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367 Speer Rd " DAVIE COUNTY HEALTH DEPARTMENT - �� Environmental Health Section `- ' P.O.Boa 848/210 Hospital Street y� , . . . ' � Mocksville,NC 27028 �� `c.�� (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002728 Tax PIN/EH#: 5812-64-6422.01 Billed To: Richard Mullis Subdivision Info: Reference Name: Location/Address: Speer Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3453 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AtTTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People� #Bedrooms�� #Baths � Dishwasher: � Garbage Disposal: � Washing Machine� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �� Type Water Supply C'p Design Wastewater Flow(GPD) 3� � Site: New�Repair❑ System Specifications: Tank Size�(�GAL. Pump Tank GAL. Trench Width��Rock Depth��Lineaz Ft.� � Other: Required Site Modifications/Conditions: 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 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.**** f� Environmental Health SpecialisYs Signature: � Date: ��''(�U DCHD OS/99(Revised) /., � � � lJ � ' �� DAVIE COUNTY HEALTH DEPARTMENT � � ' Environmental Health Section . P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002728 Tax PIN/EH#: 5812-64-6422.01 Billed To: Richard Mullis Subdivision Info: Reference Name: Location/Address: Speer Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3453 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 CONS UCTION S VALID FOR A PERIOD OF FIVE YEARS. � /�Environmental Health Specialist's Signature: / Date: `S �` � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in pliance ' Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," ut sha ' O Y be taken as a guarantee that the system will function satisfactorily for any given period of ine. / 33 X� �C/� �'��"�� Y Septic System Installed By: � ` � � Environmental Health SpecialisYs Signature: G 1/O Date: ��YG�� `� DCHD OS/99(Revised) f � � . � W�� My' . . . . � . .. . . I f ��1�� CATION FOR SITE EVALUATION IMPROVEMENT PERMIIT&ATC � / � Davie County Health Department . ��`� � O Environmenta/Hea/th Section � P.O. Box 848/210 Hospital Street Q� G1 Mocksville, NC 27028 (\ �J (336)751-8760 �j\1 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 ��^l-�_��Ll��►5 Contact Person �� u�1�5 Mailing Addresa �lp� �c(?��f1Q'C5 �/"l�• , Home Phone 3�-qai``t�S2�D City/3tate/ZIP N1pco,.Y;n�c1 �o..\\-� (�C c7tOZ4�4 Business Phone ()�LQ"��{' �'(Q� _ 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zip 3. Application For: Site Evaluation Improvement Permit/ATC Both a. syatem tb servica: House Mobile Home Business Industry Other 5. If Residence: # People �_ # Bedrooms �� # Bathrooms � -�7- Diahwasher Garbage Disposal ashing Machine Basement/Pluaibing Basement/No Plumbing 6. If Busineas/Induatry/Other. Specify typa # People # Sinks # Commodea # Showers # Urinala # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/Ca.ty Well Community s. Do you anticipate additions or expansions of tlie facility this system is intended to serve? Yes No If yes,what type? ***IMPORTANT�`**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQU�STED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by tlie client �vith THIS APPLICATIUN. i Property Dimensions: WRITE DIRECTIONS(from Mocksvillc)to PROPERTY: � i Tax Office PIN: # �81 at��l d 1�.'�.� L on� S�� h -� l��s C hu�r1��d. . 1 Property Address: Road Name_�noQ��c�. -� F �,�c-p_�L.�Ux n ��-� �+'� ��tcr�• 5 City/Zip�X�.h��\Lt r��'-TR'�.$ -� � �r�Ye�'(�,��.yZ �� If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date home corners flagged: 5-J-03 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 tlie site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand tl:at I an:responsible for all charges incurred fro�n tlris application. I,hereby,give consent to the Authorized Representative of the D �e County Healtli Department to enter upon above described property located in Davie County and owned by �e,nr��,�� to conduct all testing procedures as necessary to determine tl�e site suitability. DATE ,K��-[�3 SIGNATURE 1�YI'��i l�. 1 J,Y THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of tlie following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Char�;e Datc(s): � � �^` ^�� Clieut Noti�cation Date: � / ' ��.. � [ l-(p 7 �r � 'a EHS: � 1Q �' � � . � Sign given Account No. �� Revised DCHD(07/99) Livoice No. _�,�.S--S_�_ i � . , (,J A � O C� W � c,a D � p A I O ! ��rl�,tir� � J � I c �� y�/ kc '---1 V; �i O� � / � `� A � I N � � Sp� D�.;I��i� �R R�i9(},, Bs�l ' w , i h' ��,�+ � (3�8� � ' I � �Z • ;�� ,� � , N �ZZb� , � r3o2� N 04i 210 � � � �ti ' , (265) ' , (217) , .. . � 19U4) r v - DAVIE COUNTY HEALTH DEPARTMENT . '� .' ' ��`,� Environmental Health Section � Soil/Site Evaluation ' APPLICANI'INFORMATION PROPERTY INFORMATION Account #: 990002728 Tax PIN/EH#: 5812-64-6422 Billed To: Richard Mullis Subdivision Info: Reference Name: Location/Address: Speer Road-27028 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 osition Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEP'TH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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 Mois 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-Granulaz 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-gaUday/ft2 DCHD OS/99(Revised)