211 Shady Grove Lane Lot 13A! bN' NO: , 1453 . DAVIE COUNTY HEALTH DEPARTMENT Su Rg
pEnvironmental Health Section PROPERTY INFORMATTON
*% t P.O. Boz 848
Directions to property
Mocksville, NC 27028 : Subdivision Name:
Phone #r 704-634-8760 '
Section: Lot:
c 1 AUTHORIZATION ASTEWATERUR
SYSTEM CONSTRUCTION Tax. Office PIN:#--./
Road Name: '+�' rl/'704
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This FomvAuthorization Number should be'presented to the Davie County Building Inspections
Office when applying for Building Permits.
[ '' r (In' cornpliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems).
�- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
VIREIV ONMENTAL HEALTH P IALIST: DATE ISSUED
t� -�'+ ,� r L rv: Wy wt r �. +n,tyw 2n v. ,�o-s dt"�1ni�4 (.. u("fYA� �N�'Sr,�1' .. N1.�r1`'� "4 .✓ $ 5; :� .� r r "ii'� v ,.. - r > r ,, l i' i
1 4 5 3DAVIE COUNTY HEALTH DEPARTMENT s zb •4q
y i0 IMPROVEMENT AND OPERATION PERMITS " PROPERTY INFORMATION
Name. �/. a'if7f17+✓J.Q a Subdivision Namea✓ w C�Ar
birectlons to property x tom' %®' Section: Lot:
IMPROVEMENT �. �/j lL
PERMIT Tax;C;fficePIN:# �/o n'"'-/
y Rod Name: �� Il Zlp .., •Qtr
**NOTE** This Improvement Permit DOES NOT authodze'the construction or insd1lation of a septic tank system or any wastewater system An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construcdon/installaticn 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)
r.� ***NOTICE*** THIS PERMIT IS S[[JJ� CT TO REVOCATION IF SITE
/Z�f�9l PLANS OR TIRE INTENDED USE SCZGE. YOUR WASTEWATER
ONMENTAL HEALTH(sPECIAI IST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL Yes orNo
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No -
LOT SIZE3�,. TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) s.45 NEW SITEy/REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 2 GAL. PUMP TANK GAL. TRENCH WIDTH ,!?� ROCK DEPTH eV LINEAR FT--rOD'
OTHER" - U
REQUIRED SITE MODIFICATIONSICONDITIONS: '
I�Y� ae4APPLICATION SITE EVALUATION/IMPROVEMENT PERMI
Davie County Health Department IS U
Environmental Health Section
P. 0. Box JM I O I
r O^vp' IIh - Upp�i l2 Mocksviville, NC 27028
�J'M (336) ENVIRONMENT
✓1" vvvALHEALTH
DAVIECOUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNL
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billedtl�Ci1 Contact Person
Mailing Address 3�-p I (E n)AN IJHome Phone 7ryY�gO 7Cyl� I^�
City/State/Zip dk'Y': L 4 I QQo N C� ^ Business Phone
2. Name on Permit/ATC if Different than Above �()n P6t + MRM /%
Mailing Address WIG 9 0 1 5a 14-L City/S�tate/Zip Q u1Zt2(PSL- � ago (,
3. Application For: ❑ Site Evaluation a --Improvement Permit & ATC ❑ Both
4. System to Serve: C3� House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Res�id nee: # People_ # Bedrooms # Bathrooms _
If
❑ Garbage Disposal aC�W skiing Machine ❑ Basement/Plumbing L3Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats /� Estimated Water Usage (gallons per day)
7. Type of water supply: Q County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes S- V -O
If yes, what type?
***
Property Dimensions: AIS . d I X I -I `7."
Tax Office PIN: # 5784 - g%4 9
/-�/�,,I
Property Address: Road Name 00?=� L I YQP--S b
I
city/zip N0�[%HNL o i00
I
I
If in Subdivision provide information, as follows:
Name: G I
Section: Lot #: )�
I
HE PROPERTY MUST BE
WITH THIS APPLICATION:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
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. 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 4-11049 SIGNATU 42
Revised DCHD (06-96)
YOU MAY USE THE BACK Of THIS FORM FOR DRAWING IJOUR SITE PLAN.
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15.00 140.00
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` 78.00' 194.00 t q
LAIi
PARCEL 19'
W. J. ELUS
DB. 53 PG. 296
ZONED R-20
LOT ACREAGE
�f TOTAL 614.77' N 7.37 2
�CONC.
CONTROL
CORNER
HORIZONTAL CURVE C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section��
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
i
DATE EVALUATED;/�.��
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: AugerBoring Pit_ Cut
FACTORS 1
2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH +-
t
Texture group
Consistence
/
Structure /C
[
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: _ �7
LONG-TERM ACCEPTANCE RATE: y
REMARKS:
DCHD (01-901
EVALUATED BY: -14/11"
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 <:lay loam- SIL -Silty loam CL -Clay loam ISCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-.V,..-y friable FR -Friable FI -Finn 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
Mi neraloey
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/fta
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1686
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005839
Billed To: Beth Weatherman
Address: 211 Shady Grove Lane
City: Adavance
Tax PIN/EH #: H8050A0013
Subdivision Info: Shady Grove Lot# 13
Location/Address: 211 Shady Grove Lane -27006
Property Size: 0.71AC 1
Reference Name: Site Type: Repair A Expansion k)
Proposed Facility: Repair���
**NOTE** This IP/ Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any buildingpermit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ 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_,L # Bathrooms # People_ BasementO Basement plumbing
Non -Residential Specifications•. Facility Type # People_# Seats_
Square Footage(or Dimensions of Facility)
Lot Size . AL Type of Water Supply: ®County/City ❑Well OCommunityWell
System Specifications: Design Wastewater Flow (GPD) Tank QdSf%tAL. Pump Tank / GAL.
Trench Width ',Yj_ Max. Trench Depth_3_((L_ Rock Depth A`1(h .Linear Ft. 125" 2 'l0
t2cdue►nl
Site Modificafions/Conditions/Other:.
Contact the Davie County Environmental Health Section for final inspection of this system between
"8:30— 9i30a.m. on the day of installation. Telenbone # (336)753-6780.
1
DCHDII/06(Revised) � _r�,e�,,,,`/�)Gi�n„�,(� ,3/iZ