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835 Gladstone Road Lot 8DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001211 Tax PIN/EH #: 5735-69-6407 Billed To: Randy Grubb Subdivision Info: Shannon Heights Lot # 8 Reference Name: Location/Address: Gladstone Road -27028 Proposed Facility: Residence Property Size: see map **NOTE' fiffikproveMent/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 h #People #Bedrooms <2 #Baths � j_ Dishwasher:. Garbage Disposal: ❑ Washing Machine:• Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � Design Wastewater Flow (GPD) �e� Site: New ❑ Repair ❑ System Specifications: Tank Size`b0l& GAL. Pump Tank GAL. Trench Width 6 Rock Depth W " Linear Ft. 304 e Other: Required Site Modifications/Conditions: 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. y 517nistallation. Telephone # is (336)751-8760.**** [=j r Environmental Health Specialist's Signature: �G��%�C� /� Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMF,NT PERMIT & ATC Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL , fTHE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed /Aaoy L�p—uw I�iIYcST . Contact Person Of Mailing Address �3a l�P,i2Y' Z/]- Home.Phoneh7.T'Co'(�LI City/State/Zip lwocK.w& lV c- Business Phone i.5yo - qio- 077 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: Q• Dishwasher 6. If Business/Other: # Commodes If Foodservice: ❑ Site Evaluation C ty/State /Zip Y" Improvement Permit & ATC ❑ Both (1Y House Cl Mobile Home ❑ Business ❑ Industry # People # Bedrooms 13 _ ❑ Garbage Disposal Specify type _ # Showers # Seats CY Washing Machine ❑ Other # Bathrooms �i _ ❑ Basement/Plumbing ❑ Basement/No Plumbing # 'Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) 7. Type of water supply: a?( County/City, ❑ Well ❑ Community S. 'Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT*** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION., Property Dsl Dimensions:. 40 X it n 3 lS [ O i( 333.355' t WRITE DIRECTIONS (from ''� 1. 1 Mocksville) TO PROPERTY: Tax Office PIN: # �� In`'� "Cll 1 f�,S}t,nG ted. 1 I1wu tont S - Ao►-a Property Address: Road Name City/Zip (MIL� clivi e.1 Tax tk� • (� 6 If in Subdivision prozfvide information, as follows: m-4 Name: Shannon �b l Section: Lot #: U t - 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. I, also, understand that I am responsible for all charges incurred from this application. 1, 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 as necessary to dete me the site suitability. DATE 3 B (fioZ SIGNATURE Revised DCHD (06-96) cc.� conduct all testing procedures l Ls L Account #: 990001211 Billed To: Randy Grubb Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5735-69-6407 Subdivision Info: Shannon Heights Lot # 8 Location/Address: Gladstone Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3158 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIIV/E YEARS. Environmental Health Specialist's Signature: .� Date: CERTIFICATE OF COMPLETION The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliancewith 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. Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) Date: 90.00, Control 7corner n-74.00' m 1.04 Acres 0 360.00' r 90.00- T 90.00' T 90.00' N ^0019'05"E 843.64' Total +0-.E80 sq.ft. V)j N 00"18'05"E 27C.00' Tge.roo, T -�(.,;.Co, T 90.100. EIR 278.64' corner (o m 12 N 75' –C ti0 37.928 sq.ft. 232.84' 142.84' 37,142 sq. ft. E0, 'T Lo T= Tax i 9 0 � ® 4 3 � � 02 1 K.F. r DO 1' o ,� o w � o 0 0 .� w In U -) in Lo 00 LO 'r, U') Cv ro. Nn C� Co Co fl) 00 ro -NOTE: AREA OF 30,0 1 C.F. V) Ul U" 90.00' 90 00, 90.00, i Contro! Corner N 00°17105"E 9°5.46 ' SIR 2 10. ---Opx scil -------------- — — ------------------------------ 200 300 1A\ ;TONE LAND SURVE%,lNG ZO. � �= N Rt.3. Box 211-3, Uocksville, NC 27228 Ph. 910-998-4733 .5�,,�//'/' � Home Phone_/ � tT Y_l liV zf_ NCS, Business Phone SCnor. Jame on. Permit,, If, DIff rent than Above I r. t^`.. 9 ", , �pplioatlon for = O General Evaluation ❑ Septic Tank Installation Permit tem,to Serve:.House ❑ Mobile Home ❑ Place of Public Ass _ 1. Business , ❑ Industry ❑ ❑ Unknown °house, ''�+' �Other / mobile home Subtliwsion 'S�jAs�rJ�� Rin Section Lot #!'�'� ❑ BasemenVPlumbinc 0 of People �? ❑ Basement/No Pluml 0 of Bedrooms ❑ Washing Machine .I o `of Bathrooms', ❑ Dishwasher " M: ailing Dimensions ❑ Garbage Disposal business, industryplace of public assembly, othgr Specl� type 0 of.PeopieServa No. of Sinks o of Commodes •• No. of Urinals 0 o(Lavatores,;i'y No. of Water Coolers .o Showers °` Water Usage Firtures e of water supply: Public �.,,: ❑ Private ❑ pei j bimeosions' Sewage Disposal Contractor you anticipate;afditions/expansion of the facility this syterrOs intended to serve? ❑ Yes I 0,No ;s, whattvoe?' NOTE Improveme pis' Permits shall be valid for a period of 5 years from date Issued. ,Improvements Permits are subjei revocation,,! site plans or the intended use change: Effective October 1, 1989: e i: 114 ections to, Property: d A6 'ti 1.1 t ii > to certify that the information provided is correct to the best of nowledge, and I understand I am responsible for :i d from this applic Zz DATE SIGNA RE zs+ �`` NSEN FO ITE EVALUATION iQ BE BE DONE QH ABOVE DESCRIBED PE a+kf5 JST CHECK ONE ❑ 1. 1 OWN the pro party. ❑ 2. I T the proper ou checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner orebygive consent'to the authorized representative of thibavie County Health Department to enter upon above descriii :pertylocated.'In. Davie County and owned by conduct all;testing procedures as necessary to determine said site's suitability fpr a ground abso ption ;swage treatmr rl disposal'system._ DATE SIGNATURE ;: _'4 ,, NAME ADDRESS PROPOSED FACIILTY . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED �/S� PROPERTY SIZE '!,"9ZO& LOCATION OF SITE Water Supply: EvaluationBy: Evaluation On -Site Well Auger Boring - '.Community -Pit !/ - " - Public U,— Cut - Slope Z HORIZON I DEPTH FACTORS 1 2 1 3 4 Landsca e. osition C :C. Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH a S'V Texture group Consistence 41 Structure 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: EVALUATED BY: A Lz LONG-TERM ACCEPTANCE RATE: Y OTHER(S) PRESENT: REMARKS: 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 Molat. �VFR-Very friable FR-FriableFI-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 3C -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 (01-901 -