133 Sheffield Rd . �• : ; � � �,�'o t�
, DAVIE COUNTY HEALTH DEPARTMENT ��
,. . . ,. Environmental Health Section
- - P.O.Boz 848/210 Hospital Street
� , - , Mocksville,NC 27028 .
(33G)751-8760
- Account #: 990004098 : Tax PIN/EH#: 5808-00-2144
� Billed To: Dena&Jeffery Swanson Subdivision Info:
Reference Name: .. � Location/Address: 133 Sheffield Rd.-27028
Proposed Facility: Residence Property Size: 5.70 acres
ATC Number. 4499
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISStJED 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 F VE YEARS. .
Environmental Health SpecialisYs Signature: G ' Date:�
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation 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
iven eriod of time. � (�o S� �
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Septic System Installed By: �o W o�,�;. S •�ct,,...�
Environmental Health Specialist's Signature: Date: � 2� 1 3—a 4
DCHD OS/99(Revised)
; ,, , DAVIE COUNTY HEALT'H DEPARTMENT
' - - � Environmental Health Section � �.a�
. P.O.Boa 848/210 Hospital Street �O�
• Mceksville,NC 27028 (
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990004098 Tax PIN/EH#: 5808-00-2144
Billed To: Dena &Jeffery Swanson Subdivision Info:
Reference Name: Location/Address: 133 Sheffield Rd.-27028
Proposed Facility: Residence Property Size: 5.70 acres
ATC Number. 4499
**NOTE**This ImprovemendOperation 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 pertnit(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 CO CTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People � #Bedrooms � #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: U Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply� Design Wastewater Flow(GPD) "7 g� Site: New�Repair-❑
System Specifications: Tank Size ��v GAL. Pump Tank GAL. Trench Width���Rock Depth� Linear Ft,�
Other:
aCCepted Systems may also�bQ use
Required Site Modifications/Co itions:'
IN[PROVEMENT/OPERA [ON PERM T LAYOUT- APPROVED EFFLUENT FILTER RiSER(S)IF 6°�BELOW
FINISHED GRADE. **** OTICE: Co act a representative ofthe Davie County Health Department for final inspection ofthis '
system between 8:30 a.m.t 9:30 a.m.qrrl: p.m.to 1:30 p.m.on the day of install ' n. Telephone#is(336)751-87G0.****
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Environmental Health pecialisYs Signature: Date: ��Jg V��
DCHD OS/99(Revised)
� �
Davie County Health Department
Environmental Health Section
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
. - (336)751-8760/Fax(336)751-8786
� Improvement Permit
September 19,2006 �
Mr.&Mrs.Jeffery Swanson
424 Jake Alexander Blvd.
Salisbury,NC 28147
Re: 133 Sheffield Road
Tax PIN#5808002144
Dear Mr. &Mrs. Swanon,
This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if
site plans or the intended use change.
System To Serve: � Wastewater Design Flow(GPD): �gDValid: ears ❑No Expiration
SystemType: Y��onventional �Accepted ❑Innovative �Alternative ❑Other
Site Modifications/Perimt�Conditions: . ,�
�ccepted Systems may also�bQ use
Site Plan
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1�t���j ��°
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Environmenta Health Specialist ate
i.p.letter 7/06
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� r PLICATION�'OR SYTF EVALUA'I70N/IMNROVEMEN7'PERMIT&ATC
, SEp _ 5 2006 11��tY3e Couuty�1tb 1�f:partme�t �
� Enviranmentat Health Sectiion
p�����H . � .P.O BnY 8481210 Hospics�Sweec
QyViRONh1�UNN. � . MocksvtUe,NC 27b28
ppV1E _ _ .(33�751-87b0!F�c(33�?51-8786
Applicaaon For: Sicc�valuatioNtm,rovemeat pennic Ct Authoriv,�o�ro ca�b,���rc� �th
••YMPORTi1M�"TH1S APPLIC�.TiON GlNNOTBEPROCESSED C?iLESS ALL OF TFIB REQUIREn
7NPORMATTON IS PROViDED. R:ftx m the INFQItMATION BULL�^.'IN fot3a�nvc4ioas.
APPLICANT INPOTtMAT10N '
Namc to be Billed�_N� �E • R ���Co:itict Person� � /Q �le�'`
' Billing Address� u'�y,��cf� ��t.1C�N Q t� H�me phoae_�� � 3 ..
• CirylStatdZiY r A.�:s�.�.,�,e,u N�t?,.�gJ� Buxintas Phom 9 0� -,�.3 Q-S2.'t�,
Narne oa P.ermit/ATC if Dlffa+r.ni 8�arti Abore •S��M E
. Mailing Address City/St.�te/Zip
PROPERTX INFORMATCON
NO'f�:�A svrv�ypdrt or dte piaa nu+st accompsny"this epplicaaon. � -
(Pemut is valid for 60 montlu•:+ith site�lan,no aq�uatioa with cortplece ptat.) �Id l�C�i���/ao aeau!.2
, y 'Striet.Addttss l33 SlJ.f.e��tl� �i�City�+"�.'f�ic�.� ;'ax#'IlV# �1s'fn i'a�Z/ysf
�/� Subditision Nat�ee , Section/Lot# Lot Siu 3.7�e,��s
�� Dircecions 7o site:��.�D 1.� ,� . ! R w ? aEFI�:
��'� AR.��r R T'�,/`¢,nc gs G ar. �,`G 't .b�G
J/� DateHousdFacilit�CoqtetJ.Flaggcl ! / Q
� it the amwer tn any of ine follo . stiooc u c", urN N� � /U //V 0 4(,�J
1, J /% ,f wiag �ur '�e suppoRtaC dxwneounoa must aaac&d.
I!I �� Are thae any eatietin�wystcwa�er dystems oa ibc rite? ❑Ye:;ONo 7
� ^� Does tlu:ito connin jucisd;cu:mal vatiands? OYea t]�vo ? •
1�� �U Aie dxre any easemeau oc�itht-ot-anys on thc�ite? pYa:ONo y
Is the site subjeci to approval ba a�r pub6c agencr? DYe::�No �` .
Wil!wutewaser other dun don�rtic sowage be aenccatedY vYe�:f�o •
`� IFRESIDENCE F�LLUIIT THE SOX BELOW
��v �PeoDk _,�, #Bedro�>ms 1 r, #IIatluoorn�_��Gardcn TublW}Firlpool OYes o
� �� ;. Basement�Yes t�7�fo Bae�+rr.�nt Plumbing: ❑Ycs.83Po
b '
/� ff NON-RESmENCE F1LL 0117'THE BOX BELOW �
()� 'Iypt oi FacilitylBusincss � 7on1 Square Fooh.;c of Bu+ldin�_ tl People
�j N Sinka #Commodes_ N Showcrs �F Urinals � ,�
�Stimattd Water Usage(galloas per 3ay) {Attaeh docu,mnts4oa of simifar faciiity w�ter consumption)
F�ODSERVICE ONLY: #Seats
�
Typeaysumrequested:�,on�entional �Accepced ❑lnnovative OAkcrcative OOther
WuerSupplyType:�4�founry/Ciry tA'u� 0 New Wetl 't U Commtmiry Wetf .
Do you�aticipau addieioos or expw;or.;oi the 6a1iry ih;s sysrem is inteadcd ta:me9 O Yes • CENo
If sres,what rype?,
� , / � L Osr, e • �'�`'- :: � .�
�This;s to caufy that tlu in(amntion�acvided an lhis uppiication is tcnemd t rnrect to the best of r�ry knowledge:"T underswid that
any pcm+ir(a)or AT�(s)issu�d herea(cec are subject w suspension or revaxti:�t iCthe site is�lteced,tife intended usc changes,or if
the iafornndoa wbrsact�d in Ihis aDplica:ion it hlsibed or t6atigcd I undusend tAat/am mponrlbJafar a!lchnrgav ine++rred
from this applitation. I hueby gsnt iig:u ol'entry to the Au�horFted Rcpruaiarive otttu Davie C'ounty Hcalthpeputinent to
conduct necessary insp«rions to detamis comp�iance vrith appiiubk hws and rules on the abovc descrbed yropecty located in
; Dhvie Couh_ty nad ow Y R a � �,..�_•
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, ' P 'a owna's ltgnl repres4•nht signamre Site iLevis�t Chncge
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' ' '� ` ` � . . DAVIE COUNTY HEALTH DEPARTMENT
, ' t
. Environmental Health Section
' Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004098 Tax PIN/EH#: 5808-00-2144
Billed To: Dena&Jeffery Swanson Subdivision Info:
Reference Name: Location/Address: 133 Sheffield Rd.-2 028
Proposed Facility: Residence Property Size: 5.70 acres Date Evaluated: �
Water Supply: On-Site Well Community Public j/
Evaluation By: Auger Boring ��_ Pit Cut
FACTORS 1 2 3 4 5. 6 7
Landsca e sition -
,. Slo % a
HORIZON I DEPTH y ��i
Texture rou �e,�
Consistence /� �
' Structure Gr
Mineralo �
HORIZON II DEPTH ' y �4 < /
Texture rou _
Consistence r i .E l'
. Structure L
Mineralo - •
.•
HORIZON III DEPTH
Texture rou
Consistence
!
Structure
Mineralo
HORIZON IV DEP'TH !
�:
Texture rou "
Consistence '
�'
Structure
Mineralo
SOIL WETNESS - '
RESTRICTIVE HORIZON ` � /� � �� .
SAPROLITE
CLASSIFICATION
i
LONG-TERM ACCEPTANCE RATE � L
' SITE CLASSIFICATION: / EVALUATION BY:.T/L✓�l
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
I`REMARKS' • �lJ �►
LEGEND
Landsca�e Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
�g . .
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
ON4IST�.N .
a'IQ1SY '
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
� .
� : NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky ' '
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S r> >r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky "
SBK-Subangular blocky . PL-Platy PR-Prismatic
Mineralogv , �
1:1,2:1,Mixed :
. 1YQ� .
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 , DCHD OS/OS(Revised)
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r �i,'T :- DAVIE COUNTY HEALTH DEPARTMENT
��` _� -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 1�Oa �
Sanitary Sewage Systems w�; r��� .- �%� �'� /•`�� l Permit Number
Name �F.;� �l�n�� �c��.f N� ��'��
1Q:��.f��� � y>„ ♦ Date 111-y.�
��:'�s a
-,/� J "
Location � �./� ' , 5;.�,�1'r�� , .�f.��— r'�,r f;Y,( �,,:�;'l,,.� � 6.✓ 17` ,�7fi✓r i
�..�c�� �,.� /,�/f s ;
Subdivision Name Lot No. Sec. or Block No.
Lot Size /'��e House � Mobile Home _ Business Speculation
No. Bedrooms � No. Baths � No. in Family� �`=
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer � YES ❑ NO ❑ . ���x��/�'���
Auto Wash Machine YES ❑ NO ❑
, �'��
Type Water Supply _—
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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Improvements permit by ���
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number. 704-634-5985.
Final Installation Diagram: System Installed by �u---c� ���'�''
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- Certificate of Completion /��.�r Date ��"�-Q�
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time. �