Loading...
117 South Madera Drive Lot 30DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Sheet Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 Account #: 989900093 OPERATION PER1l�Iax PIN/EH #: 5749-63-7929 /`' Billed To: Shelton Construction Services Subdivision Info: McAllister Park Lot # 30 Reference Name: Location/Address: McAllister Park -27028 Proposed Facility: Residence Property Size: 108x330 . ATC Number: 4754 P&72 -M II A(Z, S BOA0061S **NOTE** The issuance of this Operation 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 Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type:15ir �Sl�'` S.T. Manufacturer S boa F Tank Date 11-13 Tank Size /SOD Pump Tank Size jW* STd 74. System Installed By:&rjrj mp it.- E.H. Specialist: W Date: 3 -27 -OK ttib"J M0 tor APPLICATION FOR SITE EVALUATION/MPROVE&IENT PERAIIT fh Davie County Health Department 0 V Environmental Health Section P.O. Box 848/210 Hospital Street APR J Mocksville, NC 27028 Z�05 (336) 751-8760 IN�lRON MfNT ***IbIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PRO VIDED. /1 Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed c�C�+ ��1j-161 e -+-Contact Person �� /-1�� C Mailing Address ��� / "/ I ��E"�'I- Home Phone City/State/ZIP le -c` ,x-7/6.5 Business Phone '41/J 7 -.Z-q 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 0 Somite Evaluation ❑ Improvement Permit/ATC 13 Both 4. System to Service: L�'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: lid' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # le Peo ? # Bedrooms �,� P , � - � #Bathrooms ���-' L9Disliwasher ❑Garbage Disposal Mfashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Busineas/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: 2 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ xP o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eithcr a PLAT or SITE PLAN MUST B SU8.4117-TED by the client with THIS APPLICATION. Property Dimensions: f)J n fc .j ' Tax Office PIN: it �� /- % 3-(- J� y`/ Property Address: Road Name 5/41 IJ141 City/Zip If in a Subdivision provide information, as follows: Name: /� e I`}l�1S'� I+r� Section: Block: Lot: l WRITE DIRECTIONS (from Mocksville) to PROPERTY: tom' 'Z' L"' ' GL "-?) e toIa c c - Date home corners flagged: `'i- This is to certify that the information provided is correct to the best of my lulowledge. I understand that any permits) 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, Iuulerstand that I ant responsible for all charges incurred front alts 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 1 ' 1.3 D�� SIGNATURI, ��-�'�*�, � �"4 TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of (IIe following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EHS: Sign given F ._. Account No. a / g g Ooo -3) Revised DCIID (05/03 Invoice No. • ♦ f • DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH.#: 5749-63-6844.31 .A . Billed To:. Richard Short S4division Info: McAllister Park Lot # 31 ' Reference Name: Location/Address:. Sain Road -27028 Proposed Facility: Residence P-roperty Size: as platted Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:c -f-.C— OTHERS) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 m ist 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 r 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 110 ID 05/99 (Revised) Landscape position Texture group ��----® Consistence Structure HORIZON 11 DEPTH KGRUMConsistence �rv.�e�o■������� KM*7!9 MOM Structure MincraloAy HORIZON III DEPTH Texture group ConsistenceHORIZON IV DEPTH Texture _grouV Mineralogy SOIL WETNESS RE-STRICTIVE HORIZON CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:c -f-.C— OTHERS) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 m ist 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 r 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 110 ID 05/99 (Revised) APPLICANT TNFOIIMATION DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation A 4 b (�- 4 1, e --N PROPERTY INFORMATION Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Lincar slope FS - Foot slope N - Nosc 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 o9s 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 j 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 611- 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 -1 AC/fill Consistence HORIZON 11 DEPTH FROM —OMM Consistence "JF Structure HORIZON III DEPTH ��r---- Texture •Consistence k�--�-� HORIZON IV DEPTH Consistence KOILWETNESS SAPROLITE CLASSIFICATION wam ME "IF SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Lincar slope FS - Foot slope N - Nosc 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 o9s 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 j 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 611- 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 -1 AC/fill DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 1 i-(336)751-8760 Fax # (336)751-8786 /o/3/07 C3%0? AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900093 Tax PIN/EH #: 5749-63-7929 Billed To: Shelton Construction Services Subdivision Info: McAllister Park Lot # 30 Reference Name: Location/Address: McAllister Park -27028 Proposed Facility: Residence Property Size: 108x330 ATC Number: 4754 Site Type: �w ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms—5- Bathrooms -z-.5# People Basement❑ Basement plumbin� Non -;Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 4'�7 Type of Water Supply:,,0rCounty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow (GPD) --2, Tank Size/AL. Pump Tank GAL. ,I u Trench Width Max. Trench Depth Rock Depth Linear Ft. SU0 1. Site Modifications/Conditions/Other: kacY�' - 0-) _ O- � ���0� -C-" t?gTU=7V� , 1.50'.mL Contact the Davie County Environmental Health.Section for final inspection of this system between 8:30 - 9:30a.m. on the day of installation. Telephone # (336)751-8760. ��hti Int, �rD Environmental Health DCHD 11/06 (Revised) F.y • ! f sclq Of ! C7310 el, 3C I... 4-d •..r Aq a *T46it '�ru '"_3 � `, il}J� y , ♦f .... W , , Sti ffis3rJ r ( � q� � � �. .........,.-" FI,,.T e � �' �,� ••p„�, 7 P' iin, d fN rz— f .. 1d, f.l pa" """n^.++w.c,.-se,,,n s5a:rzyr+'.mw.w•Ma,-uwcu�rrs,wvn.svwvsr.tmw=•+,..• Tf if{} �,`,y t.�"�^� Y a'�., }.�*�i ..+*�� �9[^ R1n•A '{ Y j ja �bµd+3' P'*.i.. 4 }j q;'.r i _r SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 catidSFgtll\���t� n/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both of Applic New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***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 i)-. r e<" �, — , 4- -- _ _ 4 : Contact Person ( _ o ., < Billing Address 12 s7,-7 V S ))I `1 V J Home Phone City/State/ZIP �I Z 7 y Business Phone y - 2 Fa Name on Permit/ATC if Different than Above Address PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Q-8ife Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name S �. Phone Number -3'4 Owner's Address 1Z N!; —7 V S C0 A I,,./ City/State/Zip/Ii., 2-7ez Property Address L 3 y /1Il: , �� I - l� City�nje ,f'; : i1 e Lot Size / 0 13' �� Tax PIN# Subdivision Name(if applicable) /17 dl/., . _ Section/Lot# 3 0 Directions To Site: / S V J-. 7—,— , L 1 ; _ 4, /'11C �%/: ,�• _ %,- lC If the answer to an of the following questions is "yes", supp rting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes B346 - Does the site contain jurisdictional wetlands? ❑Yes CNo Are there any easements or right-of-ways on the site? ❑Yes BNo Is the site subject to approval by another public agency? ❑Yes Bi'To Will wastewater other than domestic sewage be generated? ❑Yes PNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms Z > N' Garden Tub/Whirlpool es ❑No Basement: des ❑No Basement Plumbing: WYes ❑No 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:. onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 hereby grant right of entry 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 staking the house/facility location,, proposed well location and the location of any other amenities. Site Revisit Charge Prop owner' or owner's legal representative signature Date(s): U 7Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # J-09I0c)03 Revised 11/06 Invoice # W3V ALLISTER PARI LOT 30 MAC 30L0 -'-DWG / 45.03 ® / DD ru / r a / R{'VERSED L--- ---------- ---CD — N 3�i"