211 Stony Brook Trail Lot 36 OPERATION PERMIT or ice use univ
y Davie County Health Department *CDP File Number 140022- 1
Nar�t•
t 210 Hospital Street
P.O. Box 848 County ID Number.
' EXPANSION
Mocksville NC 27028 Evaluated For.
Phone:336-753-6780 Fax: 336-753-1680 Township:
Applicant: Dan Davis Property Owner: Dan Davis
Address: 211 Stony Brook Trail Address: 211 Stony Brook Trail
CRY: Mocksville City: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: (336)816-7046 Phone#: (336)816-7046
Property Location & Site Information
Address/Road #: Subdivision: North Brook Phase: Lot: 36
211 Stony Brook Trail
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 n. left on Ijames Ch Rd. right into
Northbrook
#of Bedrooms:
#of People:
*Water Supply: PUBLIC
*IP Issued by.
*System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
SaproliteSystem? QYes QNo
Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes QNo
Soil Application Rate: 0 3
*Pre Treatment:
Drain field
N Rrification Field 4 0 0 S4• ft. *System Type: INFILTRATOR STANDARD
No. Drain Lines 1 Installer: Randy Miner
Total Trench Length: 1 a 0 ft• Certification#:
Trench Spacing: — Oinches O.C.
O
Feet O.C. EH S: 2140-Nations,Robert
Trench Width: Inches— Feet Date: 0 9 / 1 a / a 0 1 4
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover. Inches Approval Status
Maximum Trench Depth: Inches FES] proved❑ Disapproved
Maximum Soil Cover: Inches
CDP File Number, 140022 - 1 Septic Tank County ID Number:
Manufacturer. Lat.
STB: Long:
Gallons: Installer.
Date: / / Certification#:
*EHS:
*Filter Brand:
ST Marker: ❑ Yes ❑ No Date:
Reinforced Tank: ❑ Yes ❑ NO Approval Status
, P Iece Tank: E] Yes ❑ No ❑ Approved❑ Disapproved'
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: =EHS:
Date: / I Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ NO (Min.6 in.) Approval Status
Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer
Pipe Length: feet Certification#:
"Schedule:
'EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑`Approved❑ Disapproved
Pump Requirement
Pum p Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches 'EHS:
*Chain: Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ NO Approval Status
PVC Unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole 0Yes ❑ NO
CDP File Number 140022- 1 County ID Number.
Electric Equipment
NEMA 4X Box or Equivalent [:1 Yes ❑ NO Installer.
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification
Box Adj.To Pump Tank #:
❑ Yes ❑ N o
Conduit Sealed ❑ Yes ❑ No THS:
Pump Manually Operable ❑ Yes ❑ NO
"Activation Method: Date:
Approval Status
Alarm Audible El Yes ElNo ❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
"Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 9 1 a / 2 0 1 4
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator. N/A
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life ofthe septic system.
Rule.1961 requires that Type VI septic systems designed fora hometbusiness owner must maintain a valid contract with a
public management entitywith a certified operator forthe life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Perm it for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 140022 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
0Inch
Dra,%ving Drawing Type: Operation Permit Scale: , Qelock
O N/A
__T_F
I ! i
-LIL
__ __ _l_.
J_ _
_LL -L F-4--
_
1 4%Af% I
.L-
LI I
IF ! FF
i cbG I _IF17 '.00
1
�� o v1VL
CONSTRUCTION ____ Foroffice.use only.
AUTHORIZATION *CDP File Number 14002
2
Davie County Health DepartmentCo
unty ID Number
r 210 Hospital Street Evaluated For , EXPANSION
P.O. Box 848 Township
---.. . ._.__.__._Mocksville - -_-_--.-----__-.NC____-__-27028____ .. _. ..____PERMIT_VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 8 1 5 a 0 1 9
FApplicant: Dan Davis Property Owner: Dan Davis
_ ss;..___211..Stony_Brook Trail___ �_ _Address: 211 Stony-Brook Trail_,__
City: Mocksville City: Mocksville
State/Zip: NC 27028 State2ip: NC 27028
Phone#: (336)816-7046 Phone#: (336)816-7046
Property Location & Site Information
Address/Road#: Subdivision: North Brook Phase: Lot: 36
211 Stony Brook Trail
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 n. left on Ijames Ch Rd. right into Northbrook
#of Bedrooms:
#of People:
"Water Supply: Puauc
System Specifications
Minimum Trench Depth: a 4
rSiteassification: Provisionally suitable Inches
Minimum Soil Cover. 1 .2teSystem? OYes @No Inches
gFlow:` 1 a Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches
"System Classification/Description: Distribution Type: GRAVITY-SERIAL
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Nkrification Field 4 0 0 Sq. ft. Pump Tank: Gallons
No. Drain Lines 1 1-Piece: OYes ONo
Total Trench Length: 1 0 0 ftGPM—vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 . @Feet O.C. Dosing Volume: _ Gallons
Trench Width: 3 ( Inches
_ Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: OI all OIII OIV
Pane 1 of 3
CDP File Number 140022 - 1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Inches O
sification:.__PnwisionattySuitable_ __ 9 Feet 0 C.
Trench Width: Q Inches
ow: 4 8 0 — Feet
Soil Application Rate: Aggregate Depth:
0 3 inches
-
`�
----.Minimum-Trench-Depth:
"System Classification/Description: .
TYPE IIA.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a
_ Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover: a 4
Nitrification Field 1 6 0 0 Sq. ft.
Inches
'Distribution Type: GRAVITY-SERIAL
No. Drain Lines 4
Total Trench Length: 4 0 0 ft Pump Required: OYes @No OMay Be Required
PreTreatment: ONSF OTS-1 OTS-II
'Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. �«
7;
'Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. °'•
2(
This Authorization for wastewater system Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and maybe Issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the Information submitted in the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance;monitoring,reporting and repair
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps.Signature, Date:
*Issued By: 2140---Nations,Robert Date of Issuer. 0 8 / 1 5 / .2 0 1 4
Authorized State Agent: Malfunction Log OYes
*Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION___ - .- _____.--_-----_--_
Davie County Health Department CDP File Number: 140022 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 8 / 1 5 / 0 1 4
Drawing Drawing Type: Construction Authorization Scale: , QBlock
QN/A
6 w
�- ,
^� o
pits r'� �d d k-. C S ics I L( 6 rod K
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
JA4's OD' P.O.Boa 848/210 Hospital Street
49 Mocksville,NC 27028
I` '
(336)753-6780%Fax(336�75
nation For. O Site Evaluation/improvement Permit O Autho Construct(ATC) ❑Both
Type of Application: ❑New System ❑Repair to Existing System xpans�on/Modi#ication of,Existing Systjyn or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INF*O�RMATION
Name to be Billed 5—arI Dl z !-5 Contact Person
Billing Address „2// SfON y ,[jrook—_-rd'Q i/ Home Phone -3,9,4 —ffl 6—20 Y6
City/State/ZIP�LtdG xS U[ � AJ4— c;�70a-9 Business Phone 33 G— V/ 70+',4
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included:0 Site Plan APlat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name ZXF III&i Phone Number 334�
Owner's Address City/State/Zip ` LP l
Property Address 5/0 t-1 y,sravzx 21rT/ City��
Lot Size �i3SIC- ' Tax PIN#
Subdivision Name(if applicable) A/e2r-,�-h b roe'IrSection/Lot# 3 6
Directions To Site:
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? XYes ONo
Does the site contain jurisdictional wetlands? ❑Yes XNo
Are there any easements or right-of-ways on the site? )(Yes 0 N
Is the site subject to approval by another public agency? 0Yes 3tNo
Will wastewater other than domestic sewage be generated? OYes JNo
IF RESIDENCE FILL OUT THE BOX BELOW
#People dT #Bedrooms #Bathrooms .3 Garden Tub/Whiripool)(Yes ONo
$asement: es ❑No Basement Plumbing: ❑Yes XNo
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:7iConventional ❑Accepted ❑Innovative OAltemative ❑Other
Water Supply Type:)G County/City Water O New Well ❑Existing Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes XNo
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 understan that I am responsible for the proper identification and labeling of property lines and corners and
C- ng and flaggin staking ouse/facility location,proposed well location and the location of any other amenities.
rty owner's r owner's le3gakifresentative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ONo Account# �
Revised 11/06 l�0 00 AA
I 1i Invoice#
P9 ai2 S + YtLKK k RlL4FRF i i ,Y
�az��; � ae,F7i!� >t.S 1`�l'tl H AsrG��ltc y, ,. .,� �: �•
+�a. tis i'a sag rss rq•x:s 1� a® ,. 4' s
s: S F. r 17x R<A3Ajol�'.
+t:C4FTCY MAP"
too.f
;lxze ec;I. .:;• tl-l�e��� �i": ., �.artaew�a G�IdL,+�t i�.,ar
�•- usr r..r. s i
a�
tY'+dwY
r4. } ' .'� Z, <'g �,;: D£R4Ff c. H'SAµ�►EI � '�€.k
rP 9aF :I►i' 14F211X F1Gf.G'+C¢;: ,am,a�,s.w t' tom`.„,„,T� ... � 1 x Z.a a d-:Air br r�a��w ,s>�4 ---'---•--` :.'...,
dsr s Asia 4a er' rA'fa
lit
1 zz��c S4 � �y ''g' •+qt.. � .. .t. � 1��6*+e k�Jk °SVEX CGl"HtY 4i.W+tF9�LYf.:
�� - 3r �1� If � l!y iy' •M �. . .. +i4.54•.tFTk 1M fA'
;� r{ � \ 3 ✓r i 1 il� t � t�s'� ai
:.:'ESS !tCltllY Ar 4 !zt!+!> i t 17 .
taw }. IIdC53 �d�}17f i ao.:' j. x
g ES1k'Tt#E<'i , ' tiY hr 1 Xt iiCwt�s trstxwx: sw �mx:r rxlnyt €
! � 2 ' i ia4era w aurz
:ti x Svi3 ani
�, +"� 'tiiri4r+',, :. t ,��' ;` ►sa a�4+�"r��
ras��a.ts
1i a ' ,1'.3� •�,t+l".� 1�� '�1 �.:.,� ��,; `'.s"��: 1 :� s�,,�r. 4 �p ;:
,_, >'�^' 4� ,1t 'ti} rsi-11�-"! .� • -d. ? .5�� '4Y y +Aqa}��yy ,� ,.t��i}td�.+':
_ ... .. .: �ti., : e�, . "�: ,4�;': "S iof���' ioT 24r k 2' _f ,�y.-;- �. :.'rxt 6 7�4x•y�s�"7� a99'�L a,. .T - '.
+. r ,� �:. aI� .?uF',1+� l �.�er�E�• r i.: M sa;a►-.
OF
.4t�'.xr N uvea
rine '��SH '"�' '•��lfi 1' �A ��, �. :J
�. ,, - .��Yy`Q �^ '-�>� � .� �' �1,• a. ;us s� .;rte....+
x ' �;.1�., .:�� �9.�4-�J'�'�,.�➢'"¢f`� ���Q".�� '� �f�<�+P•t'`... ±... J�i71A� E33 .�y�}�j(�
M . . V.1!}:
�- gsser x:.,r.: ►c�/,a ' � �� !sat it4 t• f .: i .� ;i' Arkrpt,. ,.,,..,.. .,.;..».aas�ioesaS
s �rn but I . t
;., per $k7dt?i'_M1�i} '1�1pN'IhK t�j4U�tM1 Gf'."'.."�.I14sAt k,f}!9 ..ri,...'y(:': L a�/ �!Y '�nrraw'•{ .
t':.. i.;.'''" � .,, ti (.. mU4Y p'f:WTN7pal`7.npl' �.�
.,.f - 4(Rj t�'; lNtKipC 9t NcxtplrY�tlK - OM` i cncaY�q pantr:N cna�M'&nNe(. �mm!:3�
trI
ttt'# ! t aM `rS�ii pJ.¢ xnsui s'rekactRtisM rt �; ��RlA�as�srr�A.Ar�sr�.,�s'AFi/17Y
' 4d��n�,�h�y�;Ry„„ti�j� :i :� 2 • 1 p4U�M 4 �+"'u srr�•itll. kpr "�`- M 'PdtCA r4C:
P was..vfws3u.yfr sTMu� ra+a vr:+i s!zlr+aww � :'�pc�s!Fz xb=r
;` a Ln
:,� < T•3Yrs� � !x.Vis..sr x ,�JSF.E IM#'1:Ct
A ,'Cto�tNa DAME CQ;iINTX HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
PermP.O.Box 848
A`ame: ze- f Moeksville,NC 27028 Subdivision Name:
�, �� A Phone# 336 751.8760
Directions to roperty. Section: Lot:• I 1
AUTHORIZATION FOR
r ea SYSTEWASMIARU�CTION T Office PIN:# 11
Tu
Name: ip: a as �Y
swl
**NOTE"This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to isst:anee of any Building Permits.This FormlAnthorhation Number should be pmGsented to the Davie County Building Inspections t
Office when applying for Building Permits. ±S
(In comppance'withArticle i I of G•S:Chapter I30A.Wastewater Systems.Section.1900&wage Treatment and Disposal Systems) j
�i ***N0nCE***THiSAUMOR1ZATIONFORWASTEWATER CONSTRUCTION
✓sc ,1
5'ld r d 1 �0' IS VALID FOR A PERIOD OF FIVE YEARS. !i
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED i1
RWMENTIALSPEMCATION:BUMDWGTYM ftBEDR MS -' -a ATHS #OCCUPANTS GARBAGE DWS Al. R.
. i
COMUgILCIAL SPEaF1CATI0N:FACII TIYTYPE •PEOPLE a PEOPL EMHI T N SEATS INDUSIWAL WASTE:Ya.No f,
LOTSIZF._<Ae-,1YPEWATERSUPPLY CI7 DEMON WASTEWATER FLOW(GPD)�d NEWSITE_�REPAIRSIIE ! '
SYSTEM SPECIFICATIONS:,TANK SIZE 1 1 GAL PUMP TANK _ GAL. TRENCH WIDTH ZL ROCS DEPTH —UUNEAR MZLd_+,
• 1
REQUIRED SM110DIPiCA1TONS/CONDIIIONSi
LMPROVFMENT PERMrr LAYOUT :)
.k
"*CONTACT A REPRESENTATIVE OF THE DAVIS COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF7MS SYSTEM ?�
BET WEEN 8:30-9:30 AM.OR 1,•00-1:30 PM.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751.8760.
OPERATION PERMIT t:
SYSTEM INSTALLED BY:
AUMORIZATtON NO. OPERATION PERMIT 8Y: % DATE:�O %
**'TIE ISSUANCE OF TWS OPERATION PERMIT SHALL INDICATE THATTIM SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE {`
WITH ARTICLE 11 OF CM CHAPTER 130A.SECiTON.190M"SEWAGE TRFATMHNf AND DISPOSAL SYSTEMS.BUT SHALL,IN NO\VAY BETAKEN ASA
GUARANTEZ TRATT[M SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY OIVBN PERIOD OFTIME.
DCrm 03/96(R4V1-l
f ;l+. :! .+"...,"'"....�„ 3i'e .i "'� .. 'P" '..2.a.. � -1.�r7,v :t aw. a �•n - _. �js"�ry fi .>a.E.zp !.: r...w,.,,-`s.. ._a,.�N•r'Y:�y.y.;.,. �+c.yi.'4y:
g7
AUT;JoRIZATION NO: 197
4 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee ~ � P.O..Box 848
Name: i F. Mocksville,NC 27028 Subdivision Name:
- Phone# 336-751-8760
Directions to property: ��d✓l�I +� �G� Section: Lot. y'
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:
r- -
! SYSTEM CONSTRUCTION
Road Name: Ce ' ip: i as
**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 Building Permits.
(in compliance`with Article 1 I of G.S.Chapter'130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
�,•1
'"� 'd# i DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permrtte�;s � �•
I�1ame• Subdivision Name 7:7
Directio�ts,to property: %f F`:rg ' ti,c'n Section: Lot gid► n
`IMPROVEMENTS
PERMIT Tax Office PIN:#-L "'- •�
Road Name Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIONmust 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)
> ° ` ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
.J'
i.• �`' PLANS OR THE INTENDED USE CHANGE.-YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE�/Y #BEDROOMS #BATHS F_#OCCUPANTS '�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT S17 'S G TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)% 61d NEW SITE--AZ.SITE--AZ. REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ` GAL. PUMP TANK GAL. TRENCH WIDTH,3'ROCK DEPTH LINEAR F1\2 u�
�.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00 1:30 P.M.ON THE DAY OF.INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
b ''
F
AUTHORIZATION NO.' / ` OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION:1900"SEWAGE TREATMENT'AND DISPOSAL SYSTEMS",BUT SHALL NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY.FOR ANY GIVEN PERIOD OF TIME.
DCHD 05196(Revised)
•,APPUCA]ION FOR SITE EVAL.l1AMON/IMPROVEMENT PERMI
Davie County Health Department Q
Environmental Nea11fi Se+cdon
C' <k P.O. Box 848/210 Hospital Street - I
e?irMockaville, NC 27028
(336)751-8760
ENVIRONMENTAL HEALTH
***ZMPCRTANT*ta THIS APPLICATION CANNOT BE PROCESSED UNLESS THE REQUIRED
INFORMATION IS PROVIDED. Refer tothe INFORMATION BULLETIN for instructions.
1. Name to be Billed �Q�Q A[t1L``F.- Contact Person
Nailing Address f 3*7 klTe v"�� �n: Home Phone
City/State/ZIP OL�J u i(� _ 1„(i, �_"]n'�.N Business Phone JAI
2. Name on Permit/A1C if Different than Above
Nailing Address City/state/Zip
3. Application For: U Site Evaluation Improvement Permit/ATC 0 Both
4. system to service: douse 0 Mobile Home 0 Business 0 Industry 0 Other
S. If Residence: # People # Bedrooms 3 # Bathrooms 3
XDishwasher 0 Garbage Disposal PfNashing Machine 0 Basement/Plumbing Nkasement/No Plumbing
6. If Business/Industry/other: Specify type # People ✓V # sinks
# Commodes # showers # Urinals # dater Coolers
IF FOODSERVICE: (t Seats Estimated slater Usage (gallons per day)
1-1
xcounty/city
7. Type of water supply: ❑ Well 0 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes �JNo
If yes,what type'
***IMPDRTANT***CLIENTS IIIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBi1IITTED by the client with THIS APPLICATION.
Properhr Dimensions: >_ lC' S' WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tai Office PIN:
Property Address: Road Name _ i.a.,(LJ� —r.a1l .42y r wIn t4 cM.,n,+n. r110
City/Zip /Sf S a byut�- T/.
If in a Subdivision provide Information,as follows:
Name: 1- ";'6L
3 Block: Lot: 3/�— Date Property Flagged: 2
This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permi((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 falsilied or changed. I,also,understand that I ani responsible for all charges incurred frons
this application. 1,hereby,give consent to the Authorized Representative of the Davie County He De artment
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitabili
DATE 0-1- 59 SIGNATURE
THIS AREA MAYBE USED FOR DRAWING YOUR SITE P Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No. �
Revised DCHD(07/98) invoice No. TIT
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERM EENVIRONMENTAL
R fl 2
Davie County Health Department D �� L5
• "dry Environmental Health Section
P.O.Box 848 Q
Mocksville NC 27028
( 3 6)751-8760 IMII
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLES
ALL THE REQUIRED INFORMATION IS PROVIDED.
1: Name to be Billed lO�r,�P10-112&WItzL& Contact Person L��� �
Mailing Address 10 7 / aZe afaY Home Phone 72 7
City/State/Zip �ir,,t�.�RJ�#1.if, Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address Vi//�m A pM4'L7/-A-WeWOOd br. City/State/Zip&Ilra—C-.Salcm Z 7/O#
3. Application For: / Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: Ud House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 3 # Bathrooms
I'?—
Zi Dishwasher ❑ Garbage Disposal Rf Washing Machine U(Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: Rf"County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 2-"No
If yes,what type?
PLAT OR SIZE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A P.kl ZMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: -,5 3D 2 Act 1 WRITE DIRECTIONS(from
�� - �O 1 Mocksville)TO PROPERTY:
Tax Office PIN: # -
1 6 QI At- b G' uicclr/
Property Address: Road Name 1
P
cit /zi 7d 1 � ; �Q•!�'P.!1� �u
Y
If in Subdivision provide information,as follows: 1
��� 1
Name:
1
Section:
Lot #: 36 1
1
1
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 a , J-10—.4W dtic all to procedures
as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD(06-96)
YOU MAY USE THE 13ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
PiN /10/ .67:1'o- 2-'o l`�
D.B. 112 Pg, 335 VICKIE M. GILBERT
D.B. 82 Pg. 53D.B.I D.B.. 1 148 8 Pg, 784 I TODD
I I D.B.
1
P9• 319 I D.B.
1
S 87.51'37' E --..
f 467.88 S 84.29'35' E---
299.93 299.93
CD
n
1 LOT #37 OT
(5.224 AC.) "ifs :� (5 64
S
� 953•:.f _ ��►
____STONY BR
4
±^ � L �L3CD
N.
in
�!
LOT #
(5.302
C�
LOT #41
da� (5.008 AC.)
J I
3'd'
ONp�
w . S 86!10'30'._.E--..
or a s
oD w _ --502.64-TOTAL
o H 00�- I� 472.49 -_ I0 �Or
op 30.i S W ��
.m o
�
C)M3 c 2 cl I LOT #42 ` ss
QLZ I i (5.425 AC.) \yF
. Y ICL �.
O
1 m l F�
W LOT #35 0 6 &m (6.304 AC.) 0' UTILITY a
ACCESS EASEMENT
FOR THE PURPOSE
OF INGRESS do EGRES:
� Mfr
ll`
N 87.42124' E 656.92 TIITAL
617.43 39.49p �b
W v~ f
• � S5, \
? LOT #34
m (6.076 AC.)
1�e
,ab LOT #33
f �h (7.087 AC.)
c
M 'cb
y 1
p�. V S 83.48'3 00
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME �y'�10 DATE EVALUATED
PROPOSED FACILITY /lT PROPERTY SIZE
SUBDIVISION ; o ROAD NAME
Water Supply: On-Site Well Community Public e�
Evaluation By: Auger Boring // Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position .L
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON Il DEPTH D�
Texture group
Consistence
Structure /(
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION vt
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: �� 7��
-"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(01-90) -
• Davie County Health (Department
. tJ
v and.Come Health agency
Environmenta[Healtk Section
ONFi P.O.Box 848/ 210 Hosarru.STREET
NG Qv 00509-406
1 M CKSVIL ECOURIER#N.C.27028
PHONE:(704)694-8760
June 23, 1998
Eugene Bennett
107 Nail Ln.
Mocksville, NC 27028
Re: Site Evaluation
Stoney Brook Trail
Tax PIN: #5820-20-4174
Northbrook ZZZ/Lot 36
Dear Client(s) :
As requested, a representative from this office visited the
aforementioned site on June 23, 1998. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to be provisionally suitable for installation
of an on-site sewage disposal system.
Before a permit can be issued the appropriate application must be filled
out and the house/mobile home location staked off.
If you have any questions, -please feel free to contact this office.
Sincerely,
Q,J,g, �
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/wd
Enclosure(s)
t