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911 Sheffield Rd DAVIE COUNTY HEALTH DEPARTMENT �? '�J ' ' . Environmental Health Section � ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003257 Tax PIN/EH#: 5810-04-5013 Billed To: Joe Gobble Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4135 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 Treahnent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONS UCTION IS VALID FOR A PERIOD OF FI YE . Environmental Health Specialist's Signature: Date: D� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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. { 1�JQa�1E Zo s►��t� ��^-� ''C`—�r 3 �n1� !0 t � ' � `�• � - �� � -, + 'r., ��i>�k 4�'T� '7—�'2 Septic System Installed By: �� �'`� �'J� Environmental Health SpecialisYs Signatur • ate: ! 2 LZ- 5 DCHD OS/99(Revised) - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section !� � � ; ; P.O.Boa 848/210 Hospital Street ��� �� ' Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT � '' � Account #: 990003257 Tax PIN/EH#: 5810-04-5013 `�4.� Billed To: Joe Gobble Subdivision Info: r.. Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility Residence Property Size: 1 acre , ATC Number: 4135 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AiTTHORIZATION 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 Tf�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 ��)Pi Type Water Supply� Design Wastewater Flow(GPD)� Site: New�Repair❑ System Specifications: Tank Sizel�f�fI�GAL. Pump Tank GAL. Trench Width�lv R k Depth�/Linear Ft.��� Other: . Required Site Modifications/Conditions: accepted 3yste5msNmay al8o�be use5� INIPROVEMENT/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 th ay of installation. Telephone#is(336)751-8760.**** ao� � � Environmental Health Specialist's Signature: � Date: �f DCHD OS/99(Revised) � � � 16 � � �� 1 -� i; �- '�,'. C� (� C� 0 l`�I � � ' ., / �'PLIC�l7[UN FOR SITC CViILUATION/Ih!!'fiOVL•hiFNT I -� C j -� � Davie County Hcalth Department � 1� . EP 2 3 2�05 1 h� • ,,�f-� EnYironrr�enta/Healt/�Section � �/V : � n.o. noX aao/2io FiospiLal stra �- � o ' e NC 02a � � M cksvill , 27 Qfi�,` � '� (336)751-8760 ���'���' q e ���� ***I!'IPORTANT*** TIiIS APPLICATION GINNOT I�E PROCESSED UNLESS ALL Tli� RLQUIRED INFORZSIITION IS PROVIDLD. Refer �o thn =rrroru�ll�TION DULL�TIN for inutrucL-ioiin. �l. Namo tu be Dilled J��� Contact Pcraon � )C�P. �0 fD�_ � /" tdailinc� Addrn�n ��� ltomo PlionQ 3�J!�— ��c�, 'S3[9 Ci Ly/5tato/ZZP 1"`�Gks V l �l� 1V� ���-� Duuinoaa Phono � � T 5-a a� � 2. 27amo on Pcrmit/]1TC it Diifuront than Abova ldailing Addroaa _ City/Stato/Zip 3. ]►pplicaL•ion For: Site �valuation � Improvement PermiL•/I►TC Doth 9. syatem Co scrvico: ❑ IIouua L°J 14obilo Homo ❑ Du3ine�� ❑ IndunLry ❑ OL'lier 5. Typo nynlom requn�tods ❑ Conventional �. convnntional inodi�icd ❑ innovaL•ivo (�aCCCpCetl G. If ,Ita�idenca: It Paople � I3edroom� � il DaL-hrooma �_ ODinhwa�har ❑Carbago Di�posal �ia�2iing 14achino ❑Dasement/PlunJ�ing ❑Uaaement/1�o Plwnbinc� 7. If Duaineca/Induutxy /Othor: vcrify type ;1 Pcopla If Sinku p Commodaa n Showora ►I Urinala �� WaL•or Coolora IF r00D��RVICE: 1p Scata EnL•imaLed Y7aCer Uaage (galion� per clay) a. Typo of wator aupply: L3'CounL-y/Ci.ty ❑ S4ell ❑ Community 9. Do you anticipata addition� or cxp:ii�sioris of tl�c L•iciliQ�tliis sS�stctll is iiitci�dc:cl to scl�vc? G Ycs l�'IVo If�•cs,tirliat typc? ***I�1II'O1tTi1N7'"**CLIL•'NTSAIUS'TCOdIPLETL•"I7IL: XGQUlRGD PROPCRTY I1VI�ORA•1AT10N IiIsQU1:S'tLll f31i1AtiY. I'sithcr a PI,��T or SI1'C PLAIY AlU.4TllE.SUJ7A!!7'77zD bv thc cticnt with TI[IS AI'PI.iCATJON. �l(.•�'7`7u.�.� ' 1'ropertp lliuici�sio�is: �D00 1V1tITC DIRGCI'I0�1S(!►•um 11•lucltsvillc)tu PIZOYIi(t'I'1':� •r:�a orr,«rint: f� ���o_ � y �� l 3 �o`f c� i�0 51�e-F��l� I'raperty Address: Road Naiuc s ���r e�� K�. �U C(� 2r �jc`� � �(Y�� l�5 Cily/Zip ��t�C�CSV c(� nC a-�Oc�� v!�� O�(1 (��• . � If irt a S�i6di��isioit pro��idc iiiforr»atioii,.is folIotivs: �111IC. Scction: I3loclt: Lot: llatc I�omc con�crs fl:►Egcd:— 1 �3 c"�s 'I'liis is to ccrtify thal tl�c iuformatiou providcJ is corrcct to tI�c best of uiy IU101YIC(I�C. I urulcrstaud ifi�t auy periuil(s) ISS[1CV IlC1'CAjICY are subjcct to suspcnsion or rcvoca[ion,if thc sitc plans or intcnJcd usc cl�;wgc,or if(I�c ii�formalion subu�ifted in Ihis applicatiou is falsificd or clianged. I,nlso,rrrrrlerslr»rr!llrat I nu1 resporra•iLlefo��a!!cJtrrrgcs i�rcru•rrrl fi•v�n dris rrpf�licnlroa. I,bcrcby,givc conscnt to tl�c Autl�orizcJ Rcpresentati��c of tlic Dati�ic County I�Ical(li llcpartinenf to cntcr upun abovc dcscribcd propert}'locatcd in Davic Couu(y a�id otirnccl by to conduc( all tcsli�ig proccdw•cs as ucccssary to dcicrmiuc thc sitc suitability�. �,�-��� q �a a� o s s��Ntt 1�U�: � �� TIIIS AIt�A AZAY B�US�D rOIt DItA1YING YOUR SITF.PL iicludc all of tl�c follotivii�g: Lxistinb�tid proposcQ property Jincs and dimcnsions, s(ructures, sctbacics, anJ scptic locations). ' M� �f- ,�y ��.�""""�' 3a�°Oa � Si(cRcvisitC(�ar�c G/!� . .. Datc(s): Clic�it NoliGcatioii Datc: / ' ' /�I.�• �I�IS: _/r� . Sign given w . ,�lccounl No. � . � � Itcviscd llCIIll(05/03 Iu�•oicc 1'0. �v s J ' � � ��� ...1 '� �� 965610�� � . � �� � . � � ; � gg8 � � � c�� s p � �,,� r3s� � . � �� nj � �sib� � � � �2ssl a C2.82A) . � g � (7.51A) 1190 i � . � � � 7193 � � � � � (�§�� (3o80A) � . + � & . � I � �.ts � �. . q � 8856 � / �,.M 955 � ,�.,, � � i,.s,,� ; � �°' � � ��is� � (10.93 A) . � R � 2673 F � 302237dY � � . . :ts�+J . � � � �g (9.f � '�, ��� 34: p �. / ` 92� � . � � — .� l ,' / 911 i, / e �/ � � �sa.au� ���.. s 5U13 ! / � 2to �; / ��7 . . ` 270 ���(2114) . � / ' � I {J'f7 ' (46.93A� ' . � � 8328 . . � - poe9) peU) . �sro � (4.73A) � � 9987 � ���3s1 e� / • � � � / Rp/ i � � � . � / � �. � / / � � � � / (5.15A) �/�1�P11 r— . . . � .� - ' � DAVIE COUNTY HEALTH DEPARTMENT " �= �• Environmental Health Section ' . � ' � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003257 Tax PW/EH#: 5810-04-5013 Bilied To: Joe Gobbie Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-270� � ,�� � Proposed Facility: Residence Property Size: 1 acre Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo % � � HORIZON I DEPTH � �� Texture grou . Consistence Structure - /' Mineralo , �/ HORIZON II DEPTH r � Texture rou Consistence Structure Mineralo � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTNE HORIZON - SAPROLITE . _ . __. __... ,. , CLASSIFICATION LONG-TERM ACCF.PTANCE RATE � . SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ' ' OTHER(S)PRESENT: REMARKS: • LEGEND I, n scape 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 Tcxture 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 a'�1S� . • 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 �ttli�tui'�l , SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky ; SBK-Subangulaz blocky PL-Platy PR-Prismatic MineraloQv . 1:1,2:1,Mixed . �tFs . 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) ■�■■■■■■����■■�■�■�■�■��■�■����■��■s����■�������■������o■���■�t�■■ ■■■��o■■�■■■���■�■�■�■�■■�■��■�■ ■���■�■�■■■����■���■������■����■ ■■���eee■■■■s■■s���■�■�■■e■■�■�e ■■■��oe�■o��■�■s�■■s■����■o�■��■ ■■��■�■��■�■�■���■�■�■■■■■���■■■■�■■■�����������������■��■�■■����■ ■■������■�■■■■�■����■■■■■��■�■■■■�■�■�■��■��■��■���■��■��■a■�■o��■ ■��■■�■ae�����ss��v■■�■�����■������■���■��■■■■�■■■����■■�■■�o�■■■■ ■■■■����■�■�������■■■■■��t■■�����■■■�������■�����■■��■�■■�������■■ ■■�■�■■�■�■��■��■■■■■■■��■■■■�■��■■����v�■��■■■■■■■��■■■■■���o■■�■ o■���■■�■o■���■�■■■�■�■■�■■■■�■��■■■��■����■�����■���■�■��■�����■■ ■■���■■�■■■■��■���■��■�■�s�■���■�■�■������■�see�s���������■�����■ ■����■■���■■■�■■■������■�■��■�■■ 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