Loading...
1390 Main Church Rd Ext i � DAVIE COUNTY HEALTH DEPARTMENT ; �,,- � - ; Environmental Health Section � � _ 21-- � � �� � - - P.O.Boz 848/210 Hospital Street � , Mocksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990001892 Tax PINlEH#: 5820-83-6242 Billed To: Michael Johnson Subdivision Info: Reference Name: LocatioNAddress: Main Church Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2986 **NOTE**This ImprovemendOperation 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Reside ial Specification: Building Type #People � #Bedrooms�_ #Baths � ,Dishwasher:� Garbage Disposa]X� Washing Machine:�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply L�� Design Wastewater Flow(GPD) ��� Site: Neyr.B�Repair❑ � i System Specifications: Tank Siz��GAL. Pump Tank GAL. Trench Width�1 Rock Depth���Linear Ft�Od'� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S IF 6��BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Dep or final inspection ofthis 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 installatio phoq�e#is( 6)751-8760.**** . (;Y'!� F --� - . r.�- : Environmental Health Specialist's Signature: • � Date: -�� -�`�/ DCHD OS/99(Revised) � �D .�.. , . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001892 Tax PIN/EH#: 5820-83-fi242 Billed To: Micha�l Johnsan Subdivision Info: Reference Name: LocatioNAddress: Main Church Road-27028 Pro osed Facilit : Residence Pro ert Size: see ma ATC Number: 2986 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 WASTEWAT C STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �d 2� �U l CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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. � ��5,i ��� ���s,�e� i �a � /G� ' � � � Septic System Installed By: � r e Y/JC G� Environmental Health Specialist's Signature:� Date:��--�_���,� ` DC�ID OS/99(Revised) �' �� fYla�l��•�a � �,Q �a-��-�sl �. ,-��v��s,`� , �. . � '� '�j ,�,,�,� ��� APPLICATIUN FUR SlTC EVALUATION/IMYItOV[R9CNT�'LRA9lT&ATC � Davie County Health Department �AUG 2 2 2U01 Environmenta/Hea/th secrion P.O. Box 848/210 Hospital Street Mocksville, NC 27028 � �� ENVIRONMENTAL HEALIH (336)751-8760 DAVIE COUN?Y ***IMPORTANT**�* THIS APPI,ICATION CANNOT BE PROCESSED UI�SS �I1LL TIiE R�QUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruc�ions. � 1. Name to'be IIilled �.IC,�QeI . ,JQ� S�(� Contact Person _�-� ____ __ ____ Mailinq Address �`���tn��(L1��G`(��e Fiome Phone '� 7'"(�Q�p��O��r- � City/State/ZIP w�5 I 1c , ���(7� IIusiness Phona ��j�p�-'qg���Q9 2. Name on Permit/ATC if Different than Above NQ � �(LyYLQ� Mailing ]kidress City/Stat.e/Zip � ����s�- a � � 3. Application Eor: Site Evaluation ❑ mprovement Permit/ATC II Both 4. systesn to service: UVHouse ❑ Mobile Home O Business f.l Indus�ry I.I OL-her 5. If Residence: # People _� � Bedrooms �_ # Bathrooms p�,�� I:�ishwasher U Garbaqe Disposal L�hing Machine l.l Basement/Plumbing il Basemenl-./No Plumbing 6. If Business/Industry/Other: Spec.ify type # People tl Sinks # Commodes # Showers # Urinals N Water Coolers ZF FOODSERVICE: # Seats Estimated Water Usa 2 (qallons per day) . 7. �pe of watar supply: ❑ County/City Well II Community e. Do you anticipatc additions or cxpansions of thc facility this systcm is intcndcd to scrvc? ❑ Ycs h1�lo �ry�s,�y��ac cy���� ***IdfPORTi1NT***CLIENTS AfUSTCOAiPLETCTIIG REQUIRED PROI'�RTY 1NrOItMATION IiI:QUES'I'�D BGLOW. Gilhcr a PLAT or SITL I'I.AN�1UST 13CSUBd117TED by tlu clicnt �vilL Tl11S APPLICATION. � P ' cnsions: WRl7'L DIRLCf[ONS(from 111ocicsvillc) to PRU1'l�,lt'1'1': _ �" p'° 3"'�! Tax Oflicc PIN: # S���-g 3�6�.�� f�01 �j �b �_a_v,�� Rd -�r�n � Property Address: Road Namc Ma.in Ch . �. ��C-�-, ,f� GY). �11�� ., �����_ City/Zip �QG�SY(�,�e �`Zb� .�—C111�_� " P1'Yz.l'r1 /�.LI � �)G�' . IC in a Subdivision providc information,as follows: �/1, �1(� �- GU'lU, j,�_��!/({'�,�� � IYamc: �' 1� � 1� C.e lM �.` - �o nc� [n Scction: I3locic: Lot: Datc Property Flaggcd: C�� O This is to ccrtify that thc information providcd is corrcct to thc bcst of my knowlcdgc. I undcrstand thal xny permit(s) �p� issucd hcrcaftcr are subjcct to suspcnsion or rcvocation,if tl�c sitc plans or inlendcd usc cl�angc,or if thc information -- submitted in tl�is application is falsified or cl�angcd. I, nlsv,�urderslaud 1/�ut!am respnnsiGlc fi�r n!!clrurges iitcrrrred f'ruu� ri��s an�r�u�;o,r. I, hcrc6y,givc conscnt to tlic Autl�oriud Rcnrescutativc of tlic Davic County Ilcalth Dcpartmcnl to cntcr upon abovc dcscribcd property locatcd in Davic County and owncd by ------_........—---_.. to conduct all tcsting proccdures as ncccssary to dctcrminc 11�c sitc suitaUitity. UATE ��ZZlO ( S(GNATUR� , �( J/. Tfi1S AR�A MAY BE USED FOR DRAWINC YOUR SIT�PLAN(Includc all of tl�c follo�ving: Cxistinb and pruposcd ' property lincs and dimcnsions, structures, setbacks, and scptic locations). ' Sitc Rcvisit Cl�:�r•gc � � n � Dalc(s): l �-x- � �� /, � 1 Clicut Notification Datc: � � �..-�.�--�J J � � �HS: , ,Lp _ (.�..c�---�-5 � �� ��` ,�� Account No. / � ! 2-- � Reviscd DCHD(07/99) Invoicc No. � � � (�-�t C � Z..� ��� �� � , � a� 7 , \ 5 � : � � 152 98 74 d'�: \ , � 150 � S� : `��� � , , 6'� \ � , � N � \ � 2�17 0 6'� , ' . , �Sp \ � i ^ G4Q80A003203 Sl� y�� �s i . �?�,S �s_ /j � � w ��� �2 . � w �F . �J� � w � � � 1 .80 A � � (3.90 A) � � 3263 6242 : ��S - 1230 � � ��---- -----------------� , �, , 2118 N � dQ�� � �� �9 �' .------- � , �� �p �o� 5 ' ' �� ��� � � '', � �o �'�e- , . Q- ; v ; . �,. , _ ; 10� �,� � � �02 � 1 .00A '��:, � � �o',o �270.77 � � �., , - _ _ _ _ _ _ _ _ _ _ � _ _ _ 9074 � � 101 SR 1304 � - - °�'���Hu��� 4 � 253 - - -� � _ � < 175 � - - _ _ _ 1 � �� ��% .-. 75 - � ` `L � ���b � � , �, ______- i `, 1 pp ' - n � � , � 2914 N �-------- .� . �,, _ , `' � 6903 ' 3984 � �os � , . , � , 5 � 8828 � `'' . 1� � � � 100 � � 175 75 ' - " � � � �`� (6.431 A) i1 E � � ' � � � � � � ■ ,� �' � ' ��,,- � �,> \ , � � _ 6851 . � �� � ��, 3854 N N ; .P 4798 , . . �, . O p ; . � . . � • " . � � ��. ' ' 0 2736 , 3767 . ' .��1 - - � " "`�. � _� . .. . • DAVIE COUNTY HEALTH DEPARTMENT -• - � '� ' - � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001892 Tax PIN/EH#: 5820-83-6242 Billed To: Michael Johnson Subdivision Info: Reference Name: Location/Address Main Church Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: ��� 6l Water Supply: On-Site Well Community Public � �, Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3. 4 5 6 7 Landsca e osition �- Slo % HORIZON I DEPTH � Texture rou Consistence Structure Mineralo HORIZON II DEPTH !� � Texture rou Consistence Structure i/ Mineralo � - HORIZON III DEPTH Texture rou Consistence SWcture Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON ' SAPROLITE ' CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: �G LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: t.S,� -f �� /Ll`GG� � �L�lJ'l✓ (iW� 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 tru ture SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev � 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-gaUday/ft2 DC�ID OS/99(Revised) ■��■������������■��■■���■������■■�s��■�����■��■■�■��■�������o���■■ ■�■��■���■�■■�■��■�■���■����■���■���■■���■��������■�■���s�■����■o■ ■����������o���■�■����■■�■■�■������■■■��■■���������■�■■���������■ ■����■o��■����������■��■����■�■■ ■���■■■�■�����������■■���������■ ■�����■��������00���■�v■se■����■�■���■��■�■������■�a����sa���■■��■ ■�e���■��■■��■����■��■�■■��������■■�����■�■■����■■���■��■■■�■■��■■ ■�������■�������■��■�■�����■����■��■����■■��■�maoe�■■��s���s���■�■ ■■���■�a�■��oev■s�e�����s■e�����������������������s■■�����■�■����■ ■■�����■�■�■■■�■�■��■��■������■�■■��■■■■�■■�■��■��■�■■�■ov■���e■�■ ■■���������■�■esA■ev���■�■■���■s�■om�■.e�■■o���■s■■�������■������■ ■����������■�■����■�■��■�■■�■�■��■��■■■■�■��■�■■�■��■�o������o��■ ■���������■�■■����■���■■�■■����■ ■����■■�■�����■■���■■����■■����■ ■■�■���■■�■��■����■�■��■��■■���■�■■■���■■�■������■�■�■■����■■����■ ■�■��■■���■��■�■■�■��■��■�■■������■■����■■����■�■■�■�e■■��■�■����■ ■�������■���■�■■�■�■�������■■���■��■■■■��■�■■�■��■�������������s�■ ■�����■■��■■�����■��■����■■�■�������■■■������■■�■����w���■��e�s��■ ■�����■����■�■����■���■■�o■�■■�■�■����■■■�■�■■��■�■��■�����������■ ■���■����■�■�■��■�■����■��■�������■����■■�■��■e������■������■����■ ■��■��■���■���■■��������■�■■���■��■���■■�������■■a■�����■�������■ ■��■����������■■��������■������■ ■����■■�■■��■�■��������■�����■�■ ■���������■�■�■��■�■����■��■■■�■■�■������■■■�■■��■��■����������■■■ ■��■■��■■�■■■�■�■■�■�����■�■����■��■■���■■�■��■���■�■■�����■■����■ ■�■�■��■���■■■��■��■■�����■■�����■��■��■�■��■��■��■��■■■�������■■■ ■��������■■■�■����■�■����■■��■■■�■����■■■�■���v■■���eo■■�■����e■■■ ■���������■��■�■��■�■��■■�■���■��■■�������■���■■■����■■■■�������■■ ■■��������■���■■■�■■■■����■����������■�����■���■■■���■■�■���■■■��■ ■�■�■��■■�■���■���■■�■��■�■■���■��■�����■���■��■�����■■■■����■��■ ■■�����■■���■�■���■■�■�■■��■e��■ ■�����■����■�■■■�■��■■■■������■■ ■��■■���■�����■��■�■�■■■■■�■�������■����■�■■����■■�■■���■■o���■��■ ■����■���■�■■■���■�������■�■■o��■■�■■■■�■■�■■�■��■■��■����■■�����■ ■��������■■■■■■���■���������■■�■■■■■■■■■�■�■■�■���■��■■■�����■���■ ■����������■■■■���■�t��■�■■��■�■�■��■■■■s■����■■��■���■���t����■■■ ■��■��������■■■���■����■■�■■■��■■���■■■■�■■���■■■�■����■e����■���■ ■��■����o���■�■��■■■�■������■�■�■■■■�e��:�■■����■■■■■■■�������■�■■ ■�e���■�o�■�t���■■�■�■�■■��.�.-_...��=:��■■!�■■����■��e■��������■���■ ■���■■��■��■�■���■�e■■�.�������■i�i�■����■�■■■■■��■■■■��������A■e�■ ■����■��a��■■■�■�■�s����■■�■■���■�■■����������■������■���������e■■ ■■�■�����■�■■■�■�■■���■��■����■�■��■■�■���■�■�■■��■�■■��■■■�������■ ■��■�����■■■■�e�■�►������■������■��������i���■■■��■■■■��■■■�������■ ■■■���■��■■■�■�■�������■�■■���■�■■��■■���i���■�■��■■�■■■■■■�■�����■ ■�����■■��■o�������������■■�■�■��■��■�■■t����■��■����■■���■��■��■■■ ■�����■���■����■■��������■■■��■■■�������������■■■��■■�■�■��■■���■■■ �iiiiii�iiiiii�iiiiii�i�iiiiii '�iiiiiiii�iiiiii�iiiiiiii�iiiiiii� ■���■���������■����■�■■�.�::���■��■■���■i�■■■■���■���■o��■■���■■��■ ■���■�����■■■■���■�■�■■����■s��:�e���������■■■�a��e���■����■�����■■ ■��������■■■■■���■�■■■■�������■�■►�����������■s��■■■������■■�����s ■���■�����■■■■����■��������■■■■��■►�■��=�■■■■��������■■����������■ ■�■������■��■��■�■v���■■�■■�■■���■����■�����■■■■■�■■■■■■����■■■��■ ■�s��■■■��■■���■�■����■■�■■�■���■■■�■■■■�■��■��■���■���■■■����■��■ ■��■�■��■����■■■■■■�■��■��■■■■■■�■����■■�■���������������■■���t�■ ■�■��■■�■���■�■�■�■����■■�����■■ ■����■■�■■�■�■■�■■��■■■■�■■�■��■ ■�o����t■�����o����s■■�■■�■����■�■■����■��■�e■��■■■■■��■�����e■■■■ ■�������������■�■��■�■�■■������■■�■■����������■�■s�■■��■■■��■����■ ■■■�������■■������■■�■■��■�����■���■�������■■�■��■��■�����■■���■�■ ■����������■���■�►•�����■��■�■■�■�■��������■�■■■■��■��■■������■■■■■■ ■�■�■�■■■�■■�■�■��au����s��■■■■�■■■���■�����■■■■�■■�■■■■■����■o�■■ ■�������■�■�■■�■��■�■��■��■�■■■�■■���■■■�■■�■■■■��■■■■■■�■�eo����■ ■���■������o■■■■■���■��■■�■���■■ ■���■■�■■��■�■■�■��■■■���������■ ��■■■■��■���■�■�■����►:���■������i■■�■�■■■■��■■■■■■■�■��������e��■ �:�e,a������■��������■u���■n����■����■����■■�■�����■�����e������■��■■ ���������■������■��i��■����■�■���■■�■■���■■�■�����■■■■���■■�■������■ ■■��■■■��■�■��■�■■�i��■,��►i��■�■�■�■■■���■■�■�����■�■■�������■o����■ ■■����■��■�■�����■�i���iin������■�■■�■■�■�■����■■��■■■■■���■�■���■■�■ ■��■���■�e�■�■�■�■■����►������■��■�■■�■■�■■■�■■■■■■�■■����■�■�����■ ■��■����■�■■■■�s��e,�c�■��■��■�■�■■�■■■■�■■■■■�■��■�■■■e■�■■■■■��■■ ■�■��■����■�■■�����i����■�■_��■■■■ ■����■■■�■■�■■�■■■■■�■��■�■■■��■ ■�■�■■■�■�■�■�■�■���::���■■�■�■■ ■���������■�■■�■�■■■■■�����■���■ ■���■����■��■�■���■■���■��■�■■■�a����■■��■�■■�■����■■■■�������■■■■ ■��■�������■■�■�■■■■���■��■�■■■��■��■■■■�■����■■����������������■■ ■��������■■■■�■�■■������■�■�■■■��■■�■�■■���■■�■���■�■■■■����■�■�■■ ■�■■■■■�■���■■��■■�■����■e��■��■��■�■■■■�■�■■�������������������■■ ■■�■�■��■�■��■■■■■�■■■��■s����■■�■■■�■■■�■■�■��■■���■■■■�����■■�■■ ■�������■�■��■�■�■���■■�■��■���■��■■��■■������■■��■����■����■■��■■ ■�■�����■��������■������■��■�����■�■����■■���■■■��o�■■������■��■■ ■■���■��■�■�■■�■������■��■�■��e■ ■■�■v■�■■����■��■��■■■������■�■■ ��������������������t�■■�■�■■■�■�������■��■�����e�����■■■■�������■ ■■�■■�■����■■�■■■�■■■��■�■��■�■�■��■■■■■■�■■�■��■�■��■■■■■����■��■ ■■■■■■■���■■■�■�■e■■■�����������■■�■■■��■�■����■■�■■�■■■■■�������■ ■■�����■�■���■■��■�■���■■�����������������■���■■���■�■■�■�e■■■■■�■ ■����■����■■■■■■■■�■�■��������■�■■��■�■����■��■■���■��■■��■■■■�■�■ ■��������■■■�����o���■■�■��■■■���■��■■■■�■�■■����■�■■�������■■���■ ■�■����■■�����������■�■��■�■�■■■ ■�■■■■�■��■�■■���■���������■���■ ■■s�■■����■�■■�■a■■■������■■�■�■�i■■■■■■�■■�■�■■���■���������■■��■ ■�������■■■�■��■��■���■��■■■�■�■�■■�■��■�■■���■��■�■■��■���■�■■��■ _ ..� , • • , . , .. , ..-. D��I��OUNTY�I�LT,r ,.n,. ..,. ��..,, . .... �,� . , ., , __ _ ; . . -, �I D����T1VI�NT ....... _. . .. __ , � ; , , _�.. .. . . . . .__. .. _ _ . ..ua....� ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospttal Street _ . Courler #09-4Q06 - Mocksville, NC 27028 . . � ._, ,_� ' Phone #. '(336)751 8760 :s . ... .... . .. ..... ._._.1..�,.� September 5,2001 Michael D. Johnson _ 501 Sunny Park Circle Winston-Salem,N.C. 27103 Re: Site Evaluation/ Main Church Rd. E�ct. Tax Office PIN: #5820-83-6242 Dear Client(s): As requested, a representative from this office visited the aforementioned site on September 5 , 2001. Based on information provided on the Applications for Site Evaluations and after the evaluation was completed this site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Authorization(s) to Construct can be issued the appropriate application(s)must be filled out and the house/mobile home location staked on each site. If you have any questions,please feel free to contact this office. � Sincerely, /�4������• Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s) _