113 Summer Sweet Dr Lot 13 r:.
Fermimme'. DAVIE COUNTY HEALTH DEPARTMENT
Name:_ �:% �� / G i^ Environmental Health Section PROPERTY INFORMATION
/ P.O. Box 848
Directions to property: !2—,( f1 Mocksville,NC 27028 Subdivision Name:
( Ij,., Phone#:336-751-8760 / 3
v' i `,/G 5� r �IWTHORIZATION
n e, Section: ! Lot:
1 41 /) r•.. FOR
t�S, /G' `jtr � . , , WASTEWATER 96� z3 G Ike
SYSTEM CONSTRUCTION Tax Office PIN:# -
AUTHORIZATION NO: 0 0 Z 93Road
Name: Zip:
**NOTE**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.
(In corn b ce with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
S COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
V LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
I ow 5 o
u1SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��ca— ROCK DEPTH LINEAR FT. U V
OTHER
Q F QUIRED SITE MODIFICATIONS/CONDITIONS:
i
IMPROVEMENT PERMIT LAYOUT
r Cum ° cIo 6 CGS'
L.n -P5 k5 y S
/N ! w VC IG c C t.ZI
(I vel
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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. //
DMD OM(Reviud) I D}{
- ay..`.� j-s..t .— ,. _ aA•.".ti" t r.... fir, ,. _ ' -.- �, �, .,. �,>s .o Yr ....
Recmit %�sj �. / ! ( DAVIE COUNTY HEALTH DEPARTMENT
Name:- J x_, �) ,; / j �` t" Environmental Health Section PROPERTY INFORMAT ON
_+ .: =
_ P.O. Box 848
- Dire6tidbS16 property:- r � '- Mocksville;NC 27028 Subdivision Name: /Ptl el Ilf
1 ' F,� !: %C %1' �. Phone#:336-751-8760 --,
Section: Lot:
r AUTHORIZATION FOR
WASTEWATER
_ r SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO:' 002983 f + L.. Road Name: P�
'Zi ✓'GCS�/
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST bATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE-�— #BEDROOMS—3—#BATHS #OCCUPANTS 1 GARBAGE DISPOSAL:Yes or No
S COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE O G/ TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) 6 3 NEW SITE �, REPAIR SITE G ��
yr tSYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3(g_ ROCK DEPTH404
LINEAR FT. U U
S
OTHERJIL IjcN
EQUIRED SITE MODIFICATIONS/CONDITIONS:
i
IMPROVEMENT PERMIT LAYOUT
J �
C, Ake
iv
l fa^' -c- tA e, f
Li .v lzl f4 tj�
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: r
AUTHORIZATION NO. 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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised)
.t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900093 Tax PIN/EH#: 5880-50-8948
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#13
Reference Name: Location/Address: Summer Sweet Drive-27006
Proposed Facility Residence Property Size: see map
ATC Number: 4145
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 CON`STRUCCTION IS VALID FOR A PERIOD OFF FIVE YEA/RS.
Environmental Health Specialist's Signature: TTA'/I Date:Am sMum
accepted SystemsNmay al eo be uun
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system descn on Improvement/Operation Permit
has been installed in compliance with Article 11 of.�.S Section. 00"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the tem 'll function satisfactorily for any
given period of time.
x.IVIA
1-
Septic System Installed By: �/ r
Environmental Health Specialist's Signature Date: �!g
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT 5�
Environmental Health Section d
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900093 Tax PIN/EH M 5880-50-8948
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#13
Reference Name: Location/Address: Summer Sweet Drive-27006
Proposed Facility Residence Property Size: see map
ATC Number: 4145
**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 #People #Bedrooms_� #Baths
Dishwasher: [7 Garbage Disposal: Ce"' Washing Machine:. Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply p Design Wastewater Flow(GPD) Site: New4n'lRepair❑
System Specifications: Tank Size/6F6'b��AL. Pump Tank GAL. Trench Width Rock Depth_2 Linear Ft!!1
Other: As stated In 15A NCAC 18A.1969(5�
pted S t -flt9 99-b�-tf8�
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davi ounty 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 on the da of installation. Telephone#is(336)751-8760.****
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Health Department L JUL 13 200510
EnvironmentalHeaith Section J
P.O. Box 848/210 Hospital Street i I
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
(336)751-8760 DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed PUrt/S/,,� Contact Person �sri{/
Mailing Address S'7 I-la al /y l,L/LS r Home Phone 94�% Za Z.P
City/State/ZIP Business Phone `JS/- 57 2i2
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: itt�valudtion 1801Improvement Permit/ATC ❑ Both
4. system to service: N House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: 0 Conventional ❑ conventional modified ❑ innovative pacCepted
6. If .Residence: # People Se'K/� # Bedrooms _� # Bathrooms ��ZL
Dishwasher lJOarbage Disposal C washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: IL County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes . U<0
If yes,wl:at type?
***IA1P0RTAN7'***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELONV. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli THIS APPLICATION.
F s
Property Dimensions: 17VX Y 3 rX 1z7 NVRITE DIRECTIONS(from Mocksville)to PROPERTY:`
Tax Office PIN: Xlzo 5� PV
Property Address: Road Name
city/zip j&4VzYL . 111a J-?DD4l,
If in a Subdivision provide information,as follows:
Name: A/ U___1X`0
Section: Block: Lot: Date home corners flagged: •Tg,c l4 cJu,(�
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 cliange,or if the information
submitted in this application is falsified or changed. I,also,understand that 1 am responsible for all cliarges incurred from
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
to conduct/all testing procedures as necessary to determine the site suitability. /
DATE SIGNATURE
MIS ARRA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Lusting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS•
Sign given '. Account No.
97aao 7 �
Revised DCHD(05103 Invoice No. e-17_3 0� --
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section SECTION LOTS
Soil/Site Evaluation
APPLICANT'S NAME 14-Z '!& DATE EVALUATED -2 r-,-9/
PROPOSED FACILITY PROPERTY SIZE !1��
SUBDIVISIONV_ L� ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1E2 ,
3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTHTexture ou Consistence
Structure
MineralogyHORIZON H DEPTH
Texture group
Consistence i -moi
Structure T //
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: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: ' i� OTHER(S)PRESENT:
REMARKS:
LEGE
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
Mineralogy
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(01-90)
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