Loading...
194 Overlook Drive Lot 13 Section 2�� _-�11��1L��k�-� u,' p U ~F''/~- , �� [DAVIE COUNTY HEALTH DEPARTMENT � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13o Sewage Treatment and Disposal Rules (10NCAC 10A .1934`1068) Permit Number ' Name Dude �� ��-j� Location Subdivision Name Lot No. Sec. or Block No. Lot Size House __-_-__- Mobile Home -__--_-_' Business --- Speculation No. Bedrooms No. Baths No. in Family-�� Garbage Disposal YES O NO Ej- Specifications for System: 1,%3,1 Auto Dish Washer YES g- N(] [� Auto Wash Machine YES E��- NO -E] Type Water Supply *This permit Void if sewage system described below in not installed within 30 months from doho of issue. ; � |mpmv mentapemndbv °Conbaute vepreuenta8ivo of the Davie County Health Department for final inspection of this oyuh*m between 8:30' 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by ---'--'------ --\ Cditificate of Co-mpletioh' Date ^ aa.,' ' .�""�1,-.- r.�� :.... �. „- f �\ a� �, > b. � � ._ y r ^ �s,4 _ g ?aha �'C•_, s � ��' d y y 4 � 4� Wim. � s ..,».+ ' . ^w+"T'�' -• , "� a As^� x^ t • VA 4 f b io �.. k /. ns ,!� I l -1 Lt v . R ..— -� , ate- . �,,•� - � � �e.,c �. M .�� Wit• .°'k•: y �.,� ♦s001, F •,�.• k' ,.+ �/'�..,,''�,.,. tea, u low � � ..... .+ s�' i Lina ffi-9:ib kd' ��:• � .���^a 1 Y � 1 � t9 .rte � i � + � .. • i nth �q $ +` a► � .� � .� N ij ` "1 mile ^�rk,#. f A' ' wq "�,—' �Y�' +!M5♦A �� .y�.k�\ y+ i�,.� ��.i�9"��y� stn >r"� •'*�.? �� . � �'s � � � Mt� �} '°`�� M. � � ®�� a N. � �' � •ts 1` +�` s �, � %rte,. i r x T Won -� ,:� ,,a�... { s^ ,:.� ;x�'r` a �. e >n��� .. `� � y�'� • ''a` �'�`y � .l '' 1x'� ..'rt �`..,,, tu'^.- y? yk � S." .. � WOW, ° i. � rr � ° "i°' V^^ Pr • Add^ --.4' °''a, %� �saw A�s'�> +� � �" .;,^k �r s+s� �`"R�. t;• ' of � ���� � � � . � �' � . � ,� �.. u.1?:� ••� -. ,� „� ": � rt .� s r "fir, � ..�� DAVIE COUNTY HEALTH DEPARTMENT A IMPROVEMENTS PERMIT AND CERTIFICATE OF ..COMPLETION 'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article .13c Sewage Treatment and Disposal Rules (10 NCAC 10A..1934-.1968). ''. Permit Number_Y Name Date Location Subdivision NameLot No. Sec.'or Block No. a. . Lot Size _._ House Mobile Home Business -- Speculation No. Bedrooms No. Baths _ a — No. in Family Garbage Disposal YES .0 NO :2- Specifications for System: 100S . Auto Dish Washer. YES �-. NO�aX.iz"�?- Auto Wash Machine YES NO // 2V" I �r�� hrI' rya Drr raw - d TYpe' Water Supply "This permit. Void,if,sewage system described below.is not installed within 36 months from date of issue. t Improvements permit by�N't CIL_ - 1• -- - — -- *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 day of completion. Telephone Number: 704-634-5985. Final, Installation Diagram: System Installed by .. -� ( "Certificate of Compl.etion _—_ Date r✓% "The signing of this certificate shall indicate-that' fh syst m described above has been installed in compliance with, the standards set.forth in the above regulation, but shall in.NO way be taken as a guarantee that the system will function. satisfactorily for any given period of time: f WW APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section /(!� R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested By Lr /LA— m 7 2. Address t0 3� 3. Property Owner if Different than Above Address t7L5 Home Phone Q 9 k- ^;L- 3/ b Business Phone !29 t—•P 3 S'3' 4. Permit To: a) Install �L Alter Repair b) Privy Conventional Other Type 314Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House--Ll"'Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Z a n "Z - Bed Rooms 3 Bath Rooms X Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures commodes lavatory dishwasher urinal garbage disposal showers washing machine I sinks 8. a) Type water supply: Public Private t-*'- Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions b) Land area designated to building site Zc� c) Sewage Disposal Contractor td 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. a .5- --e- s- �� Date Ow6ner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: ti rob DCHD (6-82) P-14 (4v'�q � �7 APPLICATION FOR; SITE EVALUATION/IMPROVEMENT PERMIT & ATC a Davie County Health Department 1-oo1� SAl Environmental Health Section �.n Iva v P.O. Box 848/210 Hospital Street QR - 'i 2006 Mocksville, NC 27028Ab,,,(� (336)751-8760/ Fax (336)751-8786 v�� sw �p�}1 pplicatibiNF�p�valuatio provement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed v"fq ZTZ P041.5 Contact Person Z t �� XS Billing Address V& Home Phone - Z310 City/State/ZIl'e /!/L� o'L740 (� Business Phone 999 • & FyZ Name on Permit/ATC if Different than Above -5Rine� Mailing Address PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address d i City ;/ L 6J,' AME', � Tax PIN# J�87/ - % �� ( & ZZ Subdivision Name B Section/Lot# /v2 Lot Size % ZUf ete Directions To Site: 901 S. D 6_vefloof-- dr, L-4 ,5 -til /0 f 6 of ric-,h-A Date House/Facility Corners Flagged D - 6` - If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes RNo Does the site contain jurisdictional wetlands? ❑Yes ETNo Are there any easements or right-of-ways on the site? ❑Yes ld'No Is the site subject to approval by another public agency? ❑Yes ITNo Will wastewater other than domestic sewage be generated? El Yes 6No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms I # Bathrooms off-- Garden Tub/Whirlpool ❑Yes Basement: ❑Yes W o Basement Plumbing: ❑Yes Vlo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative R ther Water Supply Type: R;,(-ounty/City Water ❑ New Well [J Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Z 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 knowledge. 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine complia�n�j'e with applicable laws and rules on the above described property located in Davie County and owned by /9-%?%A�/ /� el Property owner's or wner's legal representative signature Date Sign given ❑Yes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account #7 Invoice # " f APPLIC_ ON F0!( SITE EVALUATION IMPIiOVENIE•NT PLRMrr ATC t / J Davie County Health Department 8 �0 uv' EnlrironmentaiHeaith Section QV�jR .0. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 DiPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL T1IE REQUIRED _I INFORMATION IS PROVIDED. /Refer to the INFORMATION BULLETIN for instr�Juction/o�. 1 . Name to be Billed I�i-�} r' % AQ 7 Contact Person 6�/G cl Ae' Mailing Address 1 `� (% /QD t' 1 (/iC Home Phone ^� _ d City/State/ZIP U r/ i- c LL N , 7470 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: XSite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: X House ❑ Mobile Home ❑ Businets ❑ Industry ❑ Othcr _ 5. Type system requested: , Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People It Bedrooms _ It Bathrooms ❑Dishwasher []Garbage Disposal Xashing Machine ❑Basement/Plumbing ❑basement/No. Pluiia)ing 7. If Business/Industry /Other: verify type It People It Sinks # Commodes It Showers It Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) ___ 8. Type of water supply: ,k County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this systeni is intended to serve? ❑ Yes VNI0 If yes, what type? k**IMPORTANT'*** CLIENTS AIUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTEI) BELOW. Eitlier a PLAT or SITE PLAN MUST BESUBAIITTED by the client with THIS APPLICA'T'ION. Property Dimensions: 1. -.)—a a�'-- Tax Office PIN: # 5?, -7 / - [ Property Address: Road Name 6tIck /do City/Zip If in a Subdivision provide information, as follows: Nainc: WRITE DIRECTIONS (froni Alocksville) to PROPERTY: l 5 0t2gic- 100X- yoc &rv���� Section: Block: Lot: Date home corners flagged: This is to certify that the information provided is correct to the best of ury knowledge. I understand that any perniil(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if (lie inforlilation subinitted in this application is falsified or clianged. I, also, understand tliat I ain responsible fur all chalbes hicurred fruiu Ilds application. I, hereby, give consent to the Autliorized Representative of the Davic County IIe:dtli 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 SIGNATURE THIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of (lie following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). �) 00 Site Revisit Charge / ��- Date(s): Sign given Revised DCHD 05/03 Client Notification Date: EIIS: Account No.y� -7 Invoice No. -3to?4 �L (1.1 6A) 3627 (1.14A) 9508 (1.08A) 9911018&191 APPLICANT INFORMATION Account #: 990002571 Billed To: Garry Potts Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5871-74-6622 Subdivision Info: Location/Address: Overlook Drive-270�V/ �y Property Size: 1.20 acres Date Evaluated: Community Public 1� Evaluation By: Auger Boring . / Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH let Texture groupS.0 �— Consistence Structure Mineralogy HORIZON II DEPTH Texture group C. G Consistence Structure A 6 !4 Obhl 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: 1 S EVALUATION BY: �& a LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: . / GCY SZj C4 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) ■■ ■i No M■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENiiiiiiMEMNONiiiiii� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■Glia■■■■■■■■■■■■■ ONE ■■■ ■E■ ■E■ ME on ■ ■■■E■M■ ■■EMEM■ ■ME■E■■ ■■■MEMS ■M■■■M■ ■EMEM■■ ■M■■ME■ ■E■■M■■ NEMESES ■M■■EE■ ■M■■E■■ ■M■■ME■ NOME■■■ ■■■■■■■ ■■NEEM■ NEMESES ■E■■■■■ ■EO■E■■ ■■■■■E■ ■■■■■E■ ■■■E■■■ ■■E■■■■ ■■■NOME NEMESES ■■■■■■■ ■E■■EM■ ■■■■■■■ ■■E■■■■ ■■EE■■■ ■■■■■E■ ■■■■■E■ ■■■■■■■ ■■E■NE■ ■■E■■E■ ■■■■■O■ ■■■■■■■ IN■E■MEN■ DEME■E■■ I1■ME■■■■ INE■M■ME■ IN■E[MME■ Ioe^.w■■■■ 150mo■■■■ 11M■■■E■■ INM■■■E■■ INEMMEMME is■■■■■■■ I■■■M■■■■ IN■■■M■■■ I■■■M■■E■ ■M■■■■M■ I■■■■M■E■ INE■E■■E■ IMMEMENEM INEEMEMOM ■ ■ ME no NONE ■■■■ ■■M■ ■■M■ ■■M■ SEEN ■EN■■M■MEM■ ■■■E■■N■■M■ ■■NEMS■E■E■ ■E■■EM■EME■ ■E■EM■■MEM■ ■■■MEM■■■E■ i