Loading...
507 Moll Hodgson RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000996 Tax PIN/EH i#: 4799-69-2282 Billed To: Michael Lunsford Subdivision Info: Reference Name: Michael Lunsford Location/Address: Moll Hodgson Road -28634 Proposed Facility: Residence Property Size: 10.25 Acres ATC Nuber: 2349 **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 zaLl #People 1 #Bedrooms _�2 #Baths Dishwasher: 0"� Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: 2—"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size M I-, C Type Water Supply Design Wastewater Flow (GPD) Site: New 2 Repair ❑ i i 1/ r, System Specifications: Tank Size XW GAL. Pump Tank GAL. Trench Width.�_� Rock Depth � Linear Ft.j� 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. to 1. 0 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: t Date: 1?) 2 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ,ccount 990000996 Tax PIN/El-1 1'r: 4799-69-2282 Billed To: Michael Lunsford Subdivision Info: Reference Name: Michael Lunsford Location/Address: Moll Hodgson Road -28634 Proposed Facility: Residence Property Size: 10.25 Acres ATC Number: 2349 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 WASTEWATE ONSTRUCTION IS VALID FOR,A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:Date:_ g�L Z& 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 ti n) L2- t©o' OD Septic System Installed By: �✓1 v l S Environmental Health Specialist's Signa e: Date: 0 DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATU Davie County Health Department D Environmental Health Section v� P.O. Bou 848/210 Hospital Street FEB 17 2000 Mocksville, NC 27028 (336) 751-8760 FMVIRntde""', i ur..r ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Address City/State/ZIP 2. Name on Permit/ATCC7ift Different than Above Mailing Addrea. I �Jd Contact Person Home Phone Z� ae - &<a-,6 9 J? 7 Business Phone City/State/Zip��2c�r��—rte 3. Application For: / Site Evaluation Improvement Permit/ATC ❑ Both 4. system to Service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _3 # Bathrooms a Dishwasher ❑ Garbage Disposal 13 1i!Rahing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No 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: iii. °G� . WRITE DIRECTIONS (from Mocksville) to PROPERTY: TuRry R'S a do Tax Office PIN: #'J / �%- /� / '�� �� /Gl %o (i/���{-1 Property Address: Road Name N/S(3 °% ty Z pn Ci / �' , v p If in a Subdivision provide information, as follows:Aw- Name: Section: Block: Lot: Date Property 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suit7,',-Zre4 DATE c,?-/ 9- 4W SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN (Include all of the foowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS- Revised DCHD (07/99) Account No. #4�- Invoice No. / :2 Y i v •• ! R 4 ,t i' p 00 r f 3 • 82 .. OA CA 544 10 ?98 68 32r, t- ' 1166 Ac . ° o (13.90Ac.) _ K 1311 133 ,r — "+tt, 346.96 0 150I: r s 38 c.� �. N,N 34loft 1 0 'y ; e' �z Arc. 3 5'. 33, �. 5 yAG.) 18 26 4 0 I ��' • 96 � i r fo �� ` I t, `• i�,`.� N t r 4' R (342, : 50 9 27 .9 6 i } k !1 t g A `o•e ` r1 1 �. 4. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000996 Tax PIN/EH #: 4799-69-2282 Billed To: Michael Lunsford Subdivision Info: Reference Name: Michael Lunsford Location/Address: Moll Hodgson Road -28634 Proposed Facility: Residence Property Size: 10.25 Acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Z_ L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group 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 LONG-TERM ACCEPTANCE RATEJ__(/ SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: C REMARKS: EVALUATION BY: _ O Y�r OTHER(S) PRESENT: 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 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 05/99 (Revised) no ■ ■ NONE Enos MEMO MEMO MEMO MEMO NEON ■■E■ ■■■■ NONE NO ON ON No on No ■■ ■E■■E■M■■ ■E■■EME■■ NEEMEMEMS ■E■■M■M■ ■E■■MMEM■ EMEMEMMEM ■■■N■■ME■ Emmommomm ■■■M■M■M■ ■■■M■M■M■ ■■■momm■= ■E■■MEE■ ■MEM■■E■■ ■E■■■■■E■ ■■■■■■■E■ ■■M■■■E■■ ■■■■■M■■■ ■■■■s■■ ■■MEMO■ ■■■E■■■ monsoon SOMEONE SOMEONE MONSOON Monsoon MONSOON ■ OMEN ■M■■ MEMO ■M■■ MEMO ■E■■ MEMO MEMO ■■E■ ■E■■ ■E■■ SEEN ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■N■■■N■ME■■■■■■E■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ =c:ii ; ■■■■ -- :m■■kl■ ■■ ammoss■■■■■■■ ■■■■■■M■N■M■■ ■E■■■■MMM■■■■ ■■■■■■■■■■■■■ ■■MESE■■■■■■■ ■■EE■■■■■■EN■ ■■■■E■■■■■■E■ ■■■■■■■■■N■■■ ■■■M■M■EMEN■■ ■■■■■■EOE■■■■ ■■EEE■■M■■■■■ ■■■■EE■■E■E■■ ■■E■■■N■■■N■■ ■■■■M■■■■■■M■ ■ ■ i ■