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133 Mullins Rd ' � ` DAVIE COi1NTY HEALTH DEPARTMENT • , ' Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002751 Tax PIN/EH#: 5767-26-0864 Billed To: Sharon Swicegood &Anthony Whise Subdivision Info: Reference Name: Location/Address: Mullins Road-27028 Pro osed Facilit : Residence Pro ert Size: 1 acre ATC Number: 3474 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTR CTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: (��3��/� 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 13 , ection .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guar e that ystem will function satisfactorily for any given period of time. ! U l� 1�be� , /� Septic System Installed By: � /Y�-'J��'P Environmental Health Specialist's Signature: Date: � y�� DCHD OS/99(Revised) , , DAVIE COUNTY HEALTH DEPARTMENT `f:� . • � Environmental Health Section � . . , P.O.Boz 848/210 Hospital Street ` Mceksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990002751 Tax PIN/EH#: 5767-26-0864 Billed To: Sharon Swicegood &Anthony Whise Subdivision Info: Reference Name: Location/Address: Mullins Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC ly�m�er: 3474 **NOTE** is mprovemenUOperation 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 CONT'RACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People � #Bedrooms � #Baths o�- s Dishwasher:� Garbage Disposal: ❑ Washing Machine:�-�"Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size /—t Type Water Supply C� Design Wastewater Flow(GPD) �� Site: New�Repair❑ �� r / System Specifications: Tank Size`oov GAL. Pump Tank GAL. Trench Widt�� Rock Depth� Linear Ft. 3� a Other: Required Site Modifications/Conditions: I1�IPROVEi�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW F'INISFiED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depariment for 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 installation. Telephone#is(��C�751-87G0.**** � / S i P �)�,��,� _�.��s �� . c� �,�a� � Q�s �.s� ,� � �'�� , r �� G �� fi - �� .�e �l�-' ''` w c�y / Environmental Health SpecialisYs Signature: � Date: ' � DCHD OS/99(Revised) • . DAVIE COUNTY HEALTH DEPARTMENT �Q (Q- y 7- V� ' Environmental Health Section � � • ' , P.O.Boa 848/210 Hospital Street ' . Mocksville,NC 27028 (33G)75]-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990002751 Tax PIN/EH#: 5767-26-0864 Billed To: Sharon Swicegood &Anthony Whise Subdivision Info: Reference Name: Location/Address: Mullins Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3474 **NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 wlPlumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �iQ G Type Water Supply � Design Wastewater Flow(GPD)� Site: New�Repair❑ ) � System Specifications: Tank Size/d00 GAL. Pump Tank GAL. Trench Width� Rock Depth /��Linear Ft.S�� , Other: Required Site Modifications/Conditions: I1�IPROVEI�9ENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF("BELOW F(NISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-87G0.**** r — '� Environmental Health SpecialisYs Signature: �_r}�'// Date: �/�/�� DCHD OS/99(Revised) ,, , � w DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 990002751 Tax PIN/EH#: 5767-26-0864 Billed To: Sharon Swicegood &Anthony Whise Subdivision Info: Reference Name: Location/Address: Muilins Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3474 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 1`/�� Date: �c3'�(J�.� CERTIFICATE OF COMPLETION **NOTE** T'he 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. Septic System Installed By: Environmental Health SpecialisYs Signature: Date: DCHD OS/99(Revised) . , ' � �'-��3�n� va ' . ��y3411d11�3U`��F� LIC ION FOR SITE EVALUATION/IMPROVEMENT PER�ti11T&ATC Davie County Health Department � 3 2003 ` Environmenta/Hea/th Sectioa t,�p,`( p.o. soX s4s/aio Iiospital 5treet � Mocksville, NC 27028 � � � (336)751-8760 IM ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED ORMATION IS PROVIDED. Rafer to the INFORMATION BULLETIN for instructions. s7�!lrra�l q�✓P�77c. Swic1�c�oc�cP 1. Name to be Billed /�N7�h p ,V�) R�,� w h iSCnJ i1 u n/T Contact Person�c��i �[.�i GeC/D� Mailing Address �� Coy�, �iVEl/ �T�/AJrSUi1�e �1 4' Home Phone 3 �� '' � ! � City/State/ZIP YA�t��►��P))P, N,G. �Z 7055 susiness Phona Jl�l� 2. Name on Permit/ATC if Different than Above % Mailing Addresa City/State/Zip 3. Application For: Site Evaluation Improvement Permit/ATC t 'f 4. syatem to service: House Mobile Home Business Industry Other �1 z % � 5. If Residence: # People ot # Bedroom� 3 # Bathrooms ��' � -� ' ------�� Dishwasher Garbage Disposal Washing Machine Ba3ement/Plumbing Basement/No Plumbing 6. If Businesa/Induatry/Other: Specify type # People # Sinks # Commodes # Showera # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City Well Community s. Do you anticipate additions or expansions of the facility this system is intcnded to scrve? I'es No If yes,what type? ***IMPORTAN * TS T COIVIPLETE THE REQUIRLD PROPERTY INFORl1IATION I2EQUESTED BELOW. Either a LAT or SITE P N MUST BE SUBMITTED by thc clicnt �vitU TI IIS APPLICATION. Property Dimensions: I WKI'TG DIRGCTIONS(from Mocicsville)to 1'ROPGRTY: 'J , axOfficePIN: #:��] 7^76 '�$� � �wy � -/ ��9-ST ��l�eX 5��. /p Property Address: Road Name f"l?y J 1��1S �`'�� , ��7�u�.✓ �� h7 , 9 d �d� �dX• / City/Zip 1'ti'►oc,ksr.;�l-P� AI.C, �7Bj� �� 'i.% � To ��i��i'�S ��, �y�`P� If in a Subdivision provide i►iformation,as folluws: 1� � � P�a�e►�� S j�}y4�0�p� Name: 3 �z� FT, c•�J 6.e F� Section: Block: Lot: Date Lome corners flagged: �"//3- /� 3 This is to certify that the information provided is correct to tlie 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 thc information submitted in this application is falsified or changed. I,also,ruidersta�ld t/rat I a�n resporrsiGle for al1 ckarges incrrrred jrorn this applicatiorr. 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 o�vned by �"o e S,w a t�ca• d to conduct all testing procedures as necessary to determine the site suitability. � DATE �// � /C7 3 SIGNATUR�� -�l1 . ,,, THIS AREA MAY BE USED TOR DRAWING YOUR SITE PLAN(Liclude all of tl�e following: Existing a�id proposed property lines and dimensions, structures, setbacks, and septic locatio�►s). Site Revisit Charge �� llatc(s): � � p�` Client Noti�ication Date: , G�� EHS: Sign given . Account No. �� Revised DCFID(07/99) Iuvoicc No. --==�� f..w��{f � .�� 'i ,,,` ' ��` � � .... i � � {dt��'�� . . . , . . �.., . ,,, , � � �� , � . . �� , ss� '�.---- __ •��`� -``-�..,.�.�..y._,___:� �z�.�� ,; � ,. � �F , � , � '� �, � 4., /�,, ; � ; �� I � � �, ..-.. , N GJ I t�...,)'1 i i I �5 II --__.�__{98�) I� --..._.� - ; % �,,. _ ��----� � �°� "� � � °, �� - '" _ -�_----- I � -- � " � __- - � - � �._-_ ^--- �-------� � � I �� I , � � `° 8tr l- � �980 -� � � �- ___. �� "----___ , C� �i�i %/�r/� �bOZ 0�) „%;�j�/ € e/ I , F�,�, � � ��"�i�Z ___ _ _ �� , i �6 I 6�6� � � � �, ,- � b'�U'Z �, ��, � : ,,��,;�, , �..... � �,� ., , _ ; ,,�� ' , f��;;�,/r� � � �� $8$� ; , ;; �� , �- ,;, � i �� i�� % �% ,�:.,. ;. � � . ,.. � E „ � ; ti � p � -- - �-_� b � jf'�� -- �� a 6�b8 �� . (� "f% _._._r--.—.1 f . (1 6 ' II � t ��• � 1 . . � � � .-� e - � . . . . I °tl � , � � �'"iR�$ ' „ ;� ,,,,, , II .. �?� . � � ,_,,, ��:�� , . ... • .,,,,,,,.,,, , j ,,,,,/ „r , , � . .. � , - �,i� �......�� ;� � s / � _.. �._ ...... .. ......... ...'.... .� � �.... . .. ......... . ..� I 1 � i . .. \�� .. . . . . . l� ^y_ v N i ' I �,�__�899� M �� .._,. ,�� . . ..,_.. _ ,,,,; ,� r . � - �• � � DAVIE COUNTY HEALTH DEPARTMENT " : � •� ` Environmental Heatth Section � Soi]/Site Evaluation , APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002751 Tax PIN/EH#: 5767-26-0864 Bilied To: Sharon Swicegood &Anthony Whise Subdivision Info: Reference Name: Location/Address: Mullins Road-27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: ��_�� Water Supply: On-Site Well � Community Public Q Evaluation By: Auger Boring '� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L Slo e% o"Z HORIZON I DEPTH �` �� Texture rou "� C L Consistence Structure Mineralo HORIZON II DEPTH !� �� Texture rou G Consistence � � Swcture Mineralo '/ 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 r � SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ` OTHER(S)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 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 Mineraloav 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 DCHD OS/99(Revised) ■��■��■��■�■■��■■i��■�■�■�■��■\��■�■■■■��■��■ ■�■��■��■��■■��■�■■■��■��■��■■ ■■��/�■��■��■��■��■■��■■��■■■��■■■��■■ ■■��■■��■��■��■��■�1■�■�■ ■��■��■■�■ ■��\��\��■ ■��■��■��■■■�■■��■��■�■■■■�■��■ ■��■�■�■��■��■�■�■��■■��■��■��■��■�■��■��■��A■��■■ ■■��■��■■\■��■■��■��■��■■�■�■��■■��■■■�■■�■��A■■�■ ■�■��■■��■�■��■��■��■��■�■��■■��■��■��■��■�■■■�■ ■�■��■��■�■�■��■��■■��■■��■■■��■■��■��■ ■��■ ■■��■�■��■��■��■�■��■��■��■■ ■■■��■��■■■■�■■��■r��■■ ■��■��■�■��■��■�■■��/�■�■��■�■��■ ■��■■�■�\■■��■��■■■�■■��■��■■��■��■��■�■��■�■■��■ ■��■��■■■��■��■��r�■��■��■��■■■��■�■ ■��■��■��■ ■��■■�■��■��■�■�■��■��■��■■��■�■��■��■�\��■ 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