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200 Walt Wilson RdPermittee's / DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION ._ �.P.O. Box 848 ` /?_v Directions to property: c'°'�' '" ° �`" ' el Mocksville, NC 27028 Subdivision Name: / Phone #: 336-751-8760 Section: /�i� ., AUTHORIZATION FOR jsa�- WASTEWATER Tax Office PIN:#_ SYSTEM CONSTRUCTION AUTHORIZATION NO: A Road Name: _ Lot: Zip: _ i **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits, (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS P # OCCUPANTS �? GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ,r LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE_, _ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH /� / ROCK DEPTH ,1.7� LINEAR FF.Of REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT A I "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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO.6�/ f OPERATION PERMIT BY: /z/DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S TEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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. DCHD 02/02 (Revised) NAME_ ADDRE; DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) c� -�m "e' CAWS ^ PHONE NUMBER �c�'/ 20 DIRECTIONS TO SITE 6--f/ S fv b -ed tv-a - !ed . BDIVISION NAME ,[ / �LC /tet✓Lµ• LOT # DATE SYSTEM INSTALLED '- o NAME SYSTEM INSTALLED UNDER (Z'o ✓ i -v / �� - ca� TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLESERVE TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED/ INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for I charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT i �,� Rev. 1193 z� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health SectionC��, d/ .. , P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001902 Billed To: Kevin & Crystal Meadows Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5747-31-2092 Subdivision Info: Location/Address: 2003 Walt Wilson Road -27028 Property Size: see map **NOTE * Thnisb>emprovement/Operation 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 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 11 #Bedrooms _ 2 #Baths 2 Dishwasher Garbage Disposal: ❑ Washing Machin 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) QSoo— Site: New 11Repair System Specifications: Tank Size/00b GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width 'Rock Depth Linear F690 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 - BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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 (336)751-8760.**** — ====I E= . Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001902 Billed To: Kevin & Crystal Meadows Reference Name: Proposed Facility: Residence ATC Number: 2964 Tax PIN/EH #: 5747-31-2092 Subdivision Info: Location/Address: 2003 Walt Wilson Road -27028 Property Size: see map 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 WASTEWATER CONS U TION IS VALID FOR A PERIOD OF FIVIE YEARS/. Environmental Health Specialist's Signature: / Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I I 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. 1:5 40 _15 MIS Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: dZ L ~� APPUCATION FOR SITE EVALUATION/IhIPROVBIENT PERNUT & ATC Davie County Health Department Environmenta/Health Section R P.O. Box 848/210 Hospital Street ON�Npp�N �\�N Mocksville, NC 27028 cN�\R �i�EC (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED./T Refer to the INFORMATION BULLETIN for /instructions. 1. Name to'be Billed w,01/,/, Lrt/7T%-� ��/��l,��S Contact Person /l�G7N /51P-Iachos Mailing Address )VD/�� JP k,1,57) 1 /�R Home Phone `'[�� 5-06-y7 City/State/ZIP llgyel o;lle A%, ( o �� Business Phone ,`�7� SS Business 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: eSite Evaluation ❑ Improvement Permit/ATC EeBoth 4. System to Service: ❑ House Mobile Home ❑ Business n Industry CI Other 5. If Residence: # People _ # Bedrooms o- # Bathrooms Z Dishwasher ❑ Garbage Disposal Washing Machine ll Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: X County/City ❑ Well 11 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 17 Yes t*No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE III E REQUIRED PROPERTY 1NFORAIA'1'ION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. 5 -e -e- '"'p 1 Properly Dimensions: WRITE DIRECTIONS (from 1llocksville) to PROPERTY: Tax Office PIN: Property Address: Road Name _ '° da) b-�) zy, /?z�/ ber d Min, lLlk , T,AIf'k 4A City/zip hl DC60111t '7 br Dec°.dt� � CLQ o ��y nN If in a Subdivision provide information, as follows: W� l�i 1.5 [m n i1 k1 G 11 ' Name: S%aJk} Section: Block: Lot: Date Property Flagged: 1 / D 5 ) This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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. 1, also, understand that I ani responsible fur all charges incurred fraiii this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in DavieCounty and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE /-��/�! SIGNATURE Z�- a G/_I-- THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Dalc(s): Client Notification Date: EHS: Account No. Invoice No. a LZ t/ M � N N M WE (771) SR 1805 175 I (176) 347 u ?OJ 94 d. LO ti rn 87 L 221 l61 <� Lq o N N k APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Account #: 990001902 Billed To: Kevin & Crystal Meadows Reference Name: Proposed Facility: Residence Property Size Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5747-31-2092 Subdivision Info: Location/Address: 2003 Walt Wilson Road -27028 see map Date Evaluated: �q_'"��_ Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: - LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 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 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 - gal/day/ft2 DCHD 05/99 (Revised) ■ ■ ■■ ■■ ■■■■■■■■■U■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■iI■■ ■■■■■■■■■■■■■iI■■ MENNENiiiiiii iiiMEMMiiiiiiiiiiiii ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■ ■ ■