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218 Plum Tree LnT')i?-% E -To DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT KW A0WX4-55 uq ��T�Z g- Account #: 990001287 Tax PIN/EH #:-5 t6--3981 TAX Wit Billed To: Alma Shoaf Subdivision Info: Reference Name: Nathan .Maynard Location/Address: imp Proposed Facility: Residence Property Size: 1 acre ATC Number: 2640 **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 M . 140MC #People 2 #Bedrooms Z #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Er Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply WALL_ Design Wastewater Flow (GPD) 21 `( Site: New ❑"� Repair ❑ System Specifications: Tank Size ICOaAL. Pump Tank GAL. Trench Width �.YoRock Depth j Z Linear Ft 300 ' 0 Other: '� �tS�lL �3 w..� X -S �.� �T %-L- L-, .3�5 O.G. nn 1,5, Required Site Modifications/Conditions: i• -,Tot\ p.S 0..�'rt��2� e� �� ,,�, }Y VL-jCf 16 OyG 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 ystem 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 (336)751-8760.**** 2-5 r r 37' I M. 1-10 M,L 1 MIA., tom . SuDee. Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: —11/oboo Account #: Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990001287 Tax PIN/EH #: 5768-16-3981 Alma Shoaf Subdivision Info: Nathan wyynard Location/Address: Comatzer Road -27028 Residence Property Size: 1 acre ATC Number: 2640 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 VAL 151FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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 time.40,v 1p "5V 4 Lt 0L -,r=, C#rh&(L—Veg� 'IIt�CLTeA-Ioe ,tLc'" LLLD Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 9 S� /v to 1Z rv� . 0 Dik, NS -7D' Date: 011c)/0-1 — 2.ao y r v APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC @ Davie County Health Department D En Heath SeWoit .�. �� •�..� � P.O. Box 848/210 Hospital Street 7 2000 Mocksville, NC 27028 (336)751-8760 I ***ZIVORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. ReE1:7 to the IMPORiSTIC!T r.rr T c."RTp.+ ��.�. a..ra+...�i.. a.oi iiaa a.iIIC:ZiOAS . 1. Nasse to be Billed tC Contact Person kIV Mailing Address Y'� -o-46J !L'I�"�` per- Home Phone Z Lrj / 2 3. a. City/state/ZIP go 4-t Business Phone r' /� Name on Permit/ATC if Different than Above �' " � ` (4 YJMeJ4 Mailing Addressl.,4.14wWCity/state/Zip Application For: Site Evaluation �Im/provement Permit/ATC System to service: ❑ House WMobile Home ❑ Business ❑ Industry AJ,- a -70 1 ❑ Other ❑ Both 5. If Residence: i) People 21 II Bedrooms ✓ # Bathrooms 2-- 1-1 if1 Dishwasher rl Garbage Disposal tYl Washing Machine H Basement/Plumbing 1.1 Basement/No Plumbing 6. If Business/Industry/Other: specify type i Commodes i showers • Urinals # People # sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) IJ 7. Type of water supply: ❑ County/City V Well ❑ Community a. 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 BESUBMITTED by the client with THIS APPLICATION. 1 Property Dimensions: Z l2'fil.fi WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # '�% �-- �� - 3g�% 1 G� '" �a ed47rzoc Property Address: Road Name a?' r AC�SS�"' "� I Lu h'~} city/zips/,�i�%I, C If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: �GrY. W" %0, de O 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 :a c::ter upun above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 7-z-/,7- c e.) SIGNATURE I h Y. THIS AREA MAYBE USED FOR DRAWING YOUR SITE P (Include all of the fol4owing: Existing and proposed property lines and dimensions, structure setbacks, and septic I ations)j Revised DCHD (07/99) Date(s): Client Notification Date: EHS: Account No. Invoice No. .0 8 / '13 .Q tea,(_. r � ` stone) sto ni 2 94.5 2 n� N %D r!, % N L 0 %D O a n TRACT 3 AREA 6.086 ACRES N ,01 ! 581.35 nip �s nip 4 - pip L4b, IUC Ho. ly1 1" 54" E — 919.7 + � � Com,. �5�3 `► 4— WEST 1452.78 TOTAL CALVIN S. BARNEY D.B. 54 PG. 342 625 A Al EAST - 1562.09 TRACT 4 AREA = 6.458 ACRES EAST—. - 1421.14 TRACT 5 AREA= 4.641 ACRES EAST- 1156.27 TRACT 6 AREA= 5.041 ACRES 658.82 89 56 50" W 843.91 TOTAL 4 1 a r 1 APPLICANT INFORMATION Account #: 990001287 Billed To: Alma Shoaf Reference Name: Nathan Shoaf Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5768-16-3981 Subdivision Info: Location/Address: Comatzer Road -270 8 Property Size: 1 acre Date Evaluated: Water Supply: On -Site Well All, Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 23 4 5 6 7 Landscape position L Sloe % (a HORIZON I DEPTH p - © D - Texture groupG` t, L Consistence r S Structure C Mineralogy HORIZON II DEPTH — 2-0 Texture group Consistence �' S Structure S Mineralogy : 1 : 1 HORIZON III DEPTH l�- Texture groupG # Consistence rPr S5 519 S 49 Structure S MineralogyI ; ►'" i HORIZON IV DEPTH .4 - Texture Texture rou ct L Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE D SITE CLASSIFICATION: PS EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 0.3 OTHER(S) PRESENT:X_ L / W :S Ho 6 1' 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 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) i i ■ ■ ....................... ............................... ■■■■iiia■.■■■�.�■.■.■.■■■■.■...■■�■.■■�■..■..■�i�7■■■■■■■■ MMEMMMMEMNONMENNENMENNENEmmommZ ■■■■■i■■■■■■■■.■■■.■■■■■ ■.■■■.■■.■■.■■.■■■■■■■,■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■w■■iii■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■ � J t Davie County ,Meal th Department Environmental Wealth Section PO Box 848 / 210 Hospital street Mocksville, NC 27028 Phone: (336)751-8760 August 16, 2000 Mrs. Alma Shoaf Mr. Nathan Maynard 240 Rosewood Lane Mocksville, NC 27028 Re: Site Evaluation - 1 Acre Tract/Cornatzer Road Tax PIN #: 5768-16-3981 Dear Mrs. Shoaf. As requested, a representative from this office visited the above site on July 28, 2000. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. Please have all preliminary clearing and grading completed prior to making the request for a permit. If you have any questions, feel free to contact this office at (336)751-8760. Sincerely, Jeff G. eauchamp, R. . Environmental Health Section enc(s)