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124 McCashin LnPermittee'sj� ' jj BAVIE COUNTY HEALTH DEPARTMENT Name: -• `i �4+� ' ` � Name: Environmental � Environmental Health Section PROPERTY INFORMATION _ 1L, P.O. Box 848 Directions to property. CLQ' Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 Section:_ AU W ORIZATIOFR FOR Lot: ' t SYS I EM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002738 A Road Name: ` q ` ''�'S��ZiP: � �2 = **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 Buil I�ermits. (In compliance with Article1 I of G.S. Chapter 130,A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �� IS VALID FOR A PERIOD OF FIVE YEARS. DATE ISSU D RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL^ SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE &�� v'-'I"YPE WATER SUPPLY �=i {..� DESIGN WASTEWATER FLOW (GPD)Zk6 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS_: TANK SIZE . ______GAL. PUMP TANK GAL. TRENCHWIDTH ROCK DEPTH 17 . LINEAR OTHER �T`tG I-� j /�r.�u it= iL' 01 wC i OC Ql) Z, REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � fi1t�r1T` 26 `iUfy i It I' I_VwAb 51-)V. -VU-) 1 f-:4 1 ?410 Ujrl�� rJk A5 stated in '.5A NCAC 18A.i960-15� z accepted Sy ,ttimc :-nay elso be- use Tt n-1 2-E:�j 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 I Ari K *--j.)4TF SYSTEM INSTALLED BY: ,,,�— 7- R20 JT oaf --�RVL' AUTHORIZATION NO. / OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BU 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. DAVIE COUNTY HEALTH DEPARTMENT 7 N I Environmental Health Section PROPERTY INFORMATION P.O, Box 848 -Directions to property*—U'I,L, Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 ' Section:_ V-1 t/,,,,j � j,. , ,� �'" I . j AU R'AOSTIEWATOFR OR Lot: Tax Office PIN:# STEM CONSTRUCTION 002738 0 r\e ;'�!,`J1--3 LJ AUTHORIZATION NO: A Road 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 _applyin for Bujj rmits. (In compliance with Article 11 o�G.S. Chapter 13303, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) _, f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION T 1—... !'" I , 4'� IS VALID FOR A PERIOD OF FIVE YEARS. `ENVIRONMENTAL EAI `I•H SPECIALIST ")DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE c�� E WATER SUPPLY Q+ L1 DESIGN WASTEWATER FLOW (GPD),,go NEW SITE REPAIR SITE +� ,r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH e LIN�E+AR FT- ~i - OTHER a1.XV " `n..aV Ir +, 1`i:..-Tt: CI t)CJA --D (t li✓o 0NI, I "`REQUIRED SITE MODIFICATIONS/CONDITIONS: _IC� �f 1�J�py`- �� t' LL ��q n j -t ' ,"� IMPROVEMENT PERMIT LAYOUT kin �, 111 ` t`�"-� 41 �..••,-.... { ft;� x -.t i.. t � �T.°fit „� L) as 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 k � AJ �j-/(�, SYSTEM INSTALLED BY: v I� Z �s 10 I 3 qy cH I 7 s= AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS B 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:. DCHo 02102 (Revised) / fir? 7V �(1Z l j 4/06 rbc:' to �cYY S W - 301111v ME.NS��t1EAtIN 1+NV1R�ev1EGpUN`- ��I�c�r� #e. (44 EVALUATIONAMPROVEMENT PERMIT & ATC ie County Environmental Health .O. Box 848/210 Hospital Street .Mocksville, NC 27028iCl"' y G) 2A536)751-8760/ Fax (336)751-8786 4 ' Applicah in For:——valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of A p ication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed (7(I1 �V& J. ?I eCiOS'�r , �J�2� Contact Person�- Billing Address /-S$ Home Phone 4 98—SZgjj City/State/ZIP /1 06t6; V/ LLQ- e 2720Z9' Business Phone -,F&7^1 As lwatr& Name on Permit/ATC if Different than Above - Mailing Address PROPERTY INFORMA IUN City/State/Zip *Date House/Facility comers NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Phone Number Owner's Address i` ' City/State/Zip Property Address J-� ILl66e.41dn/6- City /l-tGGV-R LGA Lot Size Tax PIN#�c5 Z * �'7loLl3 Subdivision Name(if a able) Section/Lot# Directions To Site: , --%a s&7 CiYur r -A If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes ANO Are there any easements or right-of-ways on the site? . ❑ Yes &No Is the site subject to approval by another public agency? ❑Yes ts'No Will wastewater other than domestic sewage be generated? ❑Yes ANO - IF RESIDENCE FILL OUT THE BOX BELOW # People / # Bedrooms a # Bathrooms Garden Tub/Whirlpool ❑Yes ANO Basement: ❑Yes kNo Basement Plumbing: ❑Yes Vo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well 0�9xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes eo If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Date Sign given ❑Yes ❑No Revised 11/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # ZZ Invoice # Fryu4 1 E9 E5 t 158 . . ` p �� . �. . �I d� � � J�� M �.��" ,,,�- -'��., C� � r �'`,,,°°� : �``�,.� �`� � � C� c,, I �� `�C� �, � �� -9 �. � .� MrB2 S � � , . . �.tir �. � � �. : �.�. � i .� �N . --�-�-� � � � � � � ; �u : �� .� � _ �� , �� 1 V� � � �. � ��(120.38A) ''� � , , �� I , .�. � < , � � � - : : _ � _. u �Q�y. --�--_-.��.� . y � � � � .�. . , y � - I s. � �` �' � „ � �y ��MrB2 � - �' ,�: �. �� = � � £ ; � _ , :. _ ��. _ N �� -� — -� . � � . ; �, � � � . � n � C� � . ._ � _ � �� a s � � , e � � � � � r�� Ms D � - �� : � � � �. �� _ N �� " � � �� -�� "` � r � � �', ��, � � � � =, - � � � � — �� = � d� — � � -�' �~ � - � - � > �_ � , �,.. _ ��. �,��, � � �; � � , z. � .�. �� x. _� � ''� �- � ` � '� � � �, �, : � � � � �,1�.-`=� � � � �,: �'� �� a �;.. ,� . _ I - z ^ '��,- - � . ��. : .: . ._ _ � a; _ .�— Y �_�� r � � _ [� � � ��- ; � _ �, �' �. �" � r � _ , . �-�_ — � �.,._... ., _.E E, _ „ „ � , ' � — �-��;�� .�E.� v .,, .,��m�„�� ,��.-_ �.,� �. � � • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil / Site Evaluation APPLICANT INFORMATION Account #: 990004221 Billed To: Arthur McCashin, Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5832-40-7603 Subdivision Info: Location/Address: 124 McCashin Lane- 70 8 120 acres Date Evaluated: %* On -Site Well /V Community Auger Boring ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH d — IL Texture groupSG Consistence .- Structure Mineralogy HORIZON II DEPTH 1 r Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group�, SL Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS `- RESTRICTIVE HORIZON SAPROLITE 5 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: EVALUATION BY: OTHERS) PRESENT: REMARKS: 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 Zyet 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( rovisionall suitable) U(unsuitable) P Y , LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■1�■■■■■■■NOM■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■e■■■■■■NNN■■■■N■■■■■■�._:.�,�...�■■■M■1�■■N■N■■■N■■NOM■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■1l�:ii■■■■■■ONO■■11■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■�■■■■■■�■■■■■■�■11■■■■■■l� ■■■■■■ MONS■■ ■NN■■■ l��:��r:�»•■i■�■■■■■■�■■■■■■ ■If�i��ii�■■■��1;�r7■■ ■NN■M■ ■■MNO■ ■■■■■■■■■■■■RD■■A■OCA■■■■■■11■■■■■■■■■■■■■■ILJ�'i!l�1!■■■■■■■■■■■■■■■■■■ ONE ■■■■■■■S■ N■■■■■11■ SOMEONE mom ■■M■M■MEN M■M■MM■■mom M■MOM■■ ■■■N!�■�.====�----=========X111��■■■■■N■■■■■■■■■N■■■■t■■■■■■N■■N■■■ ■■■■■■■■■■O■■■■■■■■■■■■OO■Nil■i■■NN■■■■■M■■■■N■N■■N■■N■■■■N■tN■■■■■■ ■■■■■O■■■■■OO■■■■■■■O■■■■■■t!■NON■OO■NON■■■■■■■MON■■■OO■■SNO■■■■■ ■■■■■■■■■■■■■O■■■O■O■■■■■■■■■■■■■■■■■■■■■■N■■■O■SONO■■■O■NO■■SO■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■O■■■OO■�■■■■■■■OOSN■■■NS■MOOS■OO■■■O■■N■ ■■■■■■e■NMO■■■■■■O■O■■MON■■■■■N■ ■■■■■■■■■■■■OOMMOOS■■■■■■■■NMN■■ ■■■■■N■■■■■■■■■■■■■■■OO■■■■■■■■■■■■■■■■■■MMM■■■■■O■ON■■■■O■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■S■■■■■■O■■■■■■■O■O■■N■■■■S■■■MOOS■■■■■■■■ ■■■■■■■■■■■O■■■■■■■■■■■■■■■O■■■■■■■■O■■■■■■O■■■■■■SO■■■■■■■ON■■■N■ ■■■O■■■■■■■■■■■■■■■■■S■■■■■S■■■■■■■■■■■■■OO■■■■■■OO■■■■■■■■■■■Ott■