Loading...
345 Potts Rd (2)DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001295 Tax PIN/EH #: 5880-16-4749 Billed To: KEVIN MABE Subdivision Info: Reference Name: Location/Address: 345 Potts Road -27006 Proposed Facility: RESIDENCE Property Size: 3.30 ACRES **NOTE*'�hisblmproveme nt/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 #People #Bedrooms` #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size C ,j�&c Type Water Supply Design Wastewater Flow (GPD) Site: New B' Repair ❑ System Specifications: Tank SizeAD GAL. Pump Tank GAL. Trench Width -JV Rock Depth Linear Ft.,jZ1V Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofth vie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on a day of installation. Telephone # is (336)751-8760.**** s d� 5. 0 6 r Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) r DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001295 Tax PIN/EH #: 5880-16-4749 Billed To: KEVIN MABE Subdivision Info: Reference Name: Location/Address: 345 Potts Road -27006 Proposed Facility: RESIDENCE Property Size: 3.30 ACRES ATC Number: 2499 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://w�f/ Date: 7 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificatefof Completion all indicate the system des abed on Improvement/Operation Permit has been installed in compliance with Articl 1 of G.S. Chapter 130A, coon .1900 "Sewage Treatment and Disposal Systems," but shall irf NO WAY taken as a guarantee that a system will function satisfactorily for any given period of time. / I � PV �j,C Septic System Installed By: Environmental Health Specialist's Signature :�� Date:���`� DCHD 05/99 (Revised) ' APPLICATION FOR SITE EVAI DATION/IMPROVEMFM PERMIT & ATCt[EN Davie County Health Department Environmental Health Section a 18 2000 P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 RCNI^E�ITl�1 Fig (336) 751-8760 D.14'IF Chi'N1TV ACTH ***nWOR7ZNT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed (Q i, ((1�, I[ `Y-� o -b& Contact Person _ K}�GC% tK A%3 c Mailing Address �o ^�I Pb+jl 5 pi 1� Home Phone _q "� /�-� A ^3 07 City/state/ZIP UQ_0�•� Nc � V6g Business Phone 35-39 /C1 2. Name on Permit/ATC if Different than Mailing Address C1 3. Application For: I Site Evaluation .y Improvement Permit/ATC Both 4. system to service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms �- ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # showers # Urinals # People # sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,P'NO If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3.3a a e re5 Tax office PIN: N .5 R k () ` I Gl- lti' 'q 9 Property Address: Road Name moo+A-6 Kt4 City/Zip {�dUnAnee (� C If in a Subdivision provide information, as follows: Name: WRITE DIRECTIONS (from Mocksville) to PROPERTY: B © t -to nn L� :5; -1-C o n Section: Block: Lot: Date Property Flagged: L9 J $ 'D d 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 Deent to enter upon above described property located in Davie County and owned by "-)M 61_5 rf,\ rtm to conduct all testing procedures as necessary to determine the site suitability. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge `Date(s): Client Notification Date: EHS: Revised DCHD (07/99) Account No. c% Invoice No. rn N N (V 8z L) 0t,98 (d96 J) (690 �9z 09 ON 9tlL� 6LLV (doc c) N ON N V � }. 0 9801 (dst7*z) LP co N ®� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME Aie PROPOSED FACILITY ,o* SUBDIVISION Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit SECTION LOT, DATE EVALUATED PROPERTY SIZE ROAD NAME AcS' Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % 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 ACCEPTANCE RATE SITE CLASSIFICATION: j°S EVALUATION BY: , g 4 LONG-TERM ACCEPTANCE RATE:: � % OTHER(S) PRESENT: REMARKS: � / �'t '/7' < �/Hylcl /✓ crf4 rJ 11a /� %C ,—' 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) ■ ■ ■ ■■ ■ ■■■■■■ ■ENNE■ ■EM■■■ ■ME■■■ ■ME■E■ ■■■■M■ ■EMM■■ ■ENN■■ ■E■ME■ ■ENNE■ ■■■EM■ ■M■E■■ ■E■EM■ ■E■E■■ ■E■■O■ "ME■E■ MENN■■ ■ESE■■ ■■N■■ ■■■■■ ■■■E■ ■ENE■ ■■■E■ ■ENE■ ■E■■■ MEMOS ■■E■■ ■■E■■ ■E■E■ ■■■O■ ■ME■ ■■M■ ■E■■ NOME on ■ ■ ■MME■■ ■■■MM■ ■E■NE■ ■E■■E■ ■EMME■ ■E■■■■ ■■E■■I ■■■■■I ■■■Sri■ ■E■■UM ■M■■FAM ■■■GM■ ■E■EHM■ ■■■■\!■ ■■MMEM■ ■■ENUM■ ■■■M■E■ ■■■■l\E■ ■■■■/J■■ ■■■■ ■E■■ ONES NONE ■■M■ ■■ son MEN No ME SEEM NONE ■■N■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■MMEMME■E■■ ■■E■■■ME■■EMEME■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■■■■ME■■■■O■■■ ■■■M■■■■■■M■■■ ■E■l■■■E■■■■■■ ■E■■\■ME■■■■■■ ■■■■■N■■■■■■■■ ■■■■■NE■M■■E■■ ■■■■■■MMMMM■E■ ■■■■■E■\■■■■■■ ■■■E■E■E\ME■■■ ■■■M■ME■EME■■■ ■E■■■■EM■■EM■■ ■■■■■MEM■■■ME■ ■EMEM■EM■■MME■ ■E■■M■■MEM■ME■ ■EM■EMMEM■■■■■ ■■■■MMM■MM■■M■ ■E■MEM■■■EMM■■ ■■■■EME■■■ME■■ ■E■■MEME■■E■■■ ■■■MEM■■■■MEM■ ■E■■E■■■■■■ME■ ■■ME■■■■M■■■E■