Loading...
210 Main Church Rd %� . . DAVIE COUNTY HEALTH DEPARTMENT �,� �— d I Environmentai Health Section (�� r.o.Boz 848/210 Hospital Street � .r � , Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990�01649 Tax PIN/EH#: 5/49-19-2127 Billed To: Mainville AME Zion Church Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Fellowship Hafl Property Size: see map **N6TEC'�This�mprovemendOperation 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 PERNIIT 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�/�hGl�.(,' People #People/Shift #Seats� Industrial Waste: ❑ � Lot Size Type Water Supply�� Design Wastewater Flow(GPD) o�Q� Site: Nev�•� Repair❑ System Specifications: Tank Size,�j�GAL. Pump Tank GAL. Trench Width��� Rock Depth�� Linear Ft.�� � 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 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)751-87G0.**** � � F ,�}//7/7/��� (/�C ��_ Environmental Health Specialist's Signature:������������ Date: J `?� C./ DCHD OS/99(Revised) / . , �� DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001648 Tax PIN/EH#: 5749-19-2127 Billed To: Mainville AME Zion Church Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Fellowship Hall Property Size: see map ATC Number: 2771 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,Secf .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER O TR N IS VALID A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ' . Date: ��'—[�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation 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 oftime. �3 ��N � �� ��s� � �a u�� ��� � C�� � � �- ��X3XaY� Septic System Installed By: Giv Environmental Health Specialist's Signature: ��iD�.0 Date: �'�"7� � DCHD OS/99(Revised) . ". /_S . . � . , , . " ' APPUCATION FOR SiTE EVALUATION/IMPROVEMFNT PERMIT&ATC D � �� � Davie County Health Department Environmenta/Hea/thSe+afson � Z ' � P.O. Box 846/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENUIRONMENTAL HEALTH DAVIE COUNTY ***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCE3SED UNLES3 AIrL THE REQUIRED INE'ORMATION I3 PROVIDED. Refer to the INFORMATION BLTLZETIN for instructions. i. x� to � a�i�.a t��i,nv.i.e.�e AM�' Z.i.ovc Cl2u1C�+12 contaot poraoa fV.i,P.P,i.e F. Sco�`.t Msiliag l►ddroaa 210 Ma.i.►2 ChultCh Ro�id goma phona 336 492-7491 cis��st.��zzr Mock�sv.i.P�e, Nar,th Cana.�i,rta 27028 Bu�t�oss phono 336 751-3561 e.x�.2373 2. Nam� on P�rmit/]►TC i! Diflor�nt than �bovo Mailinq rddr�ss City/Stato/Zip 3. Appiication For: ,,�.181te Evaluation ❑ Impzovement Permit/ATC ` �Both t. systom to sos,►�co: 0 House 0 Mobile Home � Business � Iadustxy [� Other��� aw�h-ip Ha.�X. s. �f Residence: 1 People # Bedrooms # Bathsooms [7 Dishxashor fl Garbaqo Disposal Q iPashia,t Haehis�o U Basomeat/Blumbiny U Has�at/tlo plumbinq 6. Zt Hu�in�ss/Industxy/Othor: 8pacilY type F'P.P,Qp(d1�Sh,t-�J� # Poople �Jr / Sitilcs 2 � Commodos 4 � 8hoxora � Urinals 2 � Hator Coolers IF FOODSERVICE: # Seata 75 $stimated Water Usage tQ�loa.�a�- 200 when u4ed �. Type of Mater supply: [J County/City ❑ i+�ell � Community , e. Do you anHcipate additions or e=paaslons of the facility this system is intended to serve? 0 Yes �No If yes,what type? *�*lMPORTANT't**CLIENTS MIIST COMPLETETHE REQ[lIRED PROPERTY INFORMATION REQUESTED BELOW. Elther a PLAT or SITE PL.AN MUST BE SUBMI?TED by t6e cllent wtt6 THIS APPLICATION. Property Dimeosions: WRITE DIRECTIONS(trom Mocksville)to PROPERTY: Ta:Ofiic PIN: # J`l y �1 � � q �'� ��'7 Fnom MacFz�Sv.i,e.ee Nwu. 158 Non�h �a Property Address: Road Name Mcr,i,rc Chu�tch Road Ma.i.n Chu�cch Road rA���tox.3 M-i.. �u�cn � Clty/Zlp 27028 Le�4� Chu�cch on R,i.gh,t App�cox. ` 1/4 M.i. If in a Subdivision provide latormation,as lollowa: Name: , Section: Block: Lot: Date Property Fiagged: T6is is to certify t6at the iaformation provided is correct to the best of my knowledge. I nnderstand that aay permit(s) issued heceaRer are subject to suspensioa or revocatioa,if t6e slte plan�or iateaded nse c6ange,or it the information submitted in t6L�application is falslfed or changed 1,also,uddersland tba[I am responslb/e jor a!1 ctiarges Incurred jrom �hls applicatlon. I,hereby,give conseat to the Aut6orized Representative of the Davie County He,�ylth Depart ent to enter upon above described property located in Davte County and owned by �G/N .eo-5 fh'L C v to conduct all testing procedures as necessary to determine the site suItabi . /I1 ct'II��G ��' � ��on DATE 3--2/�!v/ SIGNATURE � � TH1S AREA MAY BE USED FOR DRAWII�iG YOUR SITE PL.A.N(Include all of the following: Eztsting and proposed property Unes and dimensions structures, setbacks, and septic locations). � /33 63 Site Revisit C6arge t-- -- --50 — — -- -� � Date(a): — , O' Prs pos� FCI�(o wS�;P,�B_X 15 ��� �� ; ,Ch�� x Clfent Notif�cation Date: � � � � EHS:_ � '__..._ �...� _���.� J sePf;c 7�an K �....� 'Y�; �� Pc���js�=n+ `'� nccounc tvo. � � ��� . / e e 0 �� I oc Z' V R vis ( 7/99) nv i e No. � Z s2 •- ` ; `� " ' . . DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section { . .. Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION • -----... ... 990001649 ' ._.. . .._._. . ... 5749-1J-2127 _...__ ._. MainvilleAME Zion Church ____..._.�.. ...._. .. ..__ ..._. : ___ .. _.___. Main Church Roaa-27028 �: . ...�;, ��..:_.�_: Fellowship Hall �� .:{. �:.... see map ���� c. ��,.�.�;,. 1�-,2-�;� Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring . / Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Li - Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �� �� Texture rou Consistence / Structure � / Mineralo : i �' HORIZON III DEPTH Texture rou Consistence � Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � SITE CLASSIFICATION: OS EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: . LEGEND � Landscape Position • R-Ridge S-Shoulder L-Lineaz 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 truct r 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(unsuitablej 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) ■■��������■���■�■■�■�■���■��■■■��B��O���■■■■��■■�■�■■■■�����0:■■�■ ■�■■���■■�■�����■��■���■�■■�■���■■■�■■■■■�����■���■�����■■�■�■�■■■ ■���������ee0���■�0■�����■■�■������■■■■■����■��■��■�O�v■��■�■0■�■ ■��■���■■�■���■��■�■■�■��■��■■■■ ■�■■■■■����■�■■■�■����■���■���■■ ■��■��■■■�■��a�s�■�es�■��■■�■■��■■��■■■■■■���■�■■ses���■��■�■��o�■ ■�■■��������■�voo■v.�■■��■��■�■�����������■��■■■��■o����������s�■■ ■����■���■�����■■�■�■�■■������■■���■�■■■�■■■■s■■■ee�■■�■�����■■��■ ■�■��■���■�■■s���■��■�■■��s�■�■��■�■■■■��■��■�■■����■���■���■■�■■■ ■�■����■���■■■o�s■0�se■■�■■�■�■�■��■■■■����■��■■�■�■■��■■■■■■■�■■■ ■�■�■■�����■■■���■���■■■o■■�■■������s���������■���■��s■■�■�■■■�■�■ ■���■■■����■■■���■���■���■���o■v��■����■■�■■�.�oo�o■o�■■■�■�����■ ■�����■■�■�■�■■������■■�����■��■ ■■���■■■�■■�■��■�■��■■■��������■ ■����o���■�■���■�■���■���■���������■���■■■■■■�■��■�■���■■�■��■■��■ ■�■���■■�■�■���■�■�■■�■�■■�■■���■���■��������■■���■��ees��.����e■■ ■■■�■�■■�■�■■■�■�■■�■■■■�■�����■■��■■■o■��■■■■■�■■�■�■■■■��■■■�■■■ ■■�■■�■■�■�■■■■�o���■�■■�■■�■■��■��e■■��■■■■■■■�■��■�■■■■■�■■��■�■ ■��■��■■�■o■■■■■■�■■■�■■�■■�■■■o■���■��■■■■■�■■■��■�a■■■■�■■s����■ ■�����■��■�■■■■■■��■�■■�������■■■������■■����■e���■�■■■■��■■��■��■ ■■���■��■■�■■■�������■■��■�����■������■■e■■������o��■■�■■■■��■��■ ■■���■��■■�■■■������■■■�■■�����■ ■■�■�■�����o■■e■��■■■���■■�■■��■ ■■��■■��■■�■■■■�■�■�����■��■�s�■�■■��■■■���■�■■��■■■■■��■���■■���■ ■■���■■��■���■■■�■���e■�i������■��■��■■■■■■■■■■�■■■■■■�■■■���■���■ ■■���■�������■■��������i��s�������■���■■■■��������■■■�■■�■■�■■�■�■ ■e��■�����se�s■e��■���i■■■■■s�a���■■�■�■■■■■■■■��■��■■������■■�■�■ ■■���■����■��■■■��■■�i■■�■�■■��■�■■���■■����■■■��■■■����■��■o��■■■ ■■��������s�������■�i�■■�■�����■�■�■��■��■■������■�������■■■�■��■■ o����■���■��■■�■o���■o■■��������Si�_-�����������■■■■���■■■�■o�■�t■ ■����■■��■���■�����■��■■e��■��•�.,■■�■■■���e■■e■■■�■■�■e�■■�■���■o■ ■■■�■■■��■���■■��■�■a�■e■���.��■�■■��s■��■�■�■�■■■■■��■���■■a■o��■ ■■���■■��■�■■■■t���■■■���.��■���■■■■�■■■�■��■���■■■■■■��■■■■■■■s�■■ s■���■���■��■■■o■n9�:��■■��■■■■�■■���o■■■o■��t�■��■■■��■■■■��■��■■ ■■��■■■s���■�■■c�■������■■�■■����■■■■e���■�■���■■■�■■�■�■■���■���■ ■����■���■���■�����■�■■�■��■����■■��■■■■�■�■�■■■■�■���■■����■■���■ ■■■�■�■����������■■��■■e■■�■�■■��■■���■�■��■�■■■��■■■��■■■■■■■��■■ ■�■�■■������������■�■■■■■■■■■■■■�■���■�■�����■■s��■���■■■�■��■��■ ■��■■■■�■�■�■■■■■■���������o���■ ■■■■■���■�����■■���■■■������■■�■ ■�■��■���■��������■■■■■■■■■■■■■■■■■■■���■■��■■■�■�■■■■■�■■���■■��■ ■�■ve■■�o■■■■■�■■■�o�■��■�■■�■■��■��■■��■�■���■■���■��■■�■�o��■�■■ ■�■�����■����■�e���■■■��■■■■■■■�■■��v���■■■��■�■��■����■����o�■�■■ ■■■��■��■�������■■�■�■�■■■■�■■■��■�■■���■�■���■■���■���������■■■■■ ■�■�■■��e������■��■■������■�■�■�■������■■������■��■������������■■■ ■■��■��■■�■���■■�s������s�■�■�e����■��■�e■■■■■�■■■����s■�����■■■�■ �iiiiii�iiisiii�iiiiii�i�■�iiii�iiiiii,l�iiiiii�iiiiii�iiiiei� ■��■■�■■■�■■■■�o��o■■�■■�■■o�■�■�e■■�o�■■i■��■��■��■�■■o���■■■o�■■■ ■��■��t�■■■■■��t����������v■��o���■■���■�■����■■��■e■■�■■�■■■■�■�■ ■��■�■����■��■■■�■■��■■�■■�����■■■■��■■�����■■��������■����■���■�s ■■���■������������■�■■s�■������■■■�■����■■��■■■■■�■■■�o���■■��■��■ ■■������e��e��■■e�■■■■■�■������■■■■�■�■e�������■e���■■v�����■■■■�■ ■■���■■■■�����■■���■���■■�■■i�■�■■■���■■�����■��■�■��■��■■�■���■�■■ ■����■■����■����■■�■�■���o■�i��■■�■■■■���■����■■�■��■■�■�������■�■ ■�o���ot�■������■��■o���■o�■��■■ ■■■�■■�■��■■■■���■■�o���■■■��■■■ ■■■���■��■■■�soe■■vt�s��e�■■oem�■����■■■���■■�■��■■��������s�■■s�■ ■■■��■��■�■■��■■��oe■���������■■■■��=:::�■����■�■■■■■■��■■■■■�■■�■ ■■■■■■■■��■�■■�■■�■�■�■■��■�::::���■■■���■e�����■��■■■����■■■■■��■ ■��■�������■��■�■�■����■�■■�■■■�■■�•�■����■■�����■■��■■����■■■■■�e■ ■■■■��■■■�■■■■■■■■■■■�■■�■■■■���■���■■■���■■■��■�■��■■■����■■■■■■�■ ■■■■■�■�■�■e■■�■�■■�■■������■s■�■■r:�s���■����■��■■■■����■■■■■�■■■■ ■e�����■�■�o■����■■■��■�■■��■������■���■�■���■■■�e■�����■■■■����■ ■■■�■�■��■�■■■■■�����■���ra�����■ ■���■■■�e��■�.�■s��s■■■����s■��■ ■��������■����■��■��■■■��►���������■■����■■���■■■�s�■■��■■■�������■ ■����■���■����■�■��■�����c.7�■■■■�■■��■►��■■��■■�■■����■�■■���■�s■��■ ■���■■��■■■■■�■■■������■����■■■��■■�■■���■�■■�■�����■■■���■■�����■ ■��■����■�����■a■������■�■��■■■��■■�■■■��■�■�■���■■■o■■■■����■■■�■ ■�■■�■■�■�■���■�■�■■■■�■����■■■■■■���■�����■■����■���■■����■■■���■ ■���s■�■■�■�■■■■���������■■�■o■�����■■���■e���■���s■■■����■■.�■■■■ ■��■s■■s■�e�■���■�■■■■�■��■■■����■■���■■���■���o■�■�������■■■■■■■ ■�■■��■���■��■��■�■�������■�■�■■ ■■■■��■��■��■�■■�■■�����■■���■t■ ■�■����■■�■■■■����■�■�■■�■■�■�■�����������■��■��■■��������■■■���s■ ■�a■■�■■■�■■■■���■■�■�■■�■��e���■o�■���■■■■■���■■��■����■■■■�����■ ■���■�■■■��■�■�■�■■�■■■��■�■�������■���■■�■��■�■■����■��■■�����■�■ ■�■�■�■■■�■■■■�■■■���■■�■■�■�■�■■■■■���■s■■�■■�■■���■■■�■■����■��■ ■�■■■v�■■��■■����■�■■e��■����■�■��■■�■���■��■■����■���■■■��■■■■��■ ■�����■■■�e■■■�■■■�■�■����■■■■■��■■�■��■�■�■■�■■����■■■■�����■��■■ ■���■�■����■����■■��������■■■����■���■■���■■�■��■��■��������■■�■■ ■■■■���■�■■■■�����■■■■������■■■■ ■■■■��■■��■����■�■�■�������■■■■■ ■t����■�������■����■■��■��■���■�■���■�����■a�■�����■■■���■�■■■■�■■ ■■��■�■�■�■■��■�■��■■����■■�■���■�e■�■��■�e��■��■����■������■■■■■■ ■�e�����■�■��■■���a�■�■■����■�■�■��■�■�■■�■��■��■����■■�■■��■■■��■ ■����■�■■■■■■■���■■���■��■�■�■�■■■■■���■■■��■��■■�■�es■■■��■■����■ ■��■���■■■■■■■���■■�■�■��■��■■�■■�■■����■■■�■���■�■�■■�■■■■■■����■ ■■�■��■■��■�■■■���■�■■■��■�■�■�■■■■■����■■■�■■����■�■■��■■�■■����■ ■����������■�■�■��■���■�■■���■���■■��■��■■��■�■■�■�■■�■■�■■e����■ ■���■�■����■■■���■�■■■��■■�����■ ■�■■�■�■����■■■�■■■������■�����■ ■������■t��■���■���■�■��■�■■��■■�■���■���■�■■����■�■■���■■�■�e�■�■