The URL can be used to link to this page

170 Princton Ct Lot 11 r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �17o f�ivPe�o�r Account #: 990001261 Tax PIN/EH#: 5860-81-3295s Billed To: Stone Hinge LLC Subdivision Info: Princeton Lot#11 Reference Name: Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 2882 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR Wr, WXON UC IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa ir 7: ate: G �� 1 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 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 to' LCx� YA IDD X 2 is Septic System Installed By: 1 M M �U �7-lam Environmental Health Specialist's Signature te: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT O� 61° .� Environmental Health Section P.O.Boa 848/210 Hospital Street • Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT /70 PkiAe64q Account #: 990001261 Tax PIN/EH#: 5860-81-3295s Billed To: Stone Hinge LLC Subdivision Info: Princeton Lot#11 Reference Name: Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: see map **NOTEQ* i bfmprovement/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 C #People L4 #Bedrooms #Baths 2- Dishwasher: Dishwasher: Garbage Disposal: ❑ Washing Machine: 0"' Basement w/Plumbing: 61r Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 06 A��ype Water Supply�Design Wastewater Flow(GPD) c � Site: New lea Repair❑ ICbAL. Pum Tank GAL. Trench Width�X' RockDepth th l�-�� Linear Ft.`tC01 System Specifications: Tank Size p ep Other: � -�1 , � �- �S � (� Required Site Modifications/Conditions: 1--t--�� Cir (-tpc��, G- � c�t-t- Y � �. 1�• IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISE (S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Departmeni 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# s(336)751-8760.**** Its raj' 60 1 t.g � GQo�i I�QI �� Xt2" (�� ltl d � 4 Environmental Health Specialist's Signa e: Dale: Z/ DCHD 05/99(Revised) �- PTION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC D l� Davie County Health Department Environmental Heath Section JUN 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH *** * mxra APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Son, L'.1or L L� Contact Person -7W Vowgr u ti n Mailing Address 1 7 /Q /tl L,urEl.�1<�. Home Phone 7S� O f`�/ 1 City/State/ZIP �LI./��kf 6, 11 e A)C. 220 Business Phone gn S^� /�J7 2. Name on Permit/ATC if Different than Above Mailing Address City/s /Zip 3. Application For: Ei Site Evaluation rovement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms e Dishwasher ❑ Garbage Disposal S41W-ashing Machine He;B :ement/Plumbing 1_1 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: County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes B7q-0— If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. I Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: ��- Property Address: Road Name & I ore_ E��'. �M i l"el n cCA C- City/Zip d dU o- ce- N C' III �e a, PG/ If in a Subdivision provide information,as follows: Name: �i�`I,•� c C n C p Section: Block: Lot: I' Date Property Flagged: QC) ^1'5--0 1 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 the site plans or intended use change,or if the information submitted in this application is falsified or changed. 1,also,understand that 1 am responsible for all charges incurred from this application. 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 necessary to determine the site suitability. DATE OG ^( 5--01 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all a following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: `�Z EHS• 11 Account No. / Invoice No. Revised DCHD( /99) j dC d� yk=Lr;IGATI0N-P8 TE EVALUATIONAMPROVEMENT PERMIT&ATC r r a c�_ r__ avie County Health Department U Environmental Health Section 1999 P.O.Box 848 7- 2 Mocksville,NC 27028 ERVIR lIKKAL HEALTH (704) 634-8760 n TIEaxrLN ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed GR.?a lou ?%S Contact Person MailingAddress '7nin�2l�A s i?a� Home Phone City/State/Zip 4 0%M Azc&�—, C' . Z 2041 G Business Phone :5A �L 2. Name on Permit/ATC if Different than Above .9rJL Mailing Address '�,flrr! L- ` City/State/Lip 3. Application For: [Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: PJ House [ ]Mobile Home [ ]Business [ ]Industry [ 1 Other 5. If Residence: #People #Bedrooms #Bathrooms [ J Dishwasher[ ]Garbage Disposal [ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply:[ ]County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,what type? E11110Z A PLAT Oft, SI1Li ft,tN PROPERTY INFORMATION REQUIRED:***IMPORTANT***,A'FL\AT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: c �� a ��"22,WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # 5"Seo O - E3�—- S !r ; _ !J. S J�'� L�S-7 0 Property Address: Road ame &A G -7-1,Wu gr /7 4 A C 7/'y f' city/Zip &Q VA Ale Al. �'• � 70c; 11/0,r'l-A a /= C'4z'14 7zcr.- If in Subdivision provide information,as follow f� �Q �J , •F' S ? -V L:"- Name: :Name: - ; Section: Lot# Co I.0 LJ D9A t-J ('oT 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 the site plans or intended use change,or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. 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 necessary to determine the site suitability. DATE 7- / Z '� �- SIGNATURE Revised DCHD(06-96) TI1IS AREA A(A1J 13E USED FOR 1)RA1VINC IJOUl: SITE PLAN: r 1:3ville, Health Department �;al Health Section JUL Box 848M. ospitaal Streetr# : 09-40-06h, NC 27028 Phone:(336)-753-6780 Fuc: (336) -753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name:-JCi••'S✓ C,'r.VAAJg.s' Phone Number336--C-ZC-2 l-, / (Home) Mailing Address: 17o r•:. • (Work) Z 04 Tx.Z7� ►4-$f-3�f3� Detailed Directions To Site: 15-5 -,40 / /� -�o G 3 /`t :A s /,fir-,i^C Property Address: Q I Nene 0 N Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under i/'yItKq a17 i &sttiPs Type Of Facility: , Date System Installed(Month/Date/Year): 0 ALo I Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes/GD If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: `CX`5�•�� ^ Please Fill In Then g Information About The NEW Facility: Type Of Facility: r06(/iNumber Of Bedrooms: Number of People Pool Size: l gy 3 arage Siz Other: ___// AequestedBy,,/,-/ Date Requested: 7/1clrac> (S' tore) For Environmental Health Office Use Only proved Di pproved ,�f / �� • - Comments: q Environmental Health Specialist Date:__7 *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: h Account#: _ Invoice#: ` 1 a AIrDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900111 Tax PIN/EH#: 5860-81-3295.11 Billed To: Gray Potts Subdivision Info: Princeton Lot#11 Reference Name: Gray or Betty Potts Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: 267x284x330x Date Evaluated: 2i3 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS 12, 3 4 5 6 7 Landscape position L Sloe% HORIZON I DEPTH Texture group LL'L Consistence 555r rr5515r Structure, -4 P k- Mineralogy l, 7 HORIZON II DEPTH — 14, Texture group Consistence Structure Mineralogy HORIZON III DEPTH 4so I Z-Zo Texture group G•Y Consistence r• 5 ,C - Structure A3 k- Mineralogy HORIZON IV DEPTH Texture group Consistence Structure L Mineralogy A i 1 �1 SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION .S LONG-TERM ACCEPTANCE RATE CC O- \ SITE CLASSIFICATION: r EVALUATION BY: �1PE '�►�l�C.i�/1w.( LONG-TERM ACCEPTANCE RATE: �• 3 OTHER(S)PRESENT: REMARKS: CDM,//,10 &Jt rl] Lo'T �y 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■e■■■■■e■■e■■�>t■Ile>t�■■i�■■■��e■■■■■■■■■■■■■■■■■■ea■e■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■e■■eye■■e■■■■■�■■■ ■■i■■■ri■■■■■■■■ew■■■■■e■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■►��■■■■■ILII■■■■■■■■■\\■■�■■■■■■■■■■■ � MENNENiiiiiiMENNEN MONSONsiiiiiiiiaiiMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 1