208 Victory Ln � � OPERATION PERMIT o� i�� se �v
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Oavie County Heaith Department 'CDP File PJumber 114275- �
• � -: `-'�?�`+.�
{.���,t ..���j 210 Hospital Street G2ooeooa�s
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"�'�� " '��` P.O. Box 848 County ID Plumber:
�SY.� � /bi
"���-r� Mocksville NC 27028 Evaluated For. NEW
Phone: 336-753-6780 Fax: 336-753-1680 Township:
A�p�;canr Ronald G. Jones Property oL��ner. Matt and Tracy Seats
A�dress: 142 Cedar Hill Lane Address: 2742 US Hwy 158
��Y� Advance ��Y� Mocksviile
State,Zip: NC 27006 State:2ip: NC 27028
Phone::: (336) 998-7206 phone�_ (336)817-4696
Pro ert Location � Site information
AddressiRoac7 ::: SubdNision: Phase: Lot:
208 Victory Lane
Mocksville NC 27028 Directions
str��cture: SINGLE FAMILY 64 West past Lake Myers, turn right on Callahan Rd.
go till you see Church on right property at back left
::of Bedrooms: 4 edge of chUrch.
» of People: 1
'W�ter Supply: NE:ti�::�ELL
�,.,.�,,�,�..�.�,,��,,..�,.,..,�,�, ..�,,.,�..m.�..�.,u.�.,...�.�.,��.,..�»�,�..,,.�.a,,.M....n..��_..-
"IP 155ued by: 2244-Daytivalt,Andre•.y 'System Classif�catbniDescnption:
7YPE Il A.CQVV SYS7ERt(SI�tGLE-FAh1l;.Y OR�i8D GPD OR IESS)
`GA issued by: 22aa-oaywalt,Andre•,v
Saprolite System? (JYes t��PJo
Desigrt Flot��: 4 $ 0 . Gf2.1vITY-S�RIAt Pun�a Requ:red�
Distrbution Type: �}Yes �;}tlo
So�l A�plication Rate: � 2 "Rre-Treatrnent:
Drain field
�d drificatron Field SU ft� 'SySt2m TypE: �yF�LTRATOR OUICK.STANDr1RD
�do. Dr�in Ltnes , shcrmandunn
InstaLer.
Total Trench Length: 6 0 0 n� Certification �:
Trench Spacing: _ 9 ��Inches O.C.
�?Feet O.C. 'EHS: 22aa•O,y4:i�t.Andrev!
Trench Width: ` 3 6 ('?�nches
('�Feet p�t�. 0 7 / 2 6 � 2 0 1 3
Aggregate Depth: mches
�rlinimum Trench Depth:
Inches �
t.�inimum Soi1 Cover Approval Status
Incties
r;taximum Trench Depth: Inches � Approved O DiSapprOved
,
t:laximum SoiE Cover:
Inches
, CDP F�Ie Number 114275 - 1 County ID Number: c2000000�s
. ' Septic Tank
' , t:i�nufacturer snoat Lat. ,�;�
�
STB: Long: ,
Gailons: 1G00 Instal►er:
Date: 0 4 / 2 0 � 2 0 1 3 CerU6cat�on ::
'EH S: 22•::a-Oay,.va't.Andrerr
'Ftlter Brand:
ST t.9arker: O Yes ❑ No
Date: 0 7 / 2 6 / 2 0 1 3
Reinforced Tank: ❑ Y�S ❑ NO Approval Status
1 Piece Tank: ❑ YeS 0 No � Approved O Disapproved
Pump Tank
�;tanufacturer. Instailer.
PT: Certification �:
Gallons: 'EHS:
Daie: / � Date: � �
RiserSeated ❑ Yes ❑ No
Riser Hei�ht: O Yes ❑ No (�.1in.G in.)
Approvai Status
Reiniocced Tank: ❑ Yes ❑ No Q Approved❑ Disapproved
1 Piece Tank: ❑ Y2S ❑ NO
Supply Line
Pipe Size: inch diarneter Instatler:
Pi�e Length: feet Certification K:
'Schedute: "EHS:
Pressure Rated ❑ Yes ❑ NO Date: C �
Approved fittings ❑ Yes ❑ No Apptova!Status
❑ Approved ❑ Disapproved
Pu Re uire ent
Pump Ty�pe: Installer.
Dosing Volume: — �a� Certification �:
Dra�: Do:�yn: Inches 'EHS:
'Chain: Date: � �
Valves Accessible � Yes ❑ NO
Flotv Adjustment Valve ❑ Yes . ❑ No
Chech-valve ❑ Yes ❑ No Approval Status
Pvc unions ❑ Yes � No D Approved � Disapproved
Vent Hole Q Yes ❑ N o �
Anti-siphon Hole � Yes ❑ NO
� CDP Ftite Number �14275 - 1 County ID Number: cz�aa000�a
,
Electric E ui ment
P�1FF.1A4X Eiox or Eguivalent p Yes ❑ No Instalier:
E3ox 12 inches Abovc Grade ❑ Yes ❑ NO
Certification�:
Box Adj.To Pump Tank ❑ Y8S ❑ NO
Conduit Sealed Q Yes ❑ NO 'EHS:
Pumpt�tanuallyOperable p Yes ❑ NO / /
'Activation F:tethod: Date:
Alarm Audible 0 Yes ❑ No Approval Status
� Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
22�i•i-Da�n:at;,Mdre�r
"Operation Perm�t completed by:
�liithonzed State Agent: Date of Issue: 0 7 � 2 6 � 2 0 1 3
This system has been installed in compl:ance tivrth applicable �JC General Statutes: Articfe 11,Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A FJCAC 18A .1900 et. Seq., and all condiUons of the Improvement Penn�t and
Construction iluthor¢ation. This property is seNc� by a nPE n,� sewage septic system.
Rule .1961 requires that a Type TYPE°A _____ sept�c system meet the folloti��ing cnteria:
t.tinimurn System Revie��a E3yThe l.ocal Nealth Department: N?A____________
t.9anagement Entity: o�r^��NER____
F.9iniri�uni System Inspection;l,laintenance FrequencyE3yCertitied Operator.
N?!�
Reporting Frequency E3y Certificd Operator. N�A_!_______
Rule .1�6t requires i1�at a Type IV arid V sep4�c sy�stems designed tor a home�business o�vner must maintain a valid contract
�ti dh a public management entity:radh a certif�ed operator or a pnvate cerUfied aperator tor the life of the septic sy�sterty.
Rule .1n61 requires thatType VI septic systems designed fora home�business o��rner must maintain a vatid contract with a
publfc mana�ement entity i�rith a ceRified operator for the life of the septic sy�stem.
Rule. 1�61 (2)(e)requ►res a contract shall be executed bets}�een the system oti:�ner anci a m�nagement entrty prior to the
issuance of an Operation Permit for a system required to be maintained bya pub6c or private management entity, unless the
systern atvner and certrf�ed operator are the same_ The contract shaU require specific reyuiremenls for it�aintenance and
operafion, respoE�sibiiilies nf the ovrner ac�d systems operator,prov�sions that the contract shall be u� effect tor as long as the
system is in use, and other requirements for the cont�nued proper performance oi the system. tt shall also be a condition of
the Operation Pem�it that subsequent o��rners ot the systems execute such� contract.
L>Hand Drawing Olmport Drawing
**Site PIan/Drawing attached.**
Tota1 Tfine.(HH:t.tlti)
ACtiVRy COdC: S�1�J 2Q•!-UP issueti NEti"J Typc II Quick 4 � 1 Heurs � � ►.t inutes
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�, ' . ; ° � DAVIE COUNTY ENVIRONMENTAL HEALTH
`, , P.O.Box 848/2l0 Hospital Smet
' • Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680 �
OPERATi01�1 PERMTT
Acc�►�nt #: 989900079 '��x FIf�:EH#: G200000078
�iile�To: Ronald Jones Sufadivi�ior� lnfa:
Refer�rtce Rt��te: LocaiioniAdc�r�ss: Victory Lane-27028
Pro�c�sed Fa�:i€ity: Residential Pco��r#y&iz�: 12 Acres
ATC (rlu�tb�r: 6030
. **NOTE**The issuance of thisOperation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Syst ms,"
but shall in NO WAY�be taken as a guarantee that the system will function satisfactorily for auy given perio of
time. � �
System Type:�S.T.Manufacturer_`?�� Tank Date -20 Tank Size 1 da0 ,
Pump Tank Size l Bedrooms: t�
System Installed By: ,��i^Y1n��.��y1 Installer# Date: 2 20!3
GPS Coordinat �
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Environmental Health Specialist Date:
��� <<�a��-
DCHD 11/06(Revised)
. , � CONSTRiJCTION For ottice use on�v
� � . A�UTHORIZATION 'CDP File Number 114275- �
', ��='="»'� Davie County Health Department County ID Number:
G200000078
� � ' t���'�� 210 Hospitai Street Evaluated For: NEW
`•�,�y,;,.� P.O. Box 848 Tovrnship:
Mocksvitle NC 27028 PERt.1IT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753•1680 0 1 � 0 1 � 0 0 0 6
Applicant: Ronald G.Jones Property Owner: Matt and Tracy Seats
Address: 142 Cedar Hill Lane Address: 2742 US Hwy 158
Cdy: Advance Crty: Mocksville
State2ip: NC 27006 State2ip: NC 27028
Phone#: (336)998-7206 Phone n: (336)817-4696
Propertv Location 8 Site Information
AddresslRoad #: Subdivisan: Phase: Lot:
Vctory Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY �West past Lake Myers, turn right on Callahan Rd. go
till you see Church on right property at back left edge of
#of Bedrooms: 4 churCh.
#of People: 1
'Water Supply: NEwwE��
Svstem Specifications
t�linimum 7rench Depth: a 4
Site Classification: PS Inches
Minimum Soil Cover.
Saprolite System? QYes QNo Inches
Design Flotiv: 4 $ Q Maximum Trench Depth: 3 6 Inches
Soil Application Rate: tvtaximum Soil Cover: Inches
e . a
*System Classification/Description: *Distribution Type: Gw�v�7Y-SERu�
TYPE II A COIVV SYSTEM(SINGLE-FAh7fLY OR 480 GPD OR IESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 259oREDUC7lON 1-f�iece: QYes QNo
Pump Required: QYes QNo QP�tay Be Required
Ndrification Field
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: QYes QNo
TotalTrenchLength: 6 � g ft. GPFd—vs-- ft. TDH
Trench Spacing: _ 9 Qlnches O.C. Dosin Volume: _ Gallons
QFeet O.C. 9
Trench Width: 3 6 Inches
_ (�Feet Grease Trap: Gallons
Aggregate Depth: � � -
inches Pre-Treatment: �NSF �TS-1 OTS-II
Septic Tank Installer G rade Level Required: Q I �II �I)I O IV
Page 1 of 3
. CDP File Number 114275 - 1 County ID Number. G2U0000078
' ' � ❑ Open Pump System Sheet
� Repair System RQquired:OYeS O No ONo, but has Availabie Space
epair Svstem
Trench Spacing: Inches O. .
"Site Classification: PS — 9 • Feet O.C.
Trench Width: Q Inches
Design Flo�v: 4 $ � _ 3 6 Q Feet
Aggregate Oepth:
Soil Application Rate: � , a inches
� Minimum Trench Depth: a q Inches
*System Classification/Description:
TYPE II A CO�1V SYSTEM(SlNGLE-FAh�ILY OR 480 GPO OR LESS) hlinimum Soil Cover. Inches
t�laximum Trench Depth: 3 6
'Proposed System: 25%REOUCTION Inches
hMaximum Soil Cover:
Nrtrification Field Inches
Sq. it.
No. Drain Lines 'DistnbutionType: PUh�PTOGRAvi'rv
TotalTrench Length: 6 � � � Pump Required: QYes �No �FAay Be Required
Pre-Treatment: ONSF OTS-I OTS-II
"Site Modifications
No grading or construction activity is allo�ved in areas designated for system and �epair without approval oi Health Department.
'Permit Cond(tio�s
The issuance ofthis permit bythe Health Department in no tivayguarantees the issuance of other petmits.The permit holder
is responsible for checking tivith appropriate gaverning bodies in meeting their requirements.
fiis Authorfzatfon tor Wastewater Systen Constructlon shall be valld for a person equal to the period of validity of the Improvemertt Pertnit not
to exceed five years,and mry be Issued at the saonetime the Improvement Permit Iswed�NCGS 130A-336(b)�.If tt�e installatlon has not been
completed during the perlod of vatidity of the Constructlon Permtt,the IMormatlon sudnitted In tne app�icatlon tor a permft or Constr�ution
Autt�riution is fourxi to have been incorrecL i�lsifled or ct�anged.or the site is al2ered,lhe pertnl2 or C�structlon Autho�ization shall become
inwlld,and mry be susperxied�revoked(.1937(g)).The person awning or corttrolling the system shatl be respor►sible tor assuring compliance
with the laws,n�es,and pertnft conditfons regarding system locatlon,Installation,operation,maintenaru�monitoring,reporting and repafr
(1938(b)).
ApplicanULegal Reps. Signature Required? OYes �NO
ApplicanVLegal Reps. Signature� Date: � �
*ISsued By_ 2244-Daywalt.Andrew Date of Issue: � a / 1 a / a 0 1 3
Authorized State Agent: Prtalfunction Log OYes
pHand Drawing plmport Drawing TotalTime:(HH:1,�►,��
**Site Plan/Drawing attached.**
Page 2 of 3 1 Haurs. � I.1lnutes
, � CONSTRUCTION AUTHORI2ATION
�, • , . Davie County Health Department CDP File Number: 114275 - 1
, . 210 Hospital Street G2Uo00o078
� a.o.Box sa8 County File Number:
h4ocksvilie ntc 2�o2s Date: Q � I 1 a / a o i 3
�
Qinch
Dra�viog Drawing Type: Construction Authorization Scale: � . . OBiock = .ft.
QN/A
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Paae 3 of 3
� ' . . ' �� Davie County Environmental Health
� P.O.Box 848/210 Hospital Street
� ' . Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 989900079 Tax PIN/EH #: G200000078
Billed To: Ronald Jones Subdivision Info:
Address: 142 Cedar Hill Lane Location/Address: Victory Lane-27028
City: Advance
Property Size: 12 Acres
Reference Name:
Proposed Facilit�r: Residential
**NOTE* 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,plat or the intended use change. �P � �
. J_)___:_.�Z�'-:_.._.,...__.
Permit Type: J�New ❑Repair ❑Expansion Permit Valid for: �5 Years ❑No Expiration ,
Residential Specifieations: #Bedrooms L #Bathrooms�#People � Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type � #People #Seats
Square Footage(or Dimensions of Facility) ,
Design Flow(GPD):��� Type of Water Supply: ❑County/City �Well ❑Community Well �
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial Z
Re air `e � � 'Z
• Site Plan •
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�;i�`°��� � � ,�°
) Q�,n`���,.`
/ �
�Environmental�Health Specialist \ / • Date ab� F
i.p.11-06 /
, ' � .
� � . ` � ` ' DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation � �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900079 Tax PIN/EH#: G200000078
Billed To: Ronald Jones Subdivision Info:
Reference Name: Location/Address: Victory Lane-27028
Proposed Facility: Residential ' Property Size: 12 Acres Date Evaluated: _J I��3
'I
Water Supply: On-Site Well k Community Public
Evaluation By: Auger Boring 'l. Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition I' �S
Slope% `"� �fl �°/n
HORIZON I DEPTH -Z� - �� :y(�
Texture grou
Consistence h I l� I�L �
Structure � 1�� r'il� v L� 1 i�L
Mineralo n 'xL' ?. I`
HORIZON II DEPTH Z- �I- b
Texture rou � ; � 5E
Consistence r
Structure ,�,-t,� ,�w�o
Mineralo 1;1 ;
HORIZON III DEPTH '
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICfIVE HORIZON
SAPROLITE '
CLASSIFICATION �S �5 �
LONG-TERM ACCEPTANCE RATE .1 ,'1
�-S /
SITE CLASSIFICATION: � EVALUATION BY: f'(/I.CI�i� �, �/iJd.J.�
LONG-TERM ACCEPTANCE RATE: � Z OTHER(S)PRESENT:
REMARKS: ��Lt✓Yl P ("a�j�tn►�.<_'(� ��Y' ��f��',�r'
LEGEND
i.andscape 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
CON I T .N .
1�15�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�Y�.t
� NS -Non sticky SS -Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S�tustlirg
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic •
Mineralo�v ��-� I����
1:1,2:1,Mixed �
lYQieS
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from jand 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(Redi,
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' APPLICATION FOR SITE EVALUATION/IMPROVEMENT P�E�T & ATC�
Davie County Environmental Health
�Q��' � P.O.Bog 848/210 Hospital Street /� �,�,c-C, "�� �
, '�.�" Mocksville,NC 27028 � ` � �' � �,
: .� D�C ,�, '` 20�� (336)753-6780/Fax(336)753-1680 e� ; C��/ ��lf 6�$r
�P.'�►
�ication Fo ' ' "" a uation/Improvement Permit � Authorization To Construct(ATC) ❑ ` -_..
of ion: �New System ❑Repair to Existin�System L7Expansion/Modification of Existin�Svstem or Fa ilitv
***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI�REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instructions. �yp� ���i"J
APPT,TC'ANT 1NFnRMATTnN d� C'Or��1�-I �i�����1Nsa��� �jc�Q—�rj'3 7
Name �-�+�J-�L �/ • , Contact Person �dY�' �CJ• 0
Address Home Phone ,336 ^�9'g"'�I� (v
City/State/ZII' � ,G 70D( Business Phone .33G-QO�/ -//43
Email
Name on PermidATC if D fferent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE:_ A survey plat or site plan must accompany this application. Included: ite Plan �Plat(to scale)
(Permit is vahd for 6 months wi site plan,no expiration with complete plat.)
Ow,'ner's Name' ' %���-- o� Phone Number
Owner's Address City/State/Zip
Property Address City
Lot Size Tax PIN# -cZ -000-00-O�
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
If the answer to any of the following questions is�"Yes",supporting documen�.ation must be attached:
Are there any existing wastewater systems on the site7 Yes t�i�o
Does the site contain jurisdictional wetlands? Yes �_/
Are there any easements or right-of-ways on the site? Yes �.t�g/
Is the site subject to approval by another public agency? Yes Y��
Will wastewater other than domestic sewage be generated7 Yes �1Qo
TF RF,S�nF,NCE FTT,T,ni TT THF,ROX RF,T.(�W
#People #Bedrooms #Bathrooms__`�___ Garden Tub/Whirlpool es ❑No
Basement: ❑Yes o Basement Plumbing: ❑Yes C�3�o
IF�nN-RF,STDF,NCF.,FiI I,nIJT THF,AnX�3F.L,(�W
Type of FacilityBusiness Total Square Footage of Building #People
# Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats -
Type system requested: ❑Conventionai ❑Accepted ❑Innovative ❑Alternative OOther
Water Supply Type: 0 County/City Water @�New Well ❑Existing Well ❑ Community V�e�l
Do you anticipate addit'ions or expansions of the facility this system is intended to serve? ❑ Yes [3'No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my laiowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed I hereby grant right of entr.y to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or st ing the house/facility location,proposed well location and the location of any other amenities.
Property owner's or owne ' lega��resentative signature Site Revisit Charge
Date(s):
�c�- o�'�—�Z Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# ��`I�U�L�?t
Revised 11/06 � � Invoice# ����
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P.0:Box 848/210 Hospital Street � C
Courier 09-40-06 .• �`�" �
hfocks�iile,NC 27a2S J ��
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February 14,2005
Matt&Tncy Shects
27�.2 US H'igarti•ay 153
. �Iocksville,l�TC 27028 _
Re_ Site EvaIuation.� off CalahzlnRoad
Tax Offic�PIN: ���09-58-6653
Dear Cli�t(s):
As requested,a representatice from this office visited the aforementioned site on, �
February 9,2005_ Bas�d upon the information provided on the flpplicarion for Site
�vafuation and a.�ter an evaluation v.�as completed on thc site,the site was found to be
pro�7siona2ly suitab?e for the instalIation of�a oversized iaodified on-site sewa�e system.
Be�ore anlmprove»:enz PermiU'.4uchorizaliorz to Corzrrrucr caa be issned Fhe appzopriate
applicationmustbe filled out andthehouse/mobile home location staked off.
If you have any questions,please feel free to contact this offce.
Sincerely,
���.t���'�.
Rob�t B.Hall,7r_,RS. /�{
Environmen'�al He21th Specialist ��(/
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`�����,`�"^�f; warranties of inerchantability or fitness for a particular use.All users of Davie County's GIS website shall hotd harmless the County of �U ti� �
�� D a v i e,N o rt h C a r o l i n a,i t s a g e n t s,c o n s u l W n t s,c o n t r a c t o r s o r e mp l oy e e s fro m any an d a l l c laims or causes o f ac tion due to or arising ou t o f 4 �
` t h e u s e o r i n a b i l i ry t o u s e t h e G I S d a t a p ro v i d e d b y t h i s w e b s i t e. � , � PrI C�ted.DeC 1�� 2��2 I
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� , � � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' � P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003483 Tax PIN/EH#: 5709-58-6653
Billed To: Matt&Tracy Seats Subdivision Info:
Reference Name: Location/Address: off callahan road-27028
Proposed Facility Residence Property Size: 12 acres
ATC Number: 3994
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
/
**NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 FIVE YEARS.
Environmental Health Specialist's Signature: Date:��/� ��.5�
v�--T.-�-J-
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation 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.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
� y�7S
DCHD OS/99(Revised)
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Environmental Health Section ��
P. O. Box 848/210 Hospital Street
� Courier 09-40-06 .
Mocksville, NC 27028
� �� . �' tt (336)751 8760 � �� , ",
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February 14, 2005
Matt&Tracy Sheets
2742 US Highway 158
Mocksville,NC 27028
Re: Site Evaluation/ off Calahaln Road
Tax Office PIN: #5709-58-6653
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on,
February 9,2005. Based upon the information provided on the Application for Site
Evalz�ation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an oversized modified on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely, � �
�4�����p�i.
Robert B. Hall, Jr.,R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)
��� � � i�a�s
' .� • , ' , , , . DAVIE COUNTY HEALT'H DEPARTMENT ����.���("�C.2�,
. � . . • Environmental Health Section e`����5
• ' � P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
.. - .�- " (33G)751-87C►0
. IMPROVEMENT/OPERATION PERMIT
Account #: 990003483 Tax PIN/EH#: 5709-58-6653
Billed To: Matt&Tracy Seats Subdivision Info:
Reference Name: Location/Address: off callahan road-27028
Proposed Facility Residence Property Size: 12 acres
ATC Number: 3994
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type � #People� #Bedrooms V #Baths �
Dishwasher� Garbage Disposal: ❑ Washing Machir�� 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)� Site: New� Repair❑
�i
System Specifications: Tank Size�(/�GAL. Pump Tank/Odf1 GAL. Trench WidthL� Rock Depth��Linear Ft.��
Other:
Required Site Modifications/Conditions:
11�1PROVEI�'[ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 of installation. Telephone#is(33G)751-87G0.****
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DCHD OS/99(Revised)
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� • • '• � . ' DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
r Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003483 Tax PIN/EH#: 5709-58-6653
Billed To: Matt&Tracy Seats Subdivision Info: �
Reference Name: Location/Address: off callahan road-27028
Proposed Facility: Residence Property Size: 12 acres Date Evaluated: � /��dS
r
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition //
Slo e% �Z � �-
HORIZON I DEPTH '' ��
Texture rou � '�
Consistence
Structure
Mineralo
HORIZON II DEPTH .� l'" 3 � v
Texture rou �- �
Consistence
Structure < i
Mineralo �1 c
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � �
SITE CLASSIFICATION: ,� EVALUATION BY: /7-9'��
LONG-TERM AC PTANCE RATE:� L— OTHER(S)PRESENT:
REMARKS: / � ✓ ` n� . . ��(� -� � �
Landscape Position
�9lft��e. �S ��� �
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
Mineraloev
1:1,2:1,Mixed ��
Notes I�,l 2
Horizon depth-In inches ^DP� ��
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 OS/99(Revised)
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��EB —�_2����1�' U FOR SITE EVALUA710N/IhiPROVEM1IFIVT PCRhi1T&ATC �D� ,/�
g � � Davie County Health Department ` 1��
; �E � c�
�yv�RON�?+�Nj��NEA�-�N Environmenta/Hea/th Section
f P. . Box 848/210 Hospital Street
� Mocksville, NC 27028
DPV1E COUN1`(
(336)751-8760
***IMPORTANl*** THIS APPLICATION C1lNNOT BE PROCESSED UNLESS A�L TIiE REQUIRED
INFORMATION 15 PROVIDED. Refer to the INFORMATION IIULLETIN for instructions.
1. Namo to bc Billed ./VI���f 3 /r,.iL� �C'C�S Contact Poraon ��� �L'�7>
� Mailing Addreas J.,J7�I,-,� us ��i ��,4 Home Phone 33��""' t�jU '� �C��7
City/State/ZIP _/t'l/.[_��VillO. �E c���.�,sj IIusinesa Phona _��7� y� �7�
2. Name on Permit/ATC ii Different than Above__ �t(y�` . )e�cY.A
Mailing Addresa ,�7y,�- �S f'W i � S � City/Stat /Zip �'�����r%�/P � �-'(��-�(
3. Application For: �] Site Evalua�ion �mpro��nd� Permit/ATC � I3o�h
4. system to service: I�HouBa ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type syatem requested:�Conventional ❑ convantional modifiad ❑ innovative
6. If Residence: � People �r # Bedrooms . -� � Bathroomu °.�
�Diahwanher ❑Garbago Disposal �Washinc� Dfachine �Hasement/Plumbing ❑Basement/No Plumbing
7. If Duainesa/Industry /Othar: verify typa # Paopla # Sinks
# Commodos # Showors # Urinals Ik Water Coolars
IF FOODSERVICE: # Seata Eatimated Water Usage (gallona par day)
8. Typo of water supply:� County/City �Well ❑ Community
9. no You anticipate additions or cxpausions of tl�c facility tl�is system is intcndcd to scrvc? O 1'cs l�`No
If ycs,�vl�at typc?
, ***I/IIPORTAN7�"**CLI�NTS AfUST COMPLETE TIIG RLQUIRL•D PROPGRTY INrORN1ATlON RGQU�STGD
- [3ELO�Y. �itl�cr a PLAT orSITE PLAN MUST IlI3SUBAlI7T�D by ttic clicut witl�TIIIS APPLICATION.
Property Dimet�sions: �,� �'.U1S tiVI2ITG DIRCCCIONS(from Mocicsvillc)to PROPG2Tl':
Tax OfGcc PIIY: # .S'�O 9— .S� ' (o `�3 �G���C ��)� ��+� �t� �'�.�T LC.k�,
Property AdJress: Road Namc d r�CQ/�a� ,��V�r j C�ti��i�_�. l U vn /�� ����
j ✓
CIty�7.11) �h C.C4��Ct�ZGc:+"'1 /�-�-I c�, ��Y�����' c`ICat'rl'�
If in a Subdivision proviJc information,as follotivs: �l c���' � �i t�' St'e c'� ���✓�7� u;,�
Or �,i��� �
� ,
Namc: ��<<"� 1� �W y; % .�- r E- /� S�Z���S' C�::�� l3c,.c:l�
��� ��-f� f�� f� ��i�-�- � C �r'c-,�� GiCC��SS V�>ct� sS
Sectioii: Block: Lot: __Z���y� Date liomc cdri�ers llagged: �w��
�.J1�= L
�� �7,� S f�%'t L P�'?�
Tl�is is to ccrtify tliat thc inforli�ation providcd is corrcct to tl�c bc of n�y Iaiotivlcdgc. I undcrstaiid tliat any permit(s)
issucd l�crcaftcr are subject to suspcnsion or revocatioi�,if tlic sitc �lans or intendccl use ctiangc,or if tlic ii�formation
subn�ittcd in tliis application is falsircd or cl�angcd. I,aJso,«i crstnnrllhat I aur respousiLlc for al!clrnrgcs i�icrurc�l frvm
11ris applicnlio�r. T,hereby,give consent to tl�e Autl�orize presentative of the Davie County IIealth Department
to enter upoii above described property located in Davi Coui►ty and o����ied by �
tu conduct all tcsting proccdiires as ncccsslry to dctcrmit�c tlic sitc suitabili y.
DATL � �L� �}� SIGNATUI� �J', i r - •�' .,
TIiIS AItEA MAY BE US�D FOR DRAWING YOUIt SITE PLAN( iicludc all of tlic folIotivii�g: Existing and proposcd
property lit�es and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Cliargc
Datc(s):
p�l��2�5 Clicnt Notification Datc: '
�° a� .
�FIS:
Sign givcn � / Account No. �� V �
Reviscd DCI3D(OS/03 Iiivoicc No. � 6 3� �