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184 South Madera Drive Lot 14HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Walter Gannon Address: 184 S Madera Drive City: Mocksville State2ip: NC 27028 Phone #: (336) 936-9003 r For Office Use Only 'CDP File Number 195787-1 County 1D Number. Evaluated For: HDR/WWC PERMIT VALID 0 8/ 1 4/ 2 0.2 0 UNTIL: Property Owner. Walter Gannon Address: 184 S Madera Drive City: Mocksville State2ip: NC 27028 Phone M (336) 936-9003 Property Location & Site Information Address184 S Madera Drive Subdivision: McAllister Park Road# Mocksville INC 27028 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 3 is of People: Hwy 158 right on Sain Rd. 'Water Supply: PUBLIC Phase: Lot 14 Basement: n Yes D No Type of Business: Total sq. Footage: No. Of Employees: 'Proposed Improvement: New Swimming Pool "Release Conditions Maintain a 15 foot setback to any portion of the septic system This release in no way expresses or implies that the existing subsurface sewage treatment ana disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONo Applicant/Legal Reps. Signature,• 'Date: / 'Issued By: 2140 -Nations, Robert *Date of Issue: 0 8 1 4/.2 0 1 5 Authorized $tate Agent: **Site Plan/Drawing attached.** O Hand Drawing OlmportDrawing HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Num'aer: 195787-1, County File Number: Date: 08 / 1 4/.2 0 1 5 Qlnch Scale: QBrock �.... V Q p1836j� Davie County Health Department Environmental Health Section 11 fie , IR/o 07L(_1V P.O. Box 848 Al 210 Hospital Street Q'� Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - ;!9,ON-SITE WASTEWATE$T�FICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name:%)At ra�NNOn/ Phone Number 33& - 93& " %003 (Home) Mailing Address: ! $y S. t%9yal-) A04. S /$ - g(oo- %/92_ CE// (WW A Ci'jsytc1,1= ', NC a-70,:2 g Detailed Directions To Site:ZkE' 199 FAST , 1/1116 Lik ON Sin/ jftW,,6 lel a7- QN 01-4 Nl Property Address:, M v!L D12 9 Please Fill In The Following Information About The EXISTING Facility: ouli g y 6%7o. C/-14nidGz Name System Installed Under: eQ L1 .j r G Tan/ Type Of Facility: SSDAF /000 94L.. TANK Date System Installed (Month/DatelYear): d -,206-D7 Number Of Bedrooms: 3 Number Of People: �2 Is The Facility Currently Vacant? Yes S If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Followin�14 nformation About The NEW Facility: — NEW sl�J/ rV n' /00 0 L Type Of Facility: Number Of Bedrooms: Number of People_ Pool Size: c2 X �2 S CD ge Size:_ tJ A Other: .tl Requested By: 40 Date Requested: Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *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 a Money Order # Amount:$ /00-00 Date: Paid By: Received By: Account #: �� Invoice #: s NCE POO L I::E • DAVIE COUNTYAi;�TH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH #: 5749-63-4113 Billed To: Shelton Construction Services Subdivision Info: McAllister Park I Lot # 14 Reference Name: Con Shelton Location/Address: Madera Drive -27028 -I1gt j ATC Number: 4366 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 -ATER CO • U N IS A R A PERIOD OF FIVE S. Environmental Health Specialist's Signatur . 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 l l 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. i J Z J LQ 0 1 CV Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) *-to -iZ-t,3&,ik* G 0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 843i210 Aospital Street l) b Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900093 Tax PIN/EH #: 5749-63-4113 Billed To: Shelton Construction Services Subdivision Info: McAllister Park I Lot # 14 Reference Name: Con Shelton Location/Address: Madera Drive -27028 Proposed Facility: Residence Property Size: 155x260 **NOTE *This Improvemeent/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 #Bedrooms lf�) #Baths -2-57+- 1 Dishwasher: Garbage Disposal: 12� Washing Machine: 121" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type/jj #People #People/Shift #//Seater�s Industrial Waste: -//0.-//0.❑ Lot Size c gf 2 (.,�i. Type Water Supply "�besign Wastewater Flow (GPD)Site: New Repair ❑ System Specifications: Tank SizeIOGAL. Pump Tank GAL. Trench Width JfvRock Depth Linear Ft.— 2P>, Other:1�Ic5rR I �V�IDiJ .ej[,S / Vic!-�ro-) 25' �UA2=),) :`Cy16-Aes, Required Site Modifications/Conditions: I1�i �t r--7-,,,) C c,,3- j9, , CelE d�Kt�l(?� — 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.**** 1URNE vironmental Health DCHD 05/99 (Revised) H :�f F62b I o' MW. I alist's Signature: Date: O Lt.j eS c L)T vF Li'lcS 1►J GRD APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERFUNIRONMEWAI � fi~ Davie County Health Department tS Environmental Health Section P.O. Box 848/210 Hospital StreetMAR 2 9 2006 Mocksville, NC 27028 (336) 751-8760 ***IluPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES ^T ` INFORIIATION IS PROVIDED..I Refer to the INFORMATION BULLETIN for instructions.. ` 1. Name to be Billed 1 �+ — o' �.- i �; Contact Person Mailing Address1Z �� V S 1� µ/T �� (ti% nome Phone City/State/ZIP C_ Z-7oXy Business Phone r 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 24-51-te Evaluation ❑Improvement Permit/ATC ❑ Both is 4. System Mto service: L`t'iiouse ❑ Mobile I Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: E Conventional ❑ conventional modified ❑ innovative paccepted 6. If Residence: it People # Bedrooms .31� it Bathrooms 2. S'- t-. J' O ishwasher `ETdarbage Disposal 42Washing Machine ❑Basement/Pluihbing ❑.basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers t) Urinals It Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 13. Type of water supply: Aunty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? C] Yes 0 If yes, what type? ***I,IIPORTANT*** CLIENTSMUSTC0,11PLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOIV. Either a PLAT or SITE PLAN IL1U.4T BE SUBMITTED by the client witli TIIIS APPLICA'T'ION. Property Dimensions: % YS y, Z (0 y 'Fax Office PIN: tl -7 -19 L 3 Property Address: Road Name _01!2.4 O/c City/Zip —6 Ili z�vzx If in a Subdivision provide information, as follows: Name: {�'1 L LT"S TZ --JZ Section: T- Block: Lot: WRITE DIRECTIONS (from Mochsvilie) to PROPERTY:, -}-�, �. _ ,� • c. �- ; _ � � r7� ail, ��• � P ic.' Date ]ionic corners flagged: 3z O 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 ani responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County I-Ieallh 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 /Z- `'A) SIGNATUR); TIIIS AREA 1d.AYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing anti proposed property lines and dimensions, structures, setbacks,' and septic locations). Sign given Site Revisit Charge Datc(s): Client Notification Date: EI -IS: Account No. 199q,00093 Revised DCIID (05/03 Invoice No. APPLICANT INFORMATION Account #: 989900035 Billed To:- Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.14 Si bdivision Info: McAllister Park Lot # 14 J-ocation/Address: Sain Road -27028 •— 22 r-- . Property Size: as platted Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: ) _n ._ REMARKS: EVALUATION BY:CZZ) OTHER(S) PRESENT: P# Z^ L� " - 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 ois 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 DCI ID 0.5/99 (Revised) Landscape position 101 MIR, Texture group Consistence Mineralogy HORIZON 11 DEPTH Consistence MR Mineralogy WARS Textu group Consistence Mineralogy HORIZON IV DEPTH Texture group Consistence SOIL WETNESS CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: ) _n ._ REMARKS: EVALUATION BY:CZZ) OTHER(S) PRESENT: P# Z^ L� " - 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 ois 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 DCI ID 0.5/99 (Revised) 3 J Of N.$ ot � 1 t e2A pub . 20.5 R _vi r , �,yg3'q w. ax.._.i. M m«si i j y tt(341;,454 _'g4"IY.ffi'tsbi{ ... /'y i lsy N-1 - { 1� k r s 1 r ! .. b /�. � tp R L�r .w v.-+-.w.-.wv..nama..• "'Y � �+s"«.. ! r� 3 .+}..i i. i �' •;M. ,�r•.w+....w+....-w.rv.+^.°' a..a..rvw..n ice- jt WJx'4-+c"'ynr �• k�� t [ �T TO WD R Ti' REi " l APPLICATION FOR SITE EVALUATION/Ih1PROVEhIENT PERAIIT Davie County Health Department U V EnvironmentaiHealth Section P.O. Box 848/210 hospital Street APR Mocksville, NC 27028 % 3 2005 (336) 751-8760 liv TAI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROOVVIDED. /1 Refer ito the INFORMATION BULLETIN for instructions. 1. Name to be Billed 21<-I�a•zC ��l Lp Contact Person _%�✓v, E Mailing Address � �/ I 1 �cE'_ I(- Home Phone City/State/ZIP LcJ�.v:� ��'r� c_y 1� �`� 7/Q } Business Phone 416 -7 c/ ..�� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [3"'Site Evaluation 11 Improvement Permit/ATC El Both 4. system to Service: C�House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: O'Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,3- # Bathrooms MDiehwaRsher ❑Garbage Disposal 1:41ashing,Machine ❑Basement/Plumbing ❑Basemant/No Plumbing 7. If Business/Industry /other: verify type # People It Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: tlSeats Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community / 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ m -o If yes, what type? ***I11fP0RTANT*** CLIENTS MUST COMPLETE- THE REQUIRED PROPERTY INFORMATION REQUESTED IIELOIV. Either a PLAT or SITE PLAN hIUST B SUR,4ffr —rD by the client ivitli THIS APPLICATION. Property Dimensions: _ -5 p I c:.4e Tax Office PIN: # Property Address: Road Name _ 5/4 , i�:� City/Zip If in a Subdivision provide information, as follows: Name:�° lyL Section: / Block: Lot: IVRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners !lagged: This is to certify that the information provided is correct to the best of my lunowledge. 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 ant responsible for all charges incurred fi•on1 this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. �j DATE . 'f' J�— OSS SIGNATURI✓ ��-'^��J 101 TRIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EIIS: Sign givcn Account No. Revised DCIID (05/03 Invoice No.