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119 Summer Sweet Dr Lot 12 DAVIE COUNTY HEALTH DEPARTMENT • � 7. (3-d� - Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH#: 5880-51-4715.12 CS Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres one Lot# 12 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility Residence Property Size: 11 5'x 317' ATC Number: 2083 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 UCTI N IS VALID FOR A PERIOD OF FIVE YEARS Environmental Health Specialist's Signature: Date: .g 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. Septic System Installed By: � Environmental Health Specialist's Signature: Date: ,l�" ✓ DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900093 Tax PIN/EH#: 5880-51-4715.12 CS Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres one Lot# 12 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility Residence Property Size: 11 5'x 317' ATC Number: 2083 **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 Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: Ne Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width<3�G Rock Depth.Zn Linear F4 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6-BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.t n e ation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) 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 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIlDED.1 Refer to the INFORMATION BULLETIN for instructions/. 1. Name to be Billed �/�� 1 C.�_ i ��--��. Contact Person �-_ -S i`� 1 �- Mailing Address ��ZyY7 ,u S ��J �� L._J Home Phone City/State/ZIP /� /.+`1L L i �� /lJ. L. Z�D Z S Business Phone Z a V b 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 0 Si-E-e Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ®-Vo—nventional ❑ conventional modified ❑ innovative 6. If Residence: # People _ # Bedrooms _� # Bathrooms Cfffshwasher -EIUarbage Disposal ung 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) S. Type of water supply: &-C6u'nty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes z SFr' If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: `' WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # Property Address: Road Name City/Zip AJ,._ 27(30L-,, If in a Subdivision provide information,as follows: Name: Section: _ Block: Lot: 1 �� Date home corners flagged: fa -Z S D 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 change,or if the information submitted in this application is falsified or changed. I,also,understand that I ant responsible for all charges ificurred frons this application. I,hereby,give consent to the Authorized Representative of the Davig Couijty Health Department to enter upon above described property located in Davie County and owned by S/C /�"• — e_ , _ _�: _ to conduct all testing proced7,s necessary to determine the site suitability. DAT2 E S/ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines Jd dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): s 4717 X17 `^ Client Notification Date: -- ` f� _r EHS: s. J" Sign given Account No. Ilkevised DCHD(05/03 Invoice No. a 0' f I ,� ✓ - o �� yz�- R • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION--,/--LOT�Z Soil/Site Evaluation APPLICANT'S NAME /Olt / DATE EVALUATED "�g D PROPOSED FACILITY PROPERTY SIZE SUBDIVISION i ROAD NAME_Aea a/,-C Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscapeposition ,L Slope% HORIZON I DEPTH �� v Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure ! iC Mineralogy / HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture&roup Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: / .S OTHER(S)PRESENT: REMARKS: �� Y C'G LEGENO 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(O1-90)