPLICATION. Property Dimcnsions: � Q('_i�pS T.�Xorr��v: # S��B�9��0� Property Address: Road Name � l QQIZ[,tk(,�� U 1 c�ty�z�P ��I u� nce a ��D(� If in a Subdivision providc information, as follows: Namc: Scction: Block: Lot: WRIT� DIRGC'I'IONS (from Mocksvillc) to PROPGRTI': I; A�u ln �( E Ti,�n Z � n r�►'k /3i ��{ f2� . I 5} lii 2-� i�� o n� �-�f.c 2 1:iv�nc,ond I��I . -'+�°" �I�a�w`� �" �� a -w,.rn o'11 dn �.� r�a,� ��_ Datc Property r'lagged: b"� �" �� Tl�is is ta certify tliat the information provided is correct to the best of my knowledge. 1 undcrstand tl�at any permit(s) issuccl hereaftcr are subjcct to suspension or revocation, if thc sitc plans or intended use change, or if thc information submitted in tl�is application is falsitied or changecL I, n/so, �utdersta�td t/tat I anr re.spar.sihle for n// c/rnrges iircrrrred frn�ri !llis applicafio�r. I, I�ereby, give consent to tl�e Authorized Representative of the Davie County Ilcalth Department to entcr upon above dcscribed property located in Davie County and owned by to conduct all testing procedures as necessary to detcrmine the sitc ' ability. DATG � SIGNATURG � � -C/� THIS ARCA MAY B� USED FOR DRAWING YOUR SIT� PLAN (Includc all of thc following: Cxisting and proposed property lines and dimcnsions, structures, setbacics, and septic locations). Reviscd DCHD (07/99) ��J Sitc Revisit Ct�argc Date(s): Clicnt Notilication Datc: GHS: Account No. � ' ( � Invoice No. � .1,{ - _ �.: . �....... .. ... . .. . . .�.�.. ... � . . - . <J � � "_"' a �- �- � �'-�-. "- ... . . . ... .. .. .. .. . . ��. . . ... �. . . , ., ,. .. , . . . , .. . , . . . . . .. . . . . , , . I , , . . �� . .... .. . .. .. . ... . .. ..... .. .... . .... . .. .... . . . . �� ,. ... . , , ,. <, � . .. . , �... . . . �, . �: . . .. . .. . ' a.,. ;�.. . , . . , �. , . .. . . .. , � .. . ... �. .. .. . ... . I a,ss I8�a I ' ' . . , ._ . _ � � . ,. . < . . � .. i.� ' .. . � ,., . ,., v II s .... � . .... �. . , . �. , . . . ... . . �I � �.��.�. ... � . . , '� � � � � �. �. . .. �. y i � � . `` . � . . .. .. ��. � �. �. . � . f . � {1 {�{2A} ; sssr� � . � , , ' �� ; t � �, , ; � �s a , , ; � � ` �� _ �� '� � � � -- �,� 4 i � m,��h .. `, � � � -Pp (11. 59Q) � � ( _ C W 9Q � 5202 �. '� f Y ..��psl . `` . . �. �. . .... 1 i ♦` \` .. . 6 ' � � �. .. a /��9 �. . (6011 _(867.) � .______________, --� , (1.76A) N I 3 A� �� `� 1977 � u I 92 (�J7A'1 ��, �.� � �� $809 � � $ � � �oo � I ` '- �� e a� � I �o , .,.�,�,��" , � . . . .. � . �� .. 3i3,�,i"' , , -� ; � , �s � � :� r � F �: � ��:;��. (5 03A) , N E . .� , U , �, 6691 w ' ' � 450F, . � �� . � y� (2.00A) ! p� �' v� zzs 3540 .. , , ..... ��(1I2) . - ��.. . 15: y /'� �,«., � 46 L20 259 , � ., , .. � rn � ' . . . .. .� � ?59 � . � --�_�� 5� 1 , �� r/ � � II � � , <� �;� �2os _.._.. 4294 ',., (14.48A) „' `� w 0039 � � Q�� 4 ��, � � , rn ,,, iA � �� ` �� 1 i � ?� G '_ ; �;;,:,u, o � , N „r""._`" � .. I �, 13,' ' , I --------_ l ( � 1.16A) � �� <�'' 0861 � a 3 � ", • �" , _,�X, � �,�;; ,� , . , _ iI _ — — — -- __ -J .� ' � , . ° DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002411 Billed To: Jeanna Hendren Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5778-29-5202 Subdivision Info: Location/Address: Clearwater Lane-27006 Property Size: 2 acres Date Evaluated: g�� Z Water Supply: On-Site Well � Community Evaluation By: Auger Boring �� Pit HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION T lIATl� TL'D 11.( A!`(`�iYi` A 1�T!'C D A TC SITE CLASSIFICATION: � LONG-TERM ACCEPTANCE RATE: r REMARKS: Public Cut 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 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 MineraloQv 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(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 OS/99 (Revised) ■ �� ■�■ ■�■ ■�■ � ■ ■ ■��■■■ ■��■ ■��■�■ ■■��■■ ■■��■ ■��■ ■■�■�■ ■��■ ■��■ ■��■ ■■��■ ■■��■ �� ■■ ■■ �� ■��■ ■��■ ■��■ ■��■ ■■�■ ■■ ■■ ■��■�■��■ ■�■��■ ■ ■��■ ■ ■■■��■ ■�■��■■ ■�■��■ ■��\■��■ ■��■■ ■��■��■ ■�■\■■ ■ ■■��■■ ■ ■��\►J■ ■■��■I/1■ ■��i:C ■��■�■■ ■�■�■��■■ ■��■ ■��■ ■ ■�■��■ ■ ■��■��■ ■ �� ■��■ ■��■ ■ ■ ■■�■ ■■�■ ■�■■ ■■�■ ■��■ ■■�■ ■��■ ■��■ ■��■ ■�■■ ■��■ ■■�■ ■�■��N ■�■■�■�■ ■��■ ■��■�■■ ■�■�■��■ ■��■■ ■��■ ■��■�■ ■��■�■ ■��■��■ ■��■ ■■��■�■ ■■��■��■ ■�■��■ ■�■■�■■■��■��■��■��■■�■��■ ■��■��■��■��■��■ ■��■�■■■■��■��■�■��■��■■ ■��■ ■�■��■��■��■ ■�■��■��■■■��■��■��■■■ ■��■■��■��■��■ ■��l��■ ■\��■��■■■��■��■��■��■ ■��■��■■��■��■■��■��■ ■■ ■■