150 Irishman Place Lot 25DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:
990000736
Tax PIN/EH #:
5789-83-2494.24
Billed To:
6btehIlaHei�'D.GLI"v#zry bLC-LJA►
Subdivision Info:
Shamrock AcresH970/A Lot
Reference Name:
Btdeh 1 Isker Qlvn iwu sf
Location/Address:
Irishman Place -27006
Proposed Facility: Residence
ATC Number: 2153
Property Size: See Map
150 J.Ri h nAd !Plage-
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 WASTEWATER CONSTT�RUCCTIION IS VALID FOR A PERIOD OFF FIVE YEARS.
Environmental Health Specialist's Signature: cI - fiY ? "Date: 2102 /4e
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.
Septic System Installed By: cJ
Environmental Health Specialist's Signature:. ( Date: 2 ✓
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT 156:[E1, X[RAee
Account #: 990000736 Tax PIN/EH #: 5789-83-2494.26r
Billed To: BtdehII94eFsZ•Gt&L-X 00r b"'ld" Subdivision Info: Shamrock Acres H9701A Lot #&4ww4-2-C
Reference Name: Matter JTl i-nY e rows Location/Address: Irishman Place -27006
Proposed Facility: Residence Property Size: See Map
ATC Number: 2153
**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 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_
Dishwasher: Garbage Disposal: ❑
Commercial Specification: Facility Type
#People S� #Bedrooms \,? #Baths _
Washing Machine: 21 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Cy'0f Site: New Repair ❑
l'L i
System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width,�f� Rock Depth Linear Ft d
Other:
Reauired Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 K 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 1:00P.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: � Date: �2�
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVAWA110N/IMPROVEMENT pERMI1 & ATC
Davie County Health Department
Eavlronmenta/Healtli SeW017
P.O. Sox 848/210 Hospital Street
Mooksville, HC 27028
(336)781-8760
***ZHPORTA2M*** THIS APPLICATION CAWlfOT BE PMMSEW UNLESS ALL "M REQUIRED
INFORMATION IS PROVIDED, 'Refer to the ZMMFMIITICH BUWATIH for instructions.
I- Mass to be Billed Ge
JLC U CK(FtOS i1CftC151tiLOa?S
contact. Peejz�ftlL� :son Sm , s
-7
Mailing Asides.s n0/ c-LmoR-G RD, Mase phone
city/state/zlp .. r OC.I<S �I i \lG NG X702B Business Phone
2. Name On Persit/AIC 1f Different than above -
Mailing Address City/state/sip
3• Application For: V Site Evaluation VImprovement Permit/ATC ❑ Both
e• system to service: WHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
a. E£/ Residence:
6 Dishwasher
I People # Bedrooms 3
0 garbage Disposal gashing Machine 1r Easement/Plumbing
6. If Eusiness/Industry/other: specify type
a Commodes
a showers
i urinals
i Bathrooms 2y
0 Basement/wo Plumbing
• People t sinks
t: water Coolers
IP FOODSERVICE.- ff Seats Estimated Mater Usage (gallons per day)
7. Type of water supply: @County/City ❑ Well ❑ community
B. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes II NO
If yes, what type!
***IMPDRTANT*** CUENTSAfUSTCOAIPLETEWE NEQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 00'X 379'K /V
Tax Office PIN: H
Property Address: Road Name SRl5ffw*J PjArg
City/Zip_ AJIVA J6c jUC 27006
If in a Subdivision provide information, as follows:
Name: S4AxM tout- !tic L,, -s
Section: Block: Lot: Z5
WRITE DIRECTIONS (from Macknille) to PROPERTY:
-'o 0C Rol Sotil't,. 'tom
iPepp (zs CK R. -k 0 1-44 f.17R "cc- ) LeFr-
661 {�eopieS GIG -t0 Sh*MPocic L, --Fr
o4 Duct^rJ P-1. kkc7wr o4
Zeislh.-,n,J PlftcE /LMT 2,5 on/ &,94:rCmfuuz '
Date Property Flagged:
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• 1, also, snderatand that I am "VonAble for all charges incurred jrom
..this application. 1, hereby give consent to the Authoriz4,d Representative of the Davie County ITealtb Department
to enter upon above described property located lit Davie County and owned by _ �a RN Tin/% P_A.at s
to conduct all testing procedures as necessary to determine the site suits li
DATE S- -3O -0' SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locatlons).
• � ��� [ � AIDvotccount Na. _��71 v� 3�C
Revised DCHD (07!98) n ��`7� ee No. ,7l B
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC U D
Davie County Health Department
Envlronmenfof Health Section E -AUG 2 3 1999
P.O. Box 848/230 Hospital street
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
(336) 751-8760 DAME
MINTY
IwwwIMpCRTANTstt THIS APPLICATION CANNOT BE pRO=5MW UNLESS ALL TSS RSQUIRSD
IHIORMATIOH I8 nOVIDSD. Refer to the INI'ORMATIOH BUM&TIN for instructions.
I- flu* to be Billed
Railing address
Cite/state/SIP
a. Kase on Pereit/AM it Different than AboweA14
Nailing Address S/.l M CV
Contaot *arson
am* *bona GI Yd ` Io l u l
Suainese Phone 3� 9 - 3 Z S�
3. Application Fort D Site !valuation B�rovement permit/ATC D Both
6. Systen to s.s.ioe3 la'Bonse D Mobile Home O Business 0 Industry 0 Other
5. If 14sidance: 6 people0.L a Bedrooms _ 6 Bathrooms Zr Z
0.,lUshwasher 'O'earbsee Disposal O(Waab a meobine 0 Beseaent/exuabine KBaseynt/ao Plimbine
6. Xt Business/xndustry/Others Spenify type # People a Sinks
Coaodee I a showare a Urinals
# lhbs Coolers
IF FOODBzRVICz: # seats Sstimated Water Usage taallene per day)
7. Type of water supply: County/City 0 Well 0 Community
e. Do you anticipate additions or expansions of the facWty this system to Intended to serve? 0 Yes 00
if yes, ghat type?
e"e1MP0RTAN7"e1 CLIENTS bfUBTCOMPLEPETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESIIBMITIED by the efient with TIAs APPLICATION.
Property Dimensions: ''h0_7Z 5
4.jra
Tax Office PIN: N ILTq - L
Property Addreaat RoadNime J 8 Z� qac
CItyalp. V <.Q
WRITE DIRECTIONS (from Mockevllle) to PROPERTY:
A�
If in a Sobdivhlon provide information, as follows:
Name: 4n. 0,04 v, 001, e,re s
Section: 9q7D Blockt_ Lot: A qfS
SIL QQ7JR
Date Property Ragged:
Tbb b to certify that the Information provided h arrest to the beat of my knowledge, I understand that any permit()
Issued hereafter are subject to Inspenalun or rt 11
if the site plans or Intended we change, or If the Information
submitted ID this application h falsified or chasged. 1, also, undnamnd #Yat 1 am responstale for all charges incurredJ6om
this applIcadom 1, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described properly located In Davie County and owned by
to conduct all testing procedures as necessary to determine the site seitab.
DATE 9 `Z � — IqurSIGNATURE
THIS AREA MAY BE USED FOR DRAVMG YOUR SITE PLAN (Include all of the following: Existing and proposed
property Hues and dimensions, structures, setbacks, and septic locations).
D
DCHD (07/99)
N
�Dp
1
Site Revbit Charge
Ghent Notifladon Date:
EAS:
Account No. Jj(�_
Invoice No. 1r
SS 41
19
•i zv
---LMia-----------------
L(
M.,
8
EX
17
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation.
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE/Ae
LOCATION OF SITE
Water Supply: On -Site Well Community - Public LI--,
Evaluation By: Auger Boring Pit Gam- Cut
FACTORS
1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
d
Texture groupG
Consistence
Structure
h Jl
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
c
SITE CLASSIFICATION: _a
LONG-TERM ACCEPTANCE RATE:_
REMARKS:
DCHD (01-901
EVALUATED BY:
OTHER(S) PRESENT:
LEGEND
Landscape Position 1. -
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave slope CV -Convex slopeT-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 SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-Very friable FR -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
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