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164 Mollie Road Lot 9Pemrittee•s� DAVIE COUNTY HEALTH DEPARTMENT : Name: 4 P Q. e 1 0 S O in Environmental Health Section PROPERTY INFORMATION /� P.O. Box 848 n Directions to.prop�ity:�) l9 t L� t R (� In Mocksville, NC 27028 Subdivision Name: �l�t r �. Phone #: 336-751-8760 Section: Lot: 6 t 7q 1 ) AUTHORIWASTZATION OR ,�'�� �, _ -I (V (r ( l`G 10 -leo C: SYSTEM CONSTRUCTION Tax Office PIN:# ) TJV �r ��• �i 164/111W.( Rte.( � �; G -' � AUTHORIZATION NO: 002843 A Road Name: Zip: **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 Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NOTICE*** THIS AUTHORIZATION FOR WASTEWATER IS VALID FOR A PERIOD OF FIVE YEARS. AL HEALTH SPECIALIST DATE ISSUED - RESIDENTIAL SPECIFICATION: BUILDING TYPES �f # BEDROOMS 3 # BATHS)- # OCCUPANTS —�L GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No µ� q4S °`("�" LOT SIZEy' TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD)3 &0 NEW SITE REPAIR SITE ✓� y fit✓ ry SYSTEM SPECIFICATIONS: TANK SIZE IL )Ui GAL. PUMP TANK HGAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT. REQUIRED 1 I OC ICIM le I/ i Y a Cti,S �\JI Ot iA -1 i•P IMPROVEMENT PERMIT LAYOUT �` J- /l ye, // bi M5 �o dr tl ev'� Y Su✓ -4ac •C LU ex ev 1(lo.rt /moo r-ecir 07 YIaYDr�. �/�(� SY�O/rG QllYA' 1h10 1�le�sf 'lar e�ron5 `OI � t >L v `t FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. I OPERATION PERMIT SYSTEM INSTALLED AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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. DCHD 07(02(Revlu ) e VJ) r- i � ft 7 Directions to.proy.'� 11 tt .,1 VIE COUNTY HEALTH DEPARTMENT 1 Environmental Health Section PROPERTY INFORMATION 'P.O. Box 848 I^ Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 — Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# f�`c: ) (� - �' f�✓• `1 f AUTHORIZATION NO: 0 0 2 0 4 3 A Road N' me' ! 1 r t_ Ad l Zip. '� �' 3 I,I **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 Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pennits. (In compliance with Article 11 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 3 l3-6` IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ! < _ RESIDENTIAL SPECIFICATION: BUILDING TYPE > r # BEDROOMS # BATHS A • 7 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLE(SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE V ' 77PE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 3 &G NEW SITE REPAIR SITE ✓ SYSTEM SPECIFICATIONS: TANK SIZE VV )(L7 IBJ PUPTANK GAL. TRENCH WIDTH r/GAL ROCK DEPTH LINEAR FT. ( J OTHERKTFIS I G(''„ J _6i_ t1 _1-)_'.'\5'(,)\C! Jjc,,.,.5 1/I U( V..1 t�t ��rii�'-')L fl GaYi 1140--J )4 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: -) I'I A IMPROVEMENT PERMIT LAYOUT r, j r0 5 -/C, -f IV C! I t ✓ -I O c opt C -e Cl( 07 At,i44G-C/ S7 -/)/(G ei(/a f�, AC, t Y1 -A 1 g Sf f` Ice, GI p'C1✓ 5 ln5ule �-�nt.i5�,a1 of •. FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHC UN=(R"ind) P(A4itee,''s- � `/ �/j DAVIE COUNTY HEALTH DEPARTMENT ,Name::.. -.. a t wv t t`� Envir6mnental Health Section PROPERTY INFORMATION P.O. Box 848 r �Direction&�tcs erty: ��� IO Mocksville,NC27028 Subdivision Name:=��CFFiL1%1(' Phone #: 336-751-8760 / Section: Lot: I AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - AUTHORIZATIONNO: 002741 A RoadName:11A MOLLib �iI ipi **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 Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (IR compliance with Articlrl`I of4.$. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �_, ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER -- dul IS VALID FOR APERIOD OF FIVE YEARS. RESIDENTIAL SPECIFICATION: BUILDING TYPE AiG # BEDROOMS 3 # BATHS 45 # OCCUPANTS --41— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ # PEOPLE/SHIFT _ # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �� TYPE WATER SUPPLY(` ,, ,tel DESIGN WASTEWATER FLOW (GPD) 16W NEW SITE REPAIR SITE Z n A r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH Ca -I ROCK DEPTH)')) LINEAR Fr. -7S I knot (?,t. r,� �_�, _ % I�cT. REQUIRED SITE MODIFICATIONS/CONDITIONS:_�t�'A1,1-_ IMPROVEMENT PERMIT LAYOUT N1p(.LIC VC 0 c`f�r CEx2 vIn1U1 CEx1S-nN�i11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30. 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT `��-'JILCA S�twd QZ At Lk- 'k cv-,Cwvtl- e Qat�k4t� 3rlk /vim AUTHORIZATION NO. DP%J�OPERATION PERMIT **THE ISSUANCE OF THIS OPERATION PERMIT SHALL It, WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS DCHD 02102 (Revised) J DATE: 1T THE SYSTEM DESCRIBED AB HAS BEEN INSTALLED IN COMPLIANCE REATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A FOR ANY GIVEN PERIOD OF TIME. /i[fl��/�1, (-'���f IM. ''/ IIIW4d l• r -•••r.. ., __..r _. ♦ .. ,, .. L, . "1•�^ DAME; 00 Y HEALTH DEPARTJV�ENT .- 1 . Environmental Health Section PROPERTY INFORMATION P.O. Box 848 ' Nr restlgi)s o pro efts 1 Mocksville, NC 27028 Subdivision Name: C. �II`t I i:(5 f,• / (M �� jf,Phone #; 336-751-8760 Section: Lot: 1�t•t r AUTHORIZATION FOR WASTEWATER Tax Office PlN:# \ SYSTEM CONSTRUCTION AUTHORIZATION NO: 002741 A. RoadName:`0` MIAL)L hZip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. Tlii's Form/Authorization NumMP:should be presented to the Davie County Building Inspections Office when applying for Building Permits. 4 a (ln compliance with Article'1 I of.G-$,,Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) i .-1***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION `�.�,_ � ' _ •-�.%' t6 u-1 '- IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTALI HIE6.1,TH'SPECIALIST DATE ISSUED 2. L RESIDENTIAL SPECIFICATION: BUILDING TYPE 1 C # BEDROOMS S # BATHS # OCCUPANTS � GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No V J,� ,,•�' LOT SIZE% TYPE WATER SUPPI:Y(�.uul y DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE,; ✓ SYSTEM SPECIFICyATIONS: TANK SIZE GAL. PUMP TANK GAL: TRENCH WIDTH✓ROCK DAP/l'HW/" LfNEAR FT. OTHER '�\�1.'♦.�. G t' l �� ^ �� LTi'OnJ �f 3=� .. ' . RRnI TTRFnSITF. M0nIFICATVIN3/rnNnITIr1NS•'t1.l C'�1-UI_ li�'�t l i�N It1li IMPROVEMENT PERMIT LAYOUT 1 C M�tr�tc" e E.V-l'rfln)Ca\ (EK1,5-TINc,� :;.�'�: FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 5:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT _ , - SYSTEM INSTALLED BY: UVB S VLt Y1 _ I � C C, V amy(voe � Je1-h • �N • .�, Nov 2 AUTHORIZATION NO. D0214J OPERATION PERMIT By" b j DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIC TE HAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE l l OF G.S. CHAPTER I30A, SECTION .1900 "SE E 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. DCHD 07N2 (stAh ) . , / r DAVIE COUNTY HEALTH DEPARTMENT 7' Environmental Health Section �� �/�p((, (G ►r-1, P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003796 Billed To: Mark Davis Reference Name: ut--116MR14i'A ATC Number: 4259 Tax PIN/EH #: 5801-10-5600.09 MD Subdivision Info: Sheffield Downs Lot # 09 Location/Address: Sheffield Rd:27028 b7tsalFll�YiNt�9 accepted SystemsNmay also .1e96u9se5d 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 WASTEWAT ONSIS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's I Date: //h-5 IV CERTIFICATE OF COMPLETION The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. c�..9TQct-- Fbn5D FlUX6 1-3 1 S9S10 I� lPubuPAL. SOIL..JJS7 5&:,L D La �yi oC pozI) 't C;A ?o, Q1)lCK 1{ 5TD OA16- L 'rrov b& -r(- 11-2. Septic System Installed By: �s f�tPRef -D fl �i Environmental Health Specialist's Signature Date: DCHD 05/99 (Revised) Account #: 990003796 Billed To: Mark Davis Reference Name: Proposed Facility Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5801-10-5600.09 MD Sheffield Downs Lot # 09 Sheffield Rd:27028 .965 acres ATC Number: 4259 **NOTE** This Improvement/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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF STFE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _flolCr< #People #Bedrooms s7 #Baths 2,5 Dishwasher: 13' • Garbage Disposal: 07 Washing Machine: 00� Basement w/Plumbing: 0" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ©'�l(c5^CRi Type Water Supply(2xhyry Design Wastewater Flow (GPD) 3UD Site: New CX Repair ❑ System Specifications: Tank Size ICCO GAL. Pump Tank GAL. Trench WidtlARock Depth 12 Linear Ft. )CO Other:. -S DtST(ZttJrlaJ aceeoted SvstemsNmay also bs u se5d Required Site Modifications/Conditions: 1,JS'rbm - 0--3 Gp, )IWQ 1JIL�T S�Q kit"TL-,, vr2� I5 ef-P lbzs 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.**** yK.t�.X TQ�ti �-QCN 2y' i �-- p� t �oI Health Specialist's Signature: _ DCHD 05/99 (Revised) .uu 4 oo . t Account #: 990003796 Billed To: Mark Davis Reference Name: Proposed Facility Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5801-10-5600.09 MD Sheffield Downs Lot # 09 Sheffield Rd:27028 .965 acres ATC Number: 4259 **NOTE** This Improvement/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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF STFE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _flolCr< #People #Bedrooms s7 #Baths 2,5 Dishwasher: 13' • Garbage Disposal: 07 Washing Machine: 00� Basement w/Plumbing: 0" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ©'�l(c5^CRi Type Water Supply(2xhyry Design Wastewater Flow (GPD) 3UD Site: New CX Repair ❑ System Specifications: Tank Size ICCO GAL. Pump Tank GAL. Trench WidtlARock Depth 12 Linear Ft. )CO Other:. -S DtST(ZttJrlaJ aceeoted SvstemsNmay also bs u se5d Required Site Modifications/Conditions: 1,JS'rbm - 0--3 Gp, )IWQ 1JIL�T S�Q kit"TL-,, vr2� I5 ef-P lbzs 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.**** yK.t�.X TQ�ti �-QCN 2y' i �-- p� t �oI Health Specialist's Signature: _ DCHD 05/99 (Revised) .uu 4 oo _ .. APPLICATION FOR SITE [VALUATION/IhIPItOVEA1fM PERMIT g AT D Davie County Health Department E_: 2005 EnvirmnmentaiHeaitil SectionP.O. Box 848/210 Hospital Street Mocksville, NC 27028 LHEALTH (336)751-8760bN1Y ***XlfPORTANT*** THIS APPLICATION CANNOT BE PROCESSED -UNLESS ALL THE REQUIRED INFORI•IATION IS PROVIDED. Refe r to the INFOMIATION BULLETIN for instructions. 1. Name to be Billed Contact Parson �eyl F Mailing Address [J,Ie JLAIV �f n Iims Phone z'' & Z>q 6 0 City/Stats/ZIP tV 0),C. 7/ /? Busineso Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/Statq/Z£p rj 3. Application For. ❑ Site Evaluation -, ❑ Improvement Permit/ATC ❑ Doth a. system to cervico: 13House ❑ Idobile Homo, ❑ Business ❑ Industry ❑ Other 5. Typo system requeatod: t9 Conventional ❑ conventional modified ❑ innovative Mac Cepted 6. ,iff Residence:/ II People I.Bedrooms 11 Bathrooms- 2: L]Dinhwaahor OGarbago Disposal O/Washing Machina (abasement/Plumbing ❑Danement/no Plumbing 7. If Busineno/Induatiy /Other: verify type .6 People 11 Sinks ' '0 Commodes 0 Showers t1 urinals It Water Coolers IF FOODSERVICE: ItSe to Estimated Water usage (gallons per day) S.. Typo of water supply: bounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility tills syslettl is Intended (0 serve? ❑ Yes NO. if ycs, what type? ***1BfP0R72LV7*** CLIENTSAIUSTCOMPLETGTim REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Millers PLAT or SITE PLAN MUST BE SUBMITTED by the client with TI IIS APPLICATION. ProperlyDiulensioils: 'rax Office PIN: It 5`0 ii 1 / 0 Properly Address: Road Namc City/Zip If in a Subdivision provide Information, as follows: Namc: Date home corners Ragged: O WRITE DIRECTIONS (from A•lochsvilicl to 11ROPERT IT - Section: Block Lot: This is to certify that the information provided is correct to the best of uhy knowledge. I understand that any pernhil(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the infornhation submitted in (ills application is falsified or changed. 1, also, underslandthatlant responsiblefeir all charges incurredfrom Ills application. I, hereby, give conscut to the Authorized Representative of the Davie County Ilciltlh Deparhncut to enter upon above described property located in Davie County and oniedby to conduct all testing procedures as uccessary to deteruhine file site suitability DATE SI6NATURE _ t/ TIIIS AREA MAY Bl USED FO12 D12AtiVING YOUR S1TIi PLAN (Indudc all of the following: Existingand proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Client Notification Date: I1 HS: Account No.� Invoice No. s�� 5 PAAP LoT �1 1 4 2004API ON Foll SITC• 1:vALUATION/IhlpuaVBIWT 1'Elthilr s A•rc OCT Davie County Health Department &VII--OMM7ta/ flea/tai Section EMIRONMENTAI HEALTH .0. Dox 848/210 Hospital Street DANECO, Mockovillej NC 27028 (336)751-8760 ' ***IDIPORTANT*** THIS APPLICATION CANNOT BEPROCISSID. UNLESS ALL TILE REQUIRED INFORMATION IS PROVIDED. RePor to the INPORMATION II \ ULLETIN for inn L•rud L•ionD •,I' 1: Name to be' Dllled&�/1i/e-fin /?,olL/) �pC/�{� Contact Person Mailing Address _3 j0 — /O Q C406A ,7 /� 4 & e %�/^ Home Phone --LuTi pp ' .. . city/state/ZIP -L 4,14 f aro_ ,� L Dugincua Pbanc 0 2. Name on Permit/ATC:if Different.than Above _SiQI � - Mailing Address - City/Stn to/Zip - 1. Application For: M'Site Evaluation - ❑ Improvement- Permit/ATC ❑ Buth 4. Syaeem to Service. 0-90use ❑ Mollile Home ❑ Bus: ❑ Industry ❑ Other S. Type system requested: Q Coavontional ❑ conventional modified ❑ innovative S. If Residence: It People - # Bedrooms 3 II Datllrooiuu oZ ❑Dishwasher ❑Garbage Disposal OWashing Machin ❑Ba-emelt/Plmnbing ❑Dasmnent/No Plwnbing 7. if nupiasas/Industry /Other: vorify type - 0 People #'Dials I Commodda # Showers # Urinals # Water Cooloru -; IF FOODSERVICE: 1ASeats:'Estimated Water Usage (gallons par day) lg _-_^ ___• S. Typa of water supply: County/City ❑'Wall - - ❑ Community ` S. Do you aatinipato additions or expansions Of the facility this syslcin is hitelided to Set•ve'! ❑ Yes ❑ No If yes, what type, ***terrorretvr�**cL1EN•rsnrusrconrl�ccrL'rll1;/zLQur/uvlxol�LR•i•Y11v1�oRntn•r1oNRe�ut;STiai . —I nEL01V. EitlieraPLAT•arSlTlrPLANetUSTBCSUI1dIl7TEDbytile dial( nilh'1'1115AlPIICA'1'ION Property Dinlensionsi ��.�cl ?i TM -F'/ / -�� OR wrtrrLe DIMC'1-10NS (rival Muchsville) n, 1'I(UI1I..'U 1'1': . 1 u office PIN: if Property Address: Road Nain S/I Cityaip If in a Subdivision provide information, as follows: Name:. Scc(ia1: Bloch: Lot:_ Date honk cordels flagged: Thls is to certify that the information provided is correct to the best of illy lcuowvlcdge. I understand that any peruait(s) Issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the hnfornla lieu submitted in (Ills application is falsilied or cllangcd. 1,, also, irriderstrind tkat I wn resy;uusible jur «ll cbruges iacalrrod,jrarN this application. I, hereby, give coilscaat to lire Autliorizcd Rcpresctlla(ivc ol'lhc Duiie Couuly Ilydtla Dc rir(liicul to enter Upon above described properly located in Davie County and owned by J<rn<., Ae dl n,,r/ to conduct all testing procedures as necessary to determine the site suitability. /---" DA'I•E_ 19^ 02% d SIGNATURE' cj ti TRIS AREA MAYBE USED TOR DRAWING YOUR SITE PLAN (Includ all of lite followring: Existing alld proposed piopertyitnes and dimensions, structures, setbacics, and septic locations): Sign given AccoulltNo. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site' Evaluation APPLICANT INFORMATION PROPERTY'INFORMATION Account #: '990002086 ° Tax PIN/EH#`. 5801-10-5600.11 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property Lot # 11, Reference Name. - Location/Address: -Sheffield Rd; 27028' Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Aug 1 er,Boring ' .. Pit �.. I Cut j 1 17- ca -- FACTORS,' 3_ 4: 5 6 7 Landscape position . Slo % . G �o HORIZON I DEPTH p - —.:.10 ..O Texture group L L C'L SGC.. i (rL Consistence Cre.5SV Structure Mineralogyrj HORIZON II DEPTH (tom - p. / . Ion 2 to ^' t Texture group C 0- se - Consistence 55 Structure L_ C� Mineralogy HORIZON III DEPTH Texture group.. !2 .52: Sc Consistence SP F Structure Mineralogy HORIZON IV DEPTH. _ Texture group$L Consistence Structure Mineralogy. SOIL WETNESS C RESTRICTIVE HORIZON: SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 1 © • b - 3 SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: -'/- " - - " OTHER(S) PRESENT: REMARKS: A © %2/� �C.Lrir�b S °EGEND 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 loamL ; 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 - Finn VFI - Vey 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/ft! DCHD 05/99 (Revised) N, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760/Fax: (336)751-8786 January 11, 2008 Steve Mason 164 Mollie Road Mocksville, NC 28634 Re: Septic System -Sheffield Acres/Lot 9 Dear Mr. Mason: As we discussed, I submit the following in regards to problems with your septic system. The initial septic system was installed by Ron's Grading on May 12, 2006. Part of the system was sited downgrade from a temporary sediment basin built prior to construction of the road. This had been filled in at.the time of the septic system construction: On Oct. 18, 2006, I met with you on the site and observed surfacing effluent from the septic system. The following conditions that may have contributed to the failure were . noted at the visit: • Surface water from drive and upper side of house had no diversion in place to direct it away from the system, • Surface water from Mollie Road tile/side ditches needed to be redirected, • Gutter drain discharge at septic tank, • High water consumption reading(9/25/06) of 421 gallons per day(GPD) average, which is greater than the 360 GPD design capacity. Over the next three months, steps were taken to correct the above conditions. On' a return visit January 12, 2007, however, similar conditions of surfacing effluent were noted and the entire back yard, including areas at a higher elevation than the septic system, was wet at the surface. Soil borings were conducted, revealing nothing of significance other than the soil was wet to about 24 inches, much drier deeper. Limited sun exposure was discussed as a possible contributor to the continued wet surface conditions and you agreed to thin out some of the evergreen growth along the back property line. A repair permit was issued February 6, 2007 and a new 76' drain line was added on April 9, 2007. Over an extremely dry summer, no problems were noted until I spoke with you on December 21, 2007. I visited the site on December 28, 2007 and noted surfacing effluent at the end of the newest line. All four lines were found to be wet after probing each with a probe rod. As was noted in January '07, the entire back yard area was again wet at the surface. Based on observations of the site, soil conditions, field notes from initial site evaluations and water consumption records, I suggest the following measures to resolve the situation: 1) Continue to monitor personal water consumption. Consider low -flow fixtures such as a front -loading washer. 2) Continue,to remove evergreen vegetation along back property line(shrubs, cedars). 3) Add some fill over the newest line to bring the soil level up to the surrounding area. Rework surface water diversions at drive and side property lines to channel more water; berm up on lower sides. 4) Install a French drain in same area as surface water diversion at end of drive to intercept any, laterally -moving, perched ground water. Install a second French drain on upper side of drain field parallel to buried gutter drains. 5) Install second drain field and switching valve. At this time, my recommendation is step 44. This should be pursued prior to step #5 and would assist with the surface water diversion as well as any perched water condition. Please feel free to contact me with any questions, 751-8760. ®WI�&armlOW WA Jeff Beauchamp, R.S. Environmental Health Section Cc: Mark Davis DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848/210 Hospital Street Courier 409-40-06 Mocksville, NC 27028 Phone#: (336) 751-8760 Fax#:(336)751-8786 March 3, 2008 Steve Mason 164 Mollie Road Harmony, NC 28634 Re: Septic System/Soil Scientist Visit 2-28-08 Dear Mr. Mason, On February 28, 2008 I, Rob Nations, Kevin Neal -Regional Soil Scientist NC DENR, and Joe Mando-Environmental Health Supervisor. Davie County visited your property to investigate your failing septic system. Several holes were augured into the soil in order to observe the current soil conditions. After observing the soils, topography, surface water movement, and current state of the septic system, the following were discovered: • Surface water moves across the property, during storm water events, at a velocity enough to create scouring of the soil surface and erosion. • Storm water drainage ditches are unable to completely route all surface water through the drain system allowing overflow to run across property. • Subsurface water flow is moving through the soil and inundating the septic system possibly causing sewage to overflow the septic lines • Surface water from a neighboring property is adding the surface flow over the higher side of the property. A proposed solution to the problem is as follows: Create a larger surface water diversion (i.e. birm) than is currently present extending from the right and left rear comers of the home to the property lines Just behind the surface water diversion, install an interceptor drain that would divert subsurface water movement from the septic area extending to the property line until an outlet is reached at ground level. The drain must be lower than the lowest trench bottom for the current septic system and any subsequent repair lines. • Try to tie any foundation drains into the interceptor drains on both sides of the home that aren't currently diverted off of the property • Gently dig out the distribution points on the septic lines to ensure all are functioning properly, Attached is a permit prescribing the aforementioned solutions and diagram of current situation. If there are any concerns, comments, questions, and/or suggestions don't hesitate to contact me through the above information. Sincerely, Robert M. Nations, RS Environmental Health Specialist