2094 Sheffield Rd ' • . �'�
" •''• �i . DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002132 Tax PIN/EH#: 4890-89-7798
Billed To: Liberty Wesleyan Church Subdivision Info:
Reference Name: Location/Address: Sheffield Rd.-28634
Proposed Facility: Parsonage Property Size: 1.5 acres
ATC Number: 3302
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 WASTEWA CON TR N IS V LID FOR A PERIOD OF FI YEARS.
Environmental Health Specialist's Signatur : .� Date: �p D 2-
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion 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
given period of time.
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Septic System Installed By: � S
Environmental Health Specialist's Signature: �/ �/J�l� Date: �J �
DCHD OS/99(Revised)
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�� -" DAVIE COUNTY HEALTH DEPARTMENT
, f `�d �� � _�, �``-
, .,,%";'� � Environmental Health Section
, P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87(0
' IMPROVEMENT/OPERATION PERMIT
Account #: 990002132 Tax PIN/EH#: 4890-89-7798
Billed To: Liberty Wesleyan Church Subdivision Info:
Reference Name: Location/Address: Sheffield Rd.-28634
Proposed Facility: Parsonage Property Size: 1.5 acres
ATC Number: 3302
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AtTTHORIZATION FOR WASTEWAT'ER 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
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CI�ANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type t�Ld�- � #People '"� #Bedrooms �> #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste:❑
Lot Size �•S �=� Type Water Supply��Y Design Wastewater Flow(GPD) � Site: New� Repair❑
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System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width 3� Rock Depth �2 Linear Ft. �
t
och�: �S *�t,"•S � D•L'. w���J .
Required Site Modifications/Conditions: � �Q �� ��GL� ��cX'�
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Il�'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER, RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department 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 o�installation. Telephone#is(336)751-87G0.****
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT � D � �
� • Davie County Health Department �
` Environmenta/Hea/th Section ��T
P.O. Box 848/210 Hospital Street ' � ?��Z
• Mocksville, NC 27028
(336)751-8760 �N�/RpNM
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***Il�'ORTANT*** THIS APPI.ICATION CANNOT BE PROCESSED UNLESS ALL THE REQ
'�• INFOE2L�TION IS PROVIDED. Refer to the INFOF2t�TION BULLETIN for instructions.
1. Name to be Billed 1 � ,1 ��'S�C C't/� /�/ ~��~�� 1
^—1�"z-f N l./(U/'G�Contact Person /�/�a.�+ /�Q.� �
Mailing Address �� ( 7 �/�.-�ri t�Gl. � • Aome Phone y/ �-� ? �3 7
Ci.ty/state/zIP 'b't"�-/►�+��y , !� G Z�� s � Business Phone �S�� 3 S�i � �
2. Name on Fexmit/ATC if Different than Above �x t 2 3 9 `�
.
t Mail�t�g Addiess City/State/Zip
� ,:Application Eor: $ Site Evaluation � Improvement Permit/ATC ❑ Both
4.'` system to sensice: ❑ House ❑ Mobile Home p Business ❑ Industry Cf Other /f����
5. If Residence: ;# People _� # Bedrooms _�, # Bathrooms �
tF]'Dishxasher •-O_Garbaqe Disposal �[] Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industiy/Other: Specify type # People # Sinks
# Commodes B Shoxers # Urinals # Water Coolers
IF ,FOODSERI7ICE: # Seats Estimated Water Usage (gallons per day)
7: Type of water supply: ❑ County/City LI Well CI Community
' &: .Do you anticipate additions or expansions of the facility this system is intended to serve? �Yes �'No
If yes,what type?
**�IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTGD
BELOW. Either a PLAT or SITE PLAN MIIST BESUBMI7TED by the client with THIS APPLICATION. -
- �
Property Dimensions: ! . 5�� WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # y�ti'0 -�7- 7 7 9 0 .�(I � W e S`f- �-c� 0���7�c�L,�-
Property Address: Road Name����ie�.�- U�d� • �� . '\ ti�r� � �- ie�� "'�
- . c�ry�z�p n i (�3`1 a. � �f 11i � �r a �
—�_ _
If in a Subdivision provide information,as follows: �� � C�
Name:
Scction: Block: Lot: Date Pro e Fla ed: � � � ( d �--
P �Y gg
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T6is is to certify t6at the information provided is correct to the best of my knowledge. I understAnd that any permit(s) 'I
issued 6ereafter 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 nm responsible for a!!c/:arges incurred jron: ,
lhis applicalion. 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 neccssary to determine thc sitc suitability.
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensio s, structures, setbacks, and septic locations).
Site Revisit Cl�argc
Date(s):
(,�( Client Notification Date:
1
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! EFIS:
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Account No. ��� Z.
30 . � � �
Revised DCHD(07/ 9) ' Invoice No.
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�° ; ' • DAVIE COUNTY HEALTH DEPARTMENT "`�---._._._�� ��
Environmental Health Section Q�,� ` i f �1r�
PO Box 848%210 Hospital Street � 2_�'` ,'j�!j
Mocksville,NC 27028 L!
Phone: (336)751-8760 ENVfR0,y1�F�r��H
D�VIE COt;N.ry�LTH
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT o REMODELING o RECONNECTION ❑
Name: b� � G �ne Number: �9a— 7a 3q (Home)
Mailing Address: S i e. d. (Work)
MON . C �`-0�.3
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Detailed Directions To Site: G '�" a J! e ��e/ d ; 'c
r�r�Yox�ma,�cl� � �z miJcs bN r;ah-1- .
Property Address: SaMe
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: �.+der'�u Lt�5�ey4u '�urC{1 PqYso_n!�ype pf Dwelling: tc Se
Date System Installed(Month/Day/Year):��g•9s Number Of Bedrooms: ...� Number Of People:
Is The Dwelling Currently Vacant? Yes❑ No� If Yes,For How Long?
Any Known Problems7 Yes� No.O' If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
�;�yi s:d.�
Type Of Dwelling:���rAme �C�u�4r Number Of Bedrooms: � Number Of People:
� Requested By: ._J�� ��A� Date Requested: /U ���G,�
(Signature) ' �,
, . _ JU e-s�t S�S�"�/''` h,e.�oC-S �'" �"° � ''> �a�'�-. S i.�c2.��/ ,
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
�
Environmental Health Specialist Date
'"'I'he signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a
guazantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Paymen� Cash❑ Check❑ Money Order❑ # Amoun� $ � Date:
pazd gy; Received By:
Account #: �—� �'�i Z� Invoice #:
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� ''��l� DAVIE COUNTY HEALTH DEPARTMENT
� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•NOTE:issued in Compliance With Articie IL�qf S.Chap�ter 130a
Sanitary Sewage Syste s ����•�� /�G'���r Permit Number
Name -l� ,/�`�jr� ,, �I ,i,r 'r: �,�r/7_.��D te�/�-�=`,�/��'J`r N� � U � �
"L`�- �
���/i� ��':���;�� r ,7` .�i.'�i/a�-,�, /��� i'-J. -� i �
Location � � _ ��'`
Subdivision Name lot No. Sec. or Block No:
Lot Size ��-S/'�� _ House .�_ Mobile Home ____ Business __ Industry
No. Bedrooms �_ No. Baths _�— No. in Family�_ Public Assembly Other
Garbage Disposal YES ❑ NO p� Specifications for System: ,
Auto Dish Washer YES Q NO ❑ „ ._ �,.�r '� /(,,'�;
Auto Wash Ma^hine YES � NO Q /CG-'`��t''�•' �`"1 �"'
Type Water Supply -- �� --------- ,^ '�C����'��-�.�����
•This permit Void if sewage system described below is not installed within 5 years from date oi issue. '
.This permit is subject to revocation if site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEETHIS PERMIT/LAYOUT BEFORE INSTAWNG THIS�
SYSTEM. •��` •`-1 r, r�� . .. . . ,��`'.�'�..
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� Im rovemenis ermit b ��1. _
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•Contact a representative o(the Davie Counry Health Department for final inspection ol this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day ot completion.Telephone Number.704-634-5985.
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1Final Installat�on Diagram: System Installed by ��y¢��' '��= ,_
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Certificate oi Completion �_�-- Date � �_
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
lhe standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will tunction
satistactorily lor any given period oi 1ime.
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� ' DAVIE COUNTY HEALTH DEPARTMENT
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_ . • Environmental Health Section
� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account:'#: 990002132 Tax PIN/EH#: 4890-89-7798
Billed To: Liberty Wesleyan Church Subdivision Info:
- Reference Name: Location/Address: Sheffield Rd.-28634
Proposed Facility: Parsonage Property Size: 1.5 acres Date Evaluated: � )�
Water Supply: On-Site Well Community Public ' ✓
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo e% (o�
HORIZON I DEPTH - [o _ Co
Texture rou
Consistence f$
Structure � (` r
Mineralo � : �
HORIZON II DEPTH �� (
Texture rou
Consistence �
Structure • �
Mineralo <<
, HORIZON III DEPT'H .- - 1
��,Tezture rou �Sc C�-
� :Consistence '� �; 5 ; ry,
�' Structure - 1< Ic
`'Mineralo _ ,
`i HORIZON IV DEPTH .�;- . ,_ ' . .
`'Texture rou . -
Consistence .'�`
Structure : .
Mineralo - - �
SOIL WETNESS
RESTRICTIVE HORIZON •
SAPROLITE ; - . .
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:�` � `EVALUATION BY: G+.-�''`�
,
LONG-TERM ACCEPTANCE RATE: U• OTHER(S)PRESENT: �
REMARKS:
LEGEND � I
. Landscape Position
, R-Ridge S-Shoulder '�� L-Linear slope FS-Foot slope N-Nose slope ,
- , CC=�oncave slope �V',-'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 plasfic'- P-Plastic VP-Very plastic
I Structure �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev � `
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-gaUday/ft2
DC�ID OS/99(Revised) _
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�� �' . . . DAVIE COUNTY HEALTH DEPARTMENT '
'. - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
� `NOTE:Issued in Compliance With Article��.S.C�a�t.�er 30a �
� Sanitary Sewage Syste s r G ��c /�c/: �s Permit Number
Name -� ' Y �lr � � �� i F e S./� � ;�� Date//fl���as�.�J.l'
—.� �----� -�--�-=��' N� 8 0 6�3�
Location _��f ti/ •._�—L•/.�1�,�-f Si:�.,�/�'r ��. �:�,% ��
Subdivision Name Lot Na Sec. or Block Na
Lot Size ��S�C - House �— Mobile Home _ _ Business __ Industry
No. Bedrooms �__.No. Baths —�.— No. in Family�_ Public Assembly Other ;
Garbage Disposal YES p NO [.7� Specifications ior System:
Auto Dish Washer YES p NO p /D���_��y � �
Auto Wash Ma^hine YES [�j NO [] ��"` ��d�J � '
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Type Water Suppty _ �iUP/� --�-- ----- �o��,���ii"��� , �
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•This permit Void ii sewage sysiem described below is not installed within 5 years irom date of issue.
This permit is subject to revocation if site plans or the intended use change r
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUS SEE THI��PERMIT/LAYQU,T BEFORE INSTALUNG THIS
SYSTEM. �'�:.._-��lC���*�, .....��;.t��2.�.;~�,.. �,.,,
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. Improvemenls permit by ���...,L— i
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•Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., ;
1:00-1:30 P.M.or 4:30-5:00 P.M.on day ot completion.Telephone Number: 704-634-5985. �
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lFinal Installation Diagram: System Installed by 1 - I
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Certificate of Completion �__��_� Date .^,Z�__1y1,�, �
'The signing oi 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 tor any given period of time. �