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234 Oak Grove Church RdHEALTH DEPARTMENT RELEASE b�6 Davie County Health Department r� 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Christopher David Address: 234 Oak Grove Church Rd City: Mocksville State2ip: NC 27028 Phone #: (561) 302-7088 r For Office Use Only *CDP File Number 196216-1 5749377659 County ID Number: Evaluated For. NEW PERMIT VALID 0 9/ 1 7/ 2 0 a 0 I IAITII• Properly Owner: Christopher Davie Address: 234 Oak Grove Church Rd City: Mocksville State2ip: NC 27028 Phone #: (561) 302-7088 Property Location & site Information Address234 Oak Grove Church Road Subdivision: Road# Mocksville NC 27028 Township: Directions Hwy 158, right on Oak Grove Church Rd 'Structure: SINGLE FAMILY N of Bedrooms: 4 'Water Supply: EXISTING WELL Basement: n Yes Q No 'Proposed Improvement: # of People: Phase: Type of Business: Total sq. Footage: No. Of Employees: Building is approved to be placed at the rear of the home closest to the garage. Lot This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONo Applicant/Legal Reps. Signature-, *Date: *Issued By: 2140 -Nations, Robert *Date of Issue: 0 9/ 1 7/ a 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** O Hand Drawing Olmport Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 196216 -1 County File Number: 5749377659 Date: 09 / 1 7/ 2 0 1 5 Olnch Scale: OBlock ON/A e� R6P05e�TSW 14/ N CONSTRUCTION For Once Use Only AUTHORIZAMON "CDP File Number 196216-1 0 96216-1 ° Davie County Health Department County ID Number: 5749377659 210 Hospital Street Evaluated For'. NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753=6780 Fax: 336-753-1680 0 8/ a 8/ a 0 a 0 Applicant: Christopher David Property (Owner: Christopher Davie Address: 234 Oak Grove Church Rd Address: 234 Oak Grove Church Rd City: Mocksville City: Mocksville StatefZip: NC 27028 State0p: NC 27028 Phone #: (561) 302-7088 �P�honee (561) 302-7088 —1111 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 234 Oak Grove Church Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, right on Oak Grove Church Rd # of Bedrooms: 4 # of People: "Water Supply: EXISTING WELL L7cren I of'4 Minimum french Depth: a 4 \ Inches Sits Classification: Provisionally Suitable Saprolite System? OYes ®Na Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 5 Inches Soil Application Rate: 0 3.1 5 Maximum Soil Cover: a 4 Inches "System Classification/Description: Distribution Type: GRAVITY- PARALLEL (eq. d -box) TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 _ Gallons "Proposed System: 25% REDUCTION 1 -Piece: OYes ®No Pump Required: OYes ®No O May Be Required Nitrification Field 1 4 7 3 Sq. fit. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes ONo Total Trench Length: 3 6 9 ft GPM—vs— ft, TDH Trench Spacing: — � . 9 . 0Inches O.C. Dosing Volume: Q Feet O.C. _ Gallons Trench Width:Inches 3 Feet _ . Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV L7cren I of'4 CDP File Number 196216 - 1 County ID Number: 5749377659' ❑ Open Pump System Sheet Repair System Required:UTeS kJ IN 0 1—)140, IJUL ild8 /AV dlldwit: OlJduc "Site Classification: Provisionally Suitable Design Flow: 4 8 0 Soil Application Rate: 0 3 a 5 "System Classification/Description: TYPE III B. SYSTEM MINGLE EFFLUENT PUMP "Proposed System: 25%REDUCTION Nitrification Field 1 4 7 Sq. ft. No. Drain Lines 3 Total Trench Length: 3 6 9 ft Trench Spacing:Onches 0. 9 Feet O.G. Trench Width: 0 Inches — @Feet Aggregate Depth: inches Minimum Trench Depth: :� 4 Inches Minimum Soil Cover: 2 Inches Maximum Trench Depth: 3 Inches Maximum Soil Cover: a Inches "Distribution Type: PUMP TO GRAVITY Pump Required: @Yes ONo (May Be Required Pre -Treatment: O N SF COTS -1 CATS -II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit by the Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. '(his 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 atthe sametime the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been completed during the period of validity of the Construction Perm It, the Information submitted In the application for a permit or Construction Authorization Is found to havebeen Incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become Invalid, and maybe suspended or revoked (.9937(9)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rutes, and permit conditions regarding system location, Installation, +operation, maintenance monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? OYes ONO Applicariftegal Reps. Signature- _ Date:. . . f 2140 • Nations, Robert 0 8 l a 8 l a 0 1 5 Issued By: Date of Issue:.. Authorized State Age . Vraifunction Log OYes (Hand Drawing Qlmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davis County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number. 196216 - I County File Number: 5749377659 Date: 08 /;?8/a015 0 Inch Scale: E ('Block ft ON/A fj�, } _ 1` Page 1 of 1 http://maps2.roktech.net/davie_gomaps/index.html 8/28/2015 APPLI%TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ► Davie County Environmental Health P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) Both Type of Application: )IZ4ew System ❑Repair to Existing System ❑Expansion/Modification of Existing ystem 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 l Address Email J, Name on FemuVAI U it DWerent than Above Mailing Address PROPERTY INFORMATION Contact Person H 5 _ ,� va Home Phone30,�-7038 isiness Phone 'NAT 2S T N(:�^ 4f O(V lI FTc-n *Date House/Facility Corners T AIC NOTE: A survey plat or site plan must accompany this application. Included: Y� Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name OAJ P T5 7 -PAP-1' A V -T 0 Phone Number S 3oa76 � u Owner's Address3 W GA K GrO VE GH U fi C (1 W City/State/Zip / ►',k 5 VC; 7 %S� Property Address — Ci �/— Lot Sizes_ � 4 Lr �� ^ Tax PIN# 3TI44 TA-)( TWO—SAF 1 rIKJ4 Subdivision Name(if applicable) Section/Lot# YJA 9� Directions To Site: i q% IA// ---q4 1= R (7lh rL'1n C IC C ion! L [: Ct: /1/: 1-W d%' iCtvA/ Specify Problem Occurrin i - - —11,1 - - -1 - ` - ' p g C 11Z Cly) SI,PT,C Sysf t� I1 ZFL-05 hli�') Oleg a 6sNI)L 13 Et) 5 -.2 1311r(45 , tA)/vr TOO t�YIDA i✓O id Ll 0611. ' -3 04 T#5 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool El Yes �No Basement: Yes ❑No Basement Plumbing: VYes ❑No 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 ❑Altemativex%ther Ih%0w 11)O�(�' a% R4t4C/11L- r Water Supply Type: ❑ County/City Water ❑ New Well VeTlExisting Well ❑ Communi Well Do you anticipate additions or ex ansio* ofthe fa ' i this ste is int d d to serve�,Y s If yes, what type? l4 p �Z �JU, A U �� yI NVO I d _ ({+N 1...) h 1 {'vo 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. /9121(0 rye 13- IV s�" -a c C�,[` ILI�j5,15?Illi:.( mjdaJ, F]JSOdw(I •: , - pR1� a �Ati �n w r► i 1�j � `oL•tjti;�a 1 .�Ltc'�� :—• �r2a11 ,7�� .... Il�P�1 `,lS,�i:,?.:�i r w. H C 13Al �� C�� p f�6 70 (:� � JIM 01, Tip! T d � r N 130) J OOM tvpiH �4 T tl tvLt.- 0 w HU Lo- (VL qtr MvOOPnr sfS4t,`m W o u L 1,3[`C- T6 �' fJlt---9L IV wire, Ll A v y G -A S SSW r 7 )S Nc! i NC- SS AA DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site -Evaluation APPLICANT INFORMATION � p 6bI-302, Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit PROPERTY INFORMATION 11�k Ad V6 dA ,Gg Al -es Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Q - Texture group C L S"c L Consistence NS Structure O - Mineralo HORIZON II DEPTH — — Texture groupC Consistence . Structure Mineralogy HORIZON III DEPTH Texture grOu2 Consistence Structure Mineralogy� HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS I RESTRICTIVE HORIZON SAPROLITE CLASSIFICATIONS LONG-TERM ACCEPTANCE RATE CC) — 0. 3al;__ I d SITE CLASSIFICATION: c EVALUATION BY - LONG -TERM ACCEPTANCE RATE: OTHER(S) PRESET 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 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 VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely R 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 SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed 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 Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - eal/dav/ft2 chroma 2 or less nr,un ncvnc