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111 Shannon Drive Lot 3Account #: 990002398 Billed To: Curtis Hodges Reference Name: QA. q .6.,o Z. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5788-05-6257 Subdivision Info: Merrybrook Acres Lot # 3 Location/Address: Shannon Drive -27006 Proposed Facility: Residence Property Size: 6.244 acres ATC Number: 3237 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 WASTE WATE NSTRUCTION IS VALID OR A PERIOD OF FIVXE YEARS. Environmental Health Specialist's Signature:L��4 U' - Date: ��UZ 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. c� SO QG VGCV1 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Oq "j_rA_ja_ Date: I Zs I'D 2 _- ' Pct. gr�rOZ'. DAVIE COUNTY HEALTH DEPARTMENT • r Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002398 Tax PIN/EH #: 5788-05-6257 Billed To: Curtis Hodges Subdivision Info: Merrybrook Acres Lot # 3 Reference Name: Location/Address: Shannon Drive -27006 Proposed Facility: Residence Property Size: 6.244 acres ATC Number: 3237 **NOTE** This Improvement/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 I 1 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 #Baths��� Dishwasher:Garbage Disposal: ❑ Washing Machinwlr_ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats -Industrial Waste: ❑ Lot Size Type Water Supply e�ll/ Design Wastewater Flow (GPD) pi Site: Ney,�Repair ❑ System Specifications: Tank Size,&g GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench WidtK X Rock Depth 1,9 Linear Ft&�d 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.**** Environmental Health Specialist's Signature:Je Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmental Health Section ©� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 'W (336) 751-8760 0;1 L1:,.... ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i /tam 1. Name to be Billed [ LA, -4-.5 0 A Contact Person ::::�Ai1h Mailing Address (Y)A.n( 5Home Phone S 3 6\ / o%" -P } t;3 s City/State/ZIP ,,.\ gut; :)22 9.)r Business PhoE/4 n-eC��� / 2. Name on Permit/ATC if Different than Above /�M� ( E/4A) 33 �/ ^ /S^cO 3 Mailing Address � City/State/Zip -/ 3. Application For: 2 Site Evaluation ❑ Improvement Permit/ATC /Both 4. System to Service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People— # Bedrooms 3 # Bathrooms 3 !a Lebishwasher LI Garbage Disposal 1-f washing Machine CI Basement/Plumbing IA-15;asement/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: 01 County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ifo if yes, what type? '**IAfPOR7ANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED 3ELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: G . a T T %ICreS Tax Office PIN: # 6-7 tt ?'-a S - % 2--57 Property Address: Road Name5A ACJ lVo - t fir' City/Zip AJUAN c G If in a Subdivision provide information, as follows: Name: M exry &-': a A C res Section: Block: Lot: 3 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date Property Flagged: F/7/ t d..? This is to certify that the information provided is correct to the best of my knowledge. 1 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. 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 suitabi ' DATE -7/0.1 SIGNATURE (�J 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) S of 1� !V �I ✓ e-I� Site Revisit Charge Date(s Client Notification Date: EHS: Account No.�I Invoice No. l _ r v co N A W 0 0 5 6.66A 2312 549.36 5.01A 1758 7.00A 1 171 CPo 1811 OA0003 5788056257 1" ca( .73A) 3 LC CD 257 — CD o0 4 493.37 to 0 M w� 5.75A 6761 X69 oi h s 4 N 389 475 w 7.41A cn CD 6475 835 Tot 5�9 gds (3.80A) 6087 (11.83A) 6674 4. (312 APPLICANT INFORMATION Account #: 990002398 Billed To: Curtis Hodges Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5788-05-6257 Subdivision Info: Merrybrook Acres Lot # 3 Location/Address: Shannon Drive -27006 Property Size: 6.244 acres Date Evaluated: -V -I 6 Z Water Supply: On -Site Well i-� Community, Evaluation By: Auger Boring ' Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group e'ry k Consistence Structure Mineralogy HORIZON II DEPTH Tel. Texture group Consistence Irr Structure S_ �/rl Mineralogy14 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 , c SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: t' REMARKS: EVALUATION BY: itl & // 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) ■EMMEM■ ■■■EMM■ ■MEMEM■ ■■■MMM■ ■■M■■M■ ■M■M■M■ ■■M■MM■ ■■MMM■■ ■■■M■■■ ■ENNEN ■ENN■■ ■EMEM■ ■■MME■ ■E■■E■ ■EMEM■ ■E■■■■ ■■■N■■ ME ■■ ■ ■O■■ ■■M■ ■EM■ ■E■■ No no ■■M■■ME■■■M■■MMIIUI■ME■ ■E■■MMM■■M■■MM■ SEEN ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■M■■SSS■■ ■■M■MME■■ME■■MOM■■■M■ ■SSSS■■■■■■■■■M■■■MM■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■ME■EMM■■M■■M■■ OMEN ■SSS■SSS■■O■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■SSS■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ NONE ■E■■ ■■M■ NONE MEMO ■■ ■ ■EN ONE ■■MMIA■■■ ■E■NIMME■ ■EMM'■■M■ ■■OM■■E■ ■■■■aamm ■E■MEME■ ■E■■M■E■ ■EMEM■M■ ■■M■■EM■ ■E■EM■■■ ■■N■■ ■E■■■ ■E■E■ ■■■E■ ■E■E■ ■■NE■ P-:magm ■E■NO■ ■■ME■■ ■E■■■■ ■■M■■■ ■ENNE■ ■■■ME■ ■ME■■■ IM■E■■ ■E■■■ ■■E■E■ ■■EME■ MONS■■ ■■ME■■ ■■MMM■ ■■E■E■ ■■mons ■■MME■ ■EMEME■■ME■■ ■MEWME■■EME■ ■M■Atamm■■■■ ■■■SIM■M■■O■ ■E■/.ME■■■■E■ ■EMAMME■ME■■ ■EMEMEM■■EM■ ■■M■■M■M■■■■ ■■■E■■EM■■M■ ■MMEME■■EM■■ ■■MMEMEMEM■■ ■■■■MEEMMEM■ ■E■E■M■■M■■■ OEM on MEN mon om ■OM■■■ ■EN■■■ ■ENNE■ ■EMM■■ ■■■m■■ ■■■■M■ ■E■■E■ ■EM■O■ ■■MEME■EMEM■■■■ NOME■ME■MOMMEM■ ■■■M■■E■■E■MEM■ ■■■■MMMMM■MMM■■ ■MMMM■MMMM■■MM■ ■ME■■M■E■EM■■O■ ■■ME■■EMEMEME■■ ■E■■MMEM■■M■MM■ ■EN■EEM■■EN■■■■ ■■M■■MEMEMEMEM■ ■■E■■■■■EMEMME■ ■■EMM■M■■EMEME■ ■MMM■■■■■MMM■M■ ■E■MEMEM■■■M■■■ ■ENMMM■ ■EEM■M■ ■MEMME■ ■■■■■■■ ■E■■M■■ ■EMMEM■ ■EMEME■ ■■ ■ ■ MEMO ■■N■