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157 Tulip Magnolia Dr Lot 15 DAVIE COUNTY HEALTH DEPARTMENT P� 7.1 3-a t j Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH#: 5880-61-0351.15 CS Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot# 15 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility Residence Property Size: 1.5 acres ATC Number: 3795 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 C TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: —/x a 7 Q �Oa M 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 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. l� //45 7.1 ,dle f Septic System Installed By: rL /, eP Y� n � Environmental Health Specialist's Signature: (1,(i(y Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ,.,. A Environmental Health Section �� 74 3—v�G P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900093 Tax PIN/EH M 5880-61-0351.15 CS Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot# 15 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility Residence Property Size: 1.5 acres ATC Number: 3795 **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) �6 n Site: New 0 Repair❑ 7 G System Specifications: Tank Size��AL. Pump Tank GAL. Trench Width�/ Rock Depth/ s Linear Ft-�b Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6°f 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.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: / Date: P im DCHD 05/99(Revised) RLPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department 1 1 + 1. Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 VYt801IMNTALHlr MI (336)751-8760 RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. L 1. Name to be Billed c T U J J.-,e Contact Person el—"' Mailing Address, 2 r7 (/i A4:/ T Home Phone 7 .S S�ZX City/State/ZIP 117,� YS... j � � _/�.L• Z7 V Z Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �6,5j te Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: L-liouse Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: oIG�C nventional ❑ conventional modified ❑ innovative i 6. If Residence: # People L # Bedrooms # Bathrooms 2 . QV shwasher t65rbage Disposal ng 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: ga-Rduinty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes M-Dk� Iryes,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: /. 1 H C r �b WRITE DIRECTIONS(froin Mocl.sville)to PROPIiRTV: Tax Office PIN: # 5796- !-03�`I sr�f f-.► Z. off 41 Property Address: Road Name 5�, S vg•-1► i�:•6 - _ �� ;_ /�'�` 1 �, City/Zip 92=!A' ' t t 2--7 0�b �.' �" �..-� .R _ .G� S-F.-,�vL If in a Subdivision provide information,as follows: , Name: Section: �_ Block: Lot: / Date home corners flagged: 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 aur responsible for all charges incurred fn•onr this application. I,hereby,give consent to the Authorized Representative of the Davic Count),IIealtl Department to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures asnecessary to determine the site suitability./ DATE �� /4 SIGNATURE r TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge ' Date(s): Client Notification Date: EHS: Sign given Account No. �'S d Revised DCI-ID(05/03 Invoice No. lf' - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT-' Soil/Site Evaluation APPLICANT'S NAME 4l`/�/�� DATE EVALUATED d/ PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME sol �� Water Supply: On-Site Well Community Public !/ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,C. 'Z_ Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Yv Texture groupG Consistence Structure l �� Mineralogy , HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 77— OF LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: e -"41e L GEND 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) LIAR-Long-term acceptance rate-gal/day/ft2 DCHD(O1-90)