The URL can be used to link to this page

201 Our Place, . DAVIE COUNTY HEALTH DEPARTMENT �� .Z/� 8'/v L • � � - Environmental Health Section �' ' ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C0 Account #: 990002153 Billed To: Greg Nifong Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5769-68-5381 Subdivision Info: Location/Address: Comatzer Road-27028 Property Size: 8.28 acres ATC Number: 3066 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 3 #Bedrooms �� #Baths � Dishwasher:� Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine!� Basement w/Plumbing: 0 Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: 0 Lot Size �� Type Water Supply �i!i/ Design Wastewater Flow (GPD) �6 (,� Site: New ❑ Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank �j�GAL. Trench Width �� Rock Depth �/.� �( Linear Ft JisY��" Other: Required Site Modifications/Conditions: I INIPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW �' FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 (33C)751-8760.**** , ��% ;� Environmental Health Specialist s Signature: � --� Date: - � DCHD OS/99 (Revised) r��,s,�,� ��Py j•,�,.,�, Ll,�, ��_ z � _o y- Account #: 990002153 Billed To: Greg Nifong Reference Name: ATC Number: 3066 DAVIE COUNTY I�EEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospitai Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5769-68-5381 Subdivision Info: Location/Address: Comatzer Road-27028 5ize: ts.zu acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLTED 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 11 of G.S. Chapter 130A, Wastewater System ection .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW E NST UCTION IS VALID O A RIOD OF FIVE YEARS. � Environmental Health SpecialisYs Signature: � �� C-�'�i r ate: " �— CERTII ICATE OF COMPLETION **NOTE** The issuance ofthis 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 time. /'� � Septic System Installed By: ��2ir�li�� --� v - Environmental Health Specialist's Signature : ��,� Date: G � DCHD OS/99 (Revised) ,, APPLICATI�N FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department � Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 L5 - � � � L', � FF� � � 2o�z � EtdVIRON�s�F�vrni ur��T�� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI�TION IS PROVIDED. Refer to the INFORI�ITION BULLETIN for instructions. • 1. Name to be Billed lrr'� d1 1 V �-I-��/) q Mailing Address ��70 d lo� S4 ! � S�� i ��. �� City/State/ZZP w S / V � • � � � � / 2. Name on Permit/ATC if Different than Above Contact Person Home Phone � / �� "� Business Phone Mai.ling Address City/State/Zip 3. Application Eor: S._ Site Evaluation Improvement Permit/ATC a. system to service: fg House ❑ Mobile Home Business ❑ Industry ❑ Other s. if Residence: # People � # Bedrooms � # Bathrooms � Both � [1�'Dishxasher ❑ Garbage Disposal f�Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IE FOODSERVICE: # Seats Esti.mated Water Usage (gallons per day) 7. �pe of water supply: ❑ County/City Q Well ❑ Community e. Do you anticipate additions or expansions of the fucility +��s c�ctem is intended to serve? ❑ 7'es �7 No If yes, what type? " ' } „ _ ' � - . _ ' � / ` ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI77'ED by the client with THIS APPLiCATION. Property Dimensions: � � � � c�� Tax Office PI1�I: #�� S 6 l� "�� Property Address: Road Name �° o�.1J �-fz �� ' City/Zip If in a Subdivision provide informatioa, as follows: lYame: Section: Block: Lot: WRITG DIKGCCIONS (from Mocksville) to PROPLRTY: �( � �`� �-+✓�-` �-Z,��- �-� S l, -7`--a- � -s .. �L �� . _✓ �� -e/1�--J'�-�-�.. c n Datc Property Flagged: Ti l 0 Z� 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 intcndcd use change, or if thc information submitted in this application is falsified or changed. I, also, u�tderstand t/tat I am responsible for a!! cllarges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davic County Hcaltl� Department to enter upon above described property located in Davie County und owned by to conduct all testing procedures as necessary to determine the sitc suit ili . DATE 2 — / !� � ? SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAIY (Include all of tl�c following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). �� 0 2_ �� - ' � , � Account No. � � Revised DCHD (07/99) � Invoice No. �, � `1 � ` � „�, _ �� APPIJI'A110N FUII SIIE EVAWA7IUN/IMPROVEMENT PEflMIT d� A D L� �� • �2 p Davie County Health Department ��' �� Jd�� ,,11. - Environmenb/ Nealtfi S�+cdon FEB I'� 1999 ,� .�' � � P.O. Box 849/210 Hospital Street �{ Moakaville, NC 27028 �'� �336) 751-8760 ENVIRONh1ENTAL HEpLTH DAVIE COUNTY _ �. z. **+I!l�ORTANT**t THI3 APPLICATION CANNOT 8E PROCESSED LJNLE33 ALL TiiE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORt�ITIO�N BOLLETIN for ias�ruations. �� to � Hsiiea j21U-�1ARD ��D'i7�1�G�� Nailinq 1lddresi Soi � .S�c/fh �']?A/�tl City/8tate/ZIp ��;��C �� 1 �� ttams on Pessit/1►TC iL Dittesent than 7►�ove �QICA .IJ flailing l�ddress ��at �� K��sf-i�(� �i D��SG�� Hame P'hotte 33�0 "�$.�oZ 3�v � Business Phone 3 � �p " �y{�C� � � 3 7t'�1 �A1�S 3. 1lppliaation Sor: rYBite Evaluatiott ' U Improv�ement Pe=mit/ATC 0 Both 4. syatem to servsca: �ouse 0 Mobile Home 0 Busineas D Iadustry 0 Other s. If Resideace : # People � # Bedrooms :3 f d� i Batbrooma a'/�}. 8” Dishxasher J��arbaye Diaposal � Nashinq !lachine 0 Basement/PlnmbinQ 0 Sasement/No Dlumbing i � 6. i! Bnsiness/Induatry/other: 8pecity type # Peopie / Cammodes i 8howers + Urinals � einis % 1later Coolera IP FOOD3ERVICE: f Seata Estimated ilater Uaaqe (qalions per day) 7. Tpp� of Mater supplp: � 0 County/City 0 i%11 ❑ Coasaunity 0 e. Do you xnticipate additioaa or e:pxnsion� af the facility t6ia syatem ia iutended to eervei �'fes O No u y�, �aA� c��± ��,kk St�oS� "*'IMPIDRTAN7"** CLIENTS AlUST C0�1lPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PL.AN 11fUST BESUBI�!l1TED by the client wlt6 'fHIS APPL1CATlON. Property Dimeoaion�: �Q �� WRiT6 DIREC'f10NS (fmm Ma�svllle) to PROPERIY: Ta:Oftice PIN: # � � �D9 ' Ui� "ryi38 5(• d �� / �C � 'ho �'G�QiCi�Z� Prnperty Addraa: RoAd NAme �[7�%i1147�'�E� ci�yiztP 11��e_k.SU �II � 4 .: ► � - • . ► � :�;,c��t, s�� ■� t - - -. . If in a Subdivlaiou provide information, As foll w�: �V \ (��— Name: � �t �1 tO�:i EDI,�' ' ��. , Section: ,�_ Block: .� Date Prvperty Flagged: E �� This i� to cerlify that the informatioa provided is cor�ct to the best oi my knowledga I underat�nd that any permit(a) issued 6ereatte� are subject to au�pension or rewocalioo, if t6e eite�plans or intended use cbange, or if the informatlon su6mltied in t6ia �pplicAtion ia �alsitied or changed I, also, andentand tliat I ant r�ponsibl� jor a/! eba,ga incurred from tl,is opplication. 1, 6ereby, gWe conaent to the Aut6oriud Representative ot t6e Davie Couoty Hexlt6 DepaNment to enter upon above desc�ibed property loc�ted in DAvie County and owned b�� D to conduct all testing procedures As neca�ary to determine t6e �ite �h. DATE I�B /02� / t I SIGNATU L� �' TflIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (laclude all of the tollowing: E��ting and prnpou�l property linea and dimenaions� dructures, �etbacks, xnd �eptic locxtiona). Revised DCHD (07/98) i0� /d � , T, /�j_2 so �_.. u -----�-- J-J A��oub� No. '� '7'� Iuvoice No. a ! � �.`'y —�' _ �s • `� � � ' ^ DAVIE COUNTY HEALTH DEPARTMENT � . : #�. i � Environmental Health Section SECTION r.oT SoiUSite Evaluation APPLICANT'S NAME � � ''2 DATE EVALUATED �l �! ` PROPOSED FACILITY � PROPERTY SIZE ��j� e SUBDIVISION ROAD NAME < ( Tvf �'Y��'�� Water Supply: Evaluation By: On-Site Well � Community Auger Boring � Pit Public Cut HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 LONG-TERM ACCEPTAr SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: � OTHER(S) PRESENT: REMARKS: DCHD (01-90) 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFT - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - Very plastic tructure SC - Single grain M- Massive CR - Crumb GR - Granulaz ABK - Angular blocky SBK - Subangulaz blocky PL - Platy PR - Prismatic Mineralo�,y 1:1, 2:1, Mixed No es 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 ■■ �� ■■ ■■ ■■ ■ ■�■�■�■��■■��■ ■■��■�■��■��■■ ■��■■��■��■■■ ■��■ ■■��■■��■ ■��■��■■�■�■ ■��■��■�■��■■ ■�■�■�■■■■��■�■■ ■■��■��■�■ ■��■■��■�■�■■■ ■■■■��■�■�■■■�■■■ ■��■�■�■��■ ■��■��■■■��l�■■ ■■■�■�■��■��■�:7■ ■��/��Li!/■ ■■■��■��■■��■ri■ ■��■��■■ ■��■�■�■�■�■■ ■��■�■��■■�■ ■��■■ ■��■ ■■��■ ■■��■ ■��■�■ ■��■ ■��■�■ ■��■■ ■��■ ■■�■�:�1G ■��C ■��■ ■��■■ ■��■ ■■��■ ■■�■�■ ■��■ ■��■■■ ■��■■ ■ ■ ■�► ■��_�■�■�■■�■�■��■�r��►. ■■��■�\�■■��:�■■�■��`�Gr�l � ■��■■■��:��■�►..�::��■��■ ■��■�■��■■�■�■��■■■�■ ■��■��■��■�■■�■■■��■�■�■■ ■��■ ■��■�■��■�■■�■��■��■ ■■��■ ■��■��■■��■��■■■�■ ■��■�■�■��■■�■�■��■��■�■■ ■��■�■��■■■��■��■■�■��■■■■ ■��R■■��■■��■��■��■��■■ ■��■��■■��■�■��■��■��■ ■■�■��■��■��■��■�■ ■��■■�■��■�■��■��■��■■�■ ■��■�■�■�■�■��■��■■ ■■■■�■ ■■��■��■■��■��■■■ ■�■��■ ■��■ ■��■��■��■�■��■■�■�■■��■■ ■��■�■■�■��■��■��■■�■��■ ■��■��■■■�■�■��■■��■■■■��■ ■��■�■�■�■�■■�■�■�■■�■��■■■ ■��■��■��■■��■��■■��■■■ ■ ■ ■■��■��■��■ ■■■�■��■■�■■�■ ■��■■■��■�■ ■■■�■�■ ■�■��■ ■��■■ ■��■ ■�■�■�■ ■�■�■�■ ■�■■■�■ ■��■■�■ ■��■■ ■��■■�■ ■■�■■�■ ■��■ ■�■��■ ■��■ ■��■■�■ ■��■�■■ ■��■ ■�■�■\■ ■��■ ■��■■�■ ■��■■�■ \��■��■ ■■I,��■■ ;■ri��■■ ■��■�� . ��■��i ■��u ■��■u■ ■■►i�■■■ ■�i�■�■ ■��■ ■�\'\��■ ■��\`�■ ■■��■i\■ ■■��■1�■ ■�■��■ ■��■II�■ ■■�■�I�■ ■�■ ■ ■■ ■■ ■s ■