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425 Potts RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000711 Tax PIN/EH #: 5880-17-8787 Billed To: Mark Beverly Subdivision Info: Reference Name: Scott Smith Location/Address: 425 Potts Road -27006 Proposed Facility: Residence Property Size: See Map ATC Number: 2141 **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 1 l 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 49 H7 #People #Bedrooms J/ #Baths Dishwasher: Zr Garbage Disposal: ❑ Washing Machine: 12< Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ CommercialSpecification: Facility Type #People #People/Shift #Seats Industrial Waste: 13Lot Size 3/' ,116 Type Water Supply Design Wastewater Flow (GPD) Site: New 0-/Repa- System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width,-_� Rock Depth j,') Linear cs;'ew/ Other: Required Site Modifications/Conditions: 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 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 (336)751-8760.**** El Environmental Health Specialist's Signature: Date: 91),W DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000711 Tax PIN/EH #: 5880-17-8787 Billed To: Mark Beverly Subdivision Info: Reference Name: Scott Smith Location/Address: 425 Potts Road -27006 Proposed Facility: Residence Property Size: See Map ATC Number: 2141 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE =aZ N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:ke�Date: x/) -y /9f 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. Cha ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a that the system will function satisfactorily for any given period of time. dv L7 Septic System Installed By: Environmental Health Specialist's Signature: �/� � Date: DCHD 05/99 (Revised) t/ APPLICATION FOR SffE EVALUATION/IMPROVEMENT PFRMIa & AT ND U ��/ scoff` APPLICATION _ Davie County Health Department Environments/ Health Section AUG -6 1999 F c/ P.O. Box 848/210 Hospital Street Mockaville NC 27028 (336) 751-8760 EtiYI MVIE Cou"ITYALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed MAlf /� P Contact Person �GJyGgL'c? / N1 Mailing Address '� % Off /GS "4ZT7- � Some Phone rL7/F�/O/ —.6 �,,rb�� City/State/ZIP W /V G a -7I Z-7 Business Phone / 7 'f —'i3 o 2. Name on Permit/ATC it Different than Above Mailing Address 3. Application For: V Site Evaluation 4. system to service: ❑ House Mobile Home 5. If Residence: # People City/state/Zip ❑ Improvement Permit/ATC Both ❑ Business ❑ Industry ❑ Other # Bedrooms _ # Bathrooms,_ Dishwasher VQbn. Disposal VWahizg Machina ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/industry/Other: Specify type # People # sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 9. Type of Nater supply: 0"Co0ounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes eNo If yes, what type? ***1MPOR7ANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 4, A �-4 WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tax Office PIN: # .5 $ S D --1 % - $ 7 ?; 7 / _-r q D Property Address: Road Name q a --s- I o?�s�dn u- l4 City/Zip AJ u a&&4 , Al G 80 D b6 w, ,, e-7&7 6 .� If In a Subdivision provide information, as follows: Pf o,q-ef-+y l% A - Name: , �-c c-6 r rtie-r Section: Block: Lot: Date Property Flagged: S 121 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit($) 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 cbanged. I, also, understand that I ant 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 to conduct all testing procedures as necessary to determine the site suitability. DATE - ' SIGNATURE 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: I EHS: Revised DCHD (07/99) Account No. Invoice No. d r [VAW O . •.� N IRON SYJND 04' 5.1524 ACRES+— N o co cq RM SET ik �o O oQ-•�'�v� O RON FOUND 2O6• 1.4475 ACRES / JMAES SANDERS D.B. 154 PG. 82 cp O o % ` ' + SET L5046 ACRES `�- / ,. `e °' -to L �j till °N � d %S V l7 �'y , '� V� co Foy' K A , �o QCT ✓e c/ B. 111 PG. 69 > \S- / S 43026'11 "W 79.03' / SPIKE SET / S 43026'11 "W 37.00' 100 0 2n� �� S 35052'28"W DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000711 Tax PIN/EH #: 5880-17-8787 Billed To: Mark Beverly Subdivision Info: Reference Name: Scott Smith Location/Address: 425 Potts Road -27006 Proposed Facility: Residence Property Size: SevWj Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group C Consistence Structure Ab /9 ! 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: LONG-TERM ACCEPTANCE RATE: ` REMARKS: EVALUATION BY: .CYC CZ OTHER(S) PRESENT: 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) No ■■ ■■ ■■ ■MEMS ■■NE■ Em ■NEu ■OM■■ ■■ME■ ■■■E■ SOMME ■■■■■ ■E■■■ ■■■■ ■■■■ ■■E■ MEMO ■■■■ ■■■■ MOON NEON ■■■■■■■!111■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■ICY/■■■■■■■■■■■■■■■■■■■■ ■■��■■■■■Sri■■■■■■■■■■■■■■■■�■■ iiiiiiEMMONS ' iii ■■ No ■ No ■■ ME so ME ■■ ■■ ■■ ■■ no ■■ ■■ ■E■■E■■N■ ■E■■E■EE■ ■E■O■■NE■ ■E■■E■■E■ ■�,■■■■r�■EE■■■■■■■■■■NESE■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■fit■S■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■