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147 Irishman Place Lot 21-. "_.. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 All Jz15 in vn Aaye Account #: 990002706 Tax PIN/EH #: 5789-73-8682 Billed To: Jeff Hayes Subdivision Info: Shamrock Acres Lot # 21 Reference Name: Jeff Hayes Location/Address: Dublin Road -27006 ATC Number: 4306 As stated In 15A NCAC 18A.1969(5) accepted Systems may also be usle 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 WONS bT S V,#LID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: j 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 any given period of time. 1 i -Z Q Septic System Installed By: Environmental Health Specialist's Signature : 17' Date: DCHD 05/99 (Revised) I 1 �` DAVIE COUNTY HEALTH DEPARTMENT s Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990002706 Tax PIN/EH #: 5789-73-8682 Billed To: Jeff Hayes Subdivision Info: Shamrock Acres Lot # 21 Reference Name: Jeff Hayes Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: 3/4 acre **NOTES* Tht s 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 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 9DL)-Sr- #People #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: 1?5'� Garbage Disposal: ❑ Washing Machine: IJT�' Basement w/Plumbing: ❑ Basement/No Plumbing: 171� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size C).&( -RES Type Water SuppIvCt ,W Design Wastewater Flow (GPD) Z(OD Site: New 0' Repair ❑ „ �� System Specifications: Tank Size 1CM GAL. Pump Tank GAL. Trench Width Rock Depth P, Linear Ft. 22e Other��' EpIEI� 2�� 1�k71n,� Stis1 M . 7 bl gTA90T 2, Required Site Modifications/Conditions: IN Sa by- 6.3 czorro Q �' P L�w%S IMPROVEMENVOPERATION 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.**** n�� � �MdX•T�i-1 �-P>-1-I Ott ��c" Uzi-r�.•�, n a, mac. A -C t?ZtnO. tCCt Health Specialist's Signature luzih I j 4L - / Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street (( Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990002706 Tax PIN/EH #: 5789-73-8682 Billed To: Jeff Hayes Subdivision Info: Shamrock Acres Lot # 21 Reference Name: Jeff Hayes Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: 3/4 acre **NO7'EQx'13rIs lmprovement/Operation Permit DOES NOT authorize the construction of 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 3 #Baths 2— Dishwasher: Dishwasher: Cd Garbage Disposal:.❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial ppSpecci(fi`ccaattion: Facility Type /� #People #People/Shift 2#Seats Industrial Waste: ❑ Lot Size ®'o " _�"� Type Water Supply l.Ol� Design Wastewater Flow (GPD) -7: / Site: New Repair ❑ System Specifications: Tank Size bQQGAL. Pump Tank W( 'AL. Trench Width Rock Depth N p Linear Ft. 225 Other: Required Site Modifications/Conditions: I t'r'TALL- W C-49-�. Las- Id ©QF f". (-1A 1.J t �pw" o�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.**** NORG,�� t,nn x n cit + 24 PPa nmars 7P W"A0\14 .... rhirl.ld Environmental Health Speciaiist's Sign Nt.1 I Yy't Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENTa� Environmental Health Section Soil/Site Evaluation NAME / DATE EVALUATED S/�tC>i;���On_�(��po PROPERTY SIZE ADDRESS' � � PROPOSED FACIILTY LOCATION OF SITE i Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Ll__� Cut 2l ©('0 FACTORS 1 2 3 1 4 Landscape position L, .L- L Slope b HORIZON I DEPTH o - 1 0 Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group /V 17 Consistence Structure ii / CJZ Mineralogy .- /szyp HORIZON III DEPTH �© Texture group c: Consistence er S Structure Mineralogy HORIZON IV DEPTH Texture group Consistence t%r Structure Mineralogy 15ey SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: 4kll LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: � C.OrO kyr , Vs a y2 < 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 i. S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty ':lay 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-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 i Restrictive horizon - Thickness and inches from land surface Saprolile - 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 (01-901 200 15 23 � N W 6963 cn N W 2 0 21 -IB2 6754 0 00. 200 44 17 Cn PcC2 -6548 ss 777 9880 Qo �o 0 9732 sow 7Z 8682 5� 19 8542 �o X10 co 74� Zo 1 91 g3� N C) N il) 6141 1 0 \�V6 1331 0255 9� �9 268 27 t 1 n82O'PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnvironmentaiHeaithSection P.O. Box 846/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTALFALTH (336} 751-8760 DAVIECOUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI•ATION IS PROVIDED. Refer oto the INFORMATION BULLETIN for instructions. 1. Name to be Billed (/ / Contact Person 'Mailing Address Home Phone' Ci Ly/State/ZIP t / /�" Business Phone Z2 / /�/� 2. Name on Permit/ATC,if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation ;"--improvement Permit/ATC ❑ Both .4. System to service:MHouse ❑ Mobile Home [IBusiness 13Industry 11Other 5. Type uya L'em requested: fXIC onventional ❑ conventional modified 11innovative accepted 6. ���Inn_Residence: li//People # Bedrooms JIBathrooms 21 g11isbwasher - ❑Garbage Disposal *shing Machine ❑Basement/Plumbing - asement/Ito Plumbing 7.' / If Business/Industry /Other: verify type ,� N People'' N sinks _. .I Commodon A Showers - t) Urinals 1) Water Coolers IF 'FOODSERVICE: It Seats Estimated Water Usage (gallons per day) B.' Typo'ol:,water supply:County/City - ❑ Well ❑'Community 9. Do you anticipate additions or expansions of the facility this systcl i is intended to serve? ❑ Yes ❑ No If yes,1 flat type? "**&1,17` ANT***CLIENTSMUSTCOAfPLETE• 81iLOR'. Either a PLAT or SITE PLAN MUST BG S Property Dimensions: Tax Office PIN: S' Properly Address: Road Name If in a Name; See tion: Q Block: Lot: City/Zip provide information, as � 1�-d C/� //2 THE REQUIRED PROPERTY INFORMATION REQUESTED 7BAfITTBD by the client with THIS APPLICATION. - WRITE DIRECTIONS (from MoCksvine) to PROPERTY,.. S Date home corners Ragged: 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, widerstand that I mn responsiblejor all charges ianD•red from Uiis application. 'I, hereby, give consent to the Authorized Representative of the Davie County I-Iealth 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 - `-r/ SIGNATURE, TIIIS AREA T✓[AY BE USED FOR DRAWING YOUR SITE PLAN (Il cd I of the toll ng: Existing and proposed nronerty lines and dimensions, structures, setbacks, and septic locations). , Sign givot Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. 706 Invoice No. sad