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191 Sheffield Farms Trail Lot 1DAVIE COUNTY HEALTH DEPARTMENT Environmerital Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000789 Tax PIN/EH #: 4891-81-8453 Billed To: Edwin Allen Mathis Subdivision Info: XAP-" LCTd Reference Name: Edwin A. Mathis Location/Address: Sheffield Farm Trail -28834 Proposed Facility: Residence Property Size: 7 Acres **NOT iiIs�fmprovS mlent/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 -I1 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 }l 00-S;C #People 2 #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: 15'� Garbage Disposal: ❑ Washing Machine: 53"� Basement w/Plumbing: 121""� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��=5 Type Water Supply W E(-� Design Wastewater Flow (GPD) 3� Site: New Repair ❑ System Specifications: Tank SizeI V7GAL. Pump Tank GAL. Trench Width Z6' Rock Depth L Linear Ft. ' Other: 2 ) 1�1STNu— u.1)_S 'To.C,. M0. Required Site Modifications/Conditions: ``-�STAt- 6-3C.&xrq01Z 14EjEP US off- 1jojn` IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 w 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.**** *-<E:r t,JEaTtoo Pb,k-t P FoL ZlxS"-�T N0Mj tac- -ta w tM i Environmental Health DCHD 05/99 (Revised) Signature: tA*A. Date: DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000789 Tax PIN/EH #: 4891-81-8453 Billed To: Edwin Allen Mathis Reference Name: Edwin A. Mathis Subdivision Info: Location/Address: Sheffield Farm Trail -28634 ems. Proposed Facility: Residence Property Size: 7 Acres ATC Number. 2681 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 WASTEW=NSIS V ID FOR A PERIOD OF FIVE ARS. Environmental Health Specialist's Signatur :Date: 0 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 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 y given period of time. . 1V Me Septic System Installed By: Health Specialist's Signature: Date: r, Aq)O %. V" DCHD 05199 (Revised) �, •, i APPUUA11UN FUN 811 E EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department y Env/ronmenfa/Nea/ibSect&rn P� P.O. Box 868/210 Hospital street SEP 2 7 1999 Mocksville, He 27026 (336)751-8760 ENVIRONMENTAL ECOUNTHY LTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PRO=SMW U=SS ALL THE REQUIRED n=RFATION 28 PROVIDED. Refer to the IN!'OR Wxm; BULLETIN for instructions. 1. sat to be sin" --0jW t%l f lk'Ai M .4-A; S Contact ""On 3&Ar» e. ort- mase e Ck-b1) rt"Uw &ssrese Q31� Sk@LPeld 43eyh5 aA L aoee sties• 49.d -S(eo l Cit?/stat./sxp 0cy_ in4_. iV C 216W aoeineee stieme 4 Ar LJa- Z. aur on Pettit/ATC it Dlereraet than Above -57 C. Wiling Address -'SAy a city/etate/asp ' n% e f ,fib (0 34 3. Application Sor: pF Site Evaluation D Improvement Permit/ATC ❑ Both 4. fretea to sereioe: /D-11cuse . D Mobile Home D Business ❑ Ind:istry ❑ Other s. It Residence: # People a # Bedrooms '3 F Bathrooms a (a"Iiishwuhar 0 aarbaee Disposal D'O"Unu waddi a iueaent/fluding D sasw tmo Pivadng a. I! Dusinese/L(h,atry/othari "city type # Ceaodes # ah"ere Ir I100D8Emm: Ik Seats # vrisale # Paople # finks # water Coolers Estimated Nater Usage lgellens per say) 7. Type of water supply: ❑ County/City [7�e11 e. Dc you anticipate additions or espassions of the facWty this system is intended to serve! If yes, what type! ❑ Community ❑ Yes wfo TTANI *** CLIENTS MUST COMPLETETHE REQMRED PROPERTY INFORMATION REQUESTED Either a PLAT or SITE PLAN MUST RITSUBMITTED by the tHeat with THIS APPLICATION. Property Dimensions: atAA' / C WRITE DIRECTIONS (from MeclavHle) to PROPERTY: r Tax Otitee PINI:# q9 9Z S-1 - 0 J 3 Property Address: Rosd Name 4� ^'`� 0 O'b D tom' ' h,15 i o Cily/Zip � sus y_ "tri Q�L. '• S tt e. F Fi 2 � C� //5 If In a Subdivision provide Information, as follows: �lA �✓� �1 Q b rte RLot 0 r: Name: _Shaft LleQ FArms 0A.4 old t3 6y1 (lir / Section: Block: Lot: Date Property Flagged: I D ^ JO -171? This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(:) Issued hereafter are subject to suspension or revocation, if the site plans or Intended ase change, or U the Information submitted in this application Is falsified or changed 1, afro, andemand that 1 am responsible for aU charges incamrdJtonr Mir applfcadom I, hereby, give consent to the Authorized Representative of the County Health Department to enter upon above described property hated in Davie County and owned by Yin(? C a 0 1 L a L (ti to conduct all testing procedures as necessary to determine the site taftabIDty. U Cf DATE9 I a 1I qC1 SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eristing and proposed property lines gad dimenslons, structures, setbacks, an de ioatioss). Site Revisit Charge D R 9 R U M Dah(als JAN 2 3 2001 D ENVIRONMENTAL HEALTH DAVIE COUNTY R,Exv{ coq SOS `T- U Revtud DCItD (07/99) EHS: Date: Account Na Invoice No. /66� I 0 r' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT' INFORMATION PROPERTY INFORMATION Account #: 990000789 Tax PIN/EH #: 4891-81-8453 Billed To Edwin Alleri Mathis Subdivision Info: $6MV4 FRRma Reference Name: Edwin A. Mathis - Location/Address: Sheffiedl Farm,Trail-28634 - Proposed Facility:. Residence Property Size: 7 Acres . Date Evaluated:', DlS�i Water Supply: - - - On -Site Well t/ Community Public Evaluation By: Auger Boring / Pit Cut _ .. FACTORS 1 2 g 4 5 .. 6 7 Landscape position slope %. HORIZON I DEPTH Texture group. Consistence Structure Mineralogy HORIZON 1I DEPTH Texture group Consistence 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. EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHERS) PRESENT: —f! 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 Moist _.. VFR - Very friableFR -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 Mineraloev 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 05/99 (Revised) :.DAME COUNTY HEALTH DEPARTMENT_ ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40.06 Mocksville, NC 27028 Phone #: (336)751-8760 October 21, 1999 Edwin Allen Mathis 234 Sheffield Fauns Trail Harmony, NC 28634 Re: Site Evaluation/Sheffield Farms Trail Tax Office PIN: #4891-81-8453 Dear Mr. Mathis: As requested, a representative from this office visited the aforementioned site on October 18, 1999. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist Enclosure(s) �� i� �! �� , al Ti ;. �� if � � �� + i ��