The URL can be used to link to this page

155 Irishman Place Lot 22DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account#: 989900057 Tax PIN/EH #: 5789-73-9732.22 Billed To: Randy Grubb Subdivision Info: Shamrock Acres Lot # 22 Reference Name: Location/Address: Irishman Place -27006 Proposed Facility Residence I Property Size: see map ATC Number: 3832 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Co Istruction 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 CONSTRUCTION IS VH) F R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: W) (JC 1 Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion hall 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: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: l - DAVIE COUNTY HEALTH DEPARTMENT Z _ /� p /V Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksbille, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900057 Tax PIN/EH M 5789-73-9732.22 Billed To: Randy Grubb Subdivision Info: Shamrock Acres Lot # 22 Reference Name: Location/Address: Irishman Place -27006 Proposed Facility Residence I Property Size: see map ATC Number: 3832 **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 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 f #People #Bedrooms #Baths:- 2 i Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPDY-2"�& Site: New -Er Repair ❑ � System Specifications: Tank Sizab GAL. Pump Tank GAL. Trench Width c%�i ��' Rock Depth Linear Fbfl Other: Required Site Modifications/Conditions: 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.**** i h� 4 i Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) U�t N CA) M 9732 cp� 20 \ o(P Mocksville, NC 27028 v (336) 751-8760 ENVIRONME7yfgl AvlECOII W ***IMPORTANT*** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for JTstructions. 1. Name to be Billed Contact Person ��r y F Mailing Address Q L Home Phone Stir7029' �y G/ee City/State/ZIP GG / t%2 0 - Business Phone ��- O Tv I 2. Name on Permit/ATC if Different than Above Mailing Address " - - Cityy//State/Zip 3. Application For: �❑/SSiixa Evaluation '.!'J itImprovement Permit/ATC 13 Both -4. System to Service: (� H0use ❑ Mobile Home ❑ Business ❑ Industry ❑ .Other 5. Type system requested: EJ Conventional ❑ conventional modified ❑ innovative - -e. If RResidence: # People- " .# Bedrooms # Bathrooms Z YD"ishwasher ❑oarbage Disposal L'JNaehing Machine- ❑Basement/Plumbing ❑Basement/No Plumbing - 7. If ,Business/Industry /other: verify type # People # Sinks -- -# Commodes - # Showers # Urinals # Nater Coolers- . IF FOODSERVICE:,.#Sea B" _ Estimated Water Usage (gallons per day) s. Type of water supply: County/City ❑ Well ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes L'diVo If yes, what type? I '**IMPORTANT"** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:"] G q m j��,��3,,�' WRITE DIRECTIONS (froMocksville) to PROPER Tax Office PIN: # / 0 /' 7 3 i 2 (� c(o Property Address: .Road Namelr:^ih0.ro r City/Zip( If in a Subdivision provide information, as follows: Name: 4&s"e.4-&C At S Section: Block: Lot: �� Date home corners flagged: 7 Z— 0 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 fro'a: 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 suits ' r DATE 7- Oe - n V SIGNATURE f 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 locations). Site Revisit Charge Date(s): Client Notification Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS � Ti aC.� clwe PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE-1y15'/e/ LOCATION OF SITE BGG Water Supply: On -Site Well Community Public L/ Evaluation By: Auger Boring Pit L/ Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure S 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: /;�(_ EVALUATED BY: _LAS G LONG-TERM REMARKS: _ DCHD(01-901 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 SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay ; Moist VFR- Vc.ry 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