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275 Dublin Road Lot 14DAVIE COUNTY HEALTH DEPARTMENT �oL Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 , Account #: 990002651 Tax PIN/EH #:5789-73-4909 Billed To: Richard Wendt Subdivision Info: Shamrock Acres Lot # 14 Reference Name: Location/Address: Dublin Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3513 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 Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTE N IS V LID FOR A PERIO�D7OF FIVE YEARS. Environmental Health Specialist's Signator ate: / b3 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. ' ICO e 4'Y�fiF} 119 f TDVJK 19-21 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) i L tQ L,31LL )l0, DAVIE COUNTY HEALTH DEPARTMENT /Z7 nU Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 U IMPROVEMENT/OPERATION PERMIT Account #: 990002651 Tax PIN/EH M 5789-73-4909 Billed To: Richard Wendt Subdivision Info: Shamrock Acres Lot # 14 Reference Name: Location/Address: Dublin Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3513 **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 Noy #People a #Bedrooms L #Baths 4_ Dishwasher: L?( Garbage Disposal: 0 Washing Machine: 111" Basement w/Plumbing: a Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People _ #People/Shift #Seats Industrial Waste: 11 Lot SizeDg M—PeS Type Water Supply Design Wastewater Flow (GPD) 40 Site: New d Repair 171 System Specifications: Tank SizeVOOO GAL. Pump Tank GAL. Trench Width &-, Rock DepthI Z;' Linear Ft. q00' Other: .5 i1s�)6L-110 J �X-WS Required Site Modifications/Conditions: �AS IMPROVEMENT/OPERATION PERMIT LA FINISHED GRADE. ****NOT] E: Contact a system between 8:30 a.m. to 9:30 .m. or 0p.f ,1,,1►s�� ��sl� w s Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 0 cUT� VED EFFLU NT FIL' r(s3tative oftheD •ounty Health p1:0.m.o e day of installation. I pyJE Feo Jr. E 0 p Cg RISER(S) IF 6 " BELOW :tment for final inspection of this )ne # is (336)751-8760.**** YrF0F,) a.Ses to AL2rCej 1&Tty;-� -SgST�-r-- M z;TS QCDtx-Tto-1 R Date: 5 _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,. Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002651 Tax PIN/EH #: 5789-73-4909 _. Billed To: Richard Wendt Subdivision Info: 111. Shamrock Acres; Lot # 14 Reference Name:. Location/Address: Dublin Road -27028 Proposed Facility:, Residence. Property Size: see map: Date Evaluated: ' Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS, 1 2 3 4 5 „ 6. 7 Landscape position Slo a %a HORIZON I DEPTH Texture group_.. III DEPTH Consister Structure Mineralo Texture group' Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE I SAPROLITE ®®Illllllli SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE. OTHER(S) PRESENT; 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 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 DCHD 05/99 (Revised) t 200 60 �A t w 4909 = Zoo n- LO 61 • .< let.. _ s N N 78 73-3� 93. Tt Ct — So G M. O — HcLO Te. 389 �'Ln - — Co — Str o — Mii SO. 1 — RE;— aa�C� SAl — CL — LOI SIT! L0 — LON REM O LO, 3688 2nn NP- Non plastic . SP - Slightly Plastic.; stickyVS -Very Sticky Structure P -Plastic VP - Very plastic t APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A D Davie County Health Department Environlnelltal Heaitii Section ` MAH ,I D P.O.. Box 848/210 Hospital.Street... zQ03, Mocksville; NC 27028 - (336)751-8760 6V104!? H .. f0UNJ�� IN .***IMPORTANT*** THIS -APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRE INFORMATION IS PRO IDED." Refer to the INFORMATION BULLETIN for instructionss.. 1.•N=s to be Billed �b Contact Person �1 CRtL, "' d �+/ ,tI � fi/ Mailing Address ���I/ c1 �Jd��l�� /kl' - Some Phone -T36-7 1 T_" JTZ ! d7-; (� Z city/State%ZIP 4�i 1311ilhl ` /i/C .:7d23 Business Phone %(0r— d/6 f 2. Name on Permit/ATC if, Different than Above A101- .CGSt e- 7 Nailing Address - City/State/Zip 3. Application For: Site Evaluation - ❑ Improvements Permit/ATC 0 -Both 4. system to service: GYHouse ❑ cmobile Home : ❑ Business ❑ Industry ❑ Other tL 5. If Residence: # People U " -# Bedrooms �_.- # Bathrooms QADZshwasher '. ❑ Garbage Disposal O Washing Machine `0'Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other:Specify type, - # People # Sinks. . # Commodes - # Showers. - -# Urinals # Water Coolers IF. FOODSERVICE: # Seats Estimated',Water Usage (gallons per day) 7:- Type of Water supply: U ounty/City ❑ Well - ❑ Community s.' Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A_No If yes, what type? - ***IMPORTANT*** CLIENTS MUST COMPLETCTIIE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMi7TIED by the client with THIS APPLICATION.. -" Property Dimensions: ZnU Uo �,-�7�'� 1� W RITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #s'/ O % ` / 3 0 Property Address: Road Name / C!ty/zip oy,� ��°i/le ��coo Sr%d%Z�o .li/I (dyrew ifin a Subdivision provide information, as follows: ``�! /J ! /✓v/ytNi deo - Name: . 111dF0-te'l��/6': oft MMaY�, gi' Section: Block: Lot: Date Property Flagged: 3 G* 03 1% ✓� 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, hnderstand that I ant responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the DW o n Health Department . to enter upon above described property located in Davie County and owned by��r� to conduct all testing procedures as necessary to determine the site suitability. DATE 3 `�fI -P3 ` " 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 locations). ' H`/Px l: �tVsf /1JP�lI� ;flv�w , l,ri�r'x Lo a } Site Revisit Charge %�RrlltO� D� te(s) H!✓(��;-- __ Client Notification Date: LO 4909 13 CD 3893 V) `i m DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #:'990001551 Tax PIN /EH #: 5789-73-3893:14 - Billed To: Stacy Lavery Subdivision Info: Shamrock Acres Lot # 14 Reference Name: ` Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: i 31 L)l : Water SuOn-Sit 1 : '...' r� pp y e Well Community' Public Evaluation By Auger Boring Pit Cut FACTORS 1 2. 3 4 5 6. 71 Landscape position Slope % HORIZON I DEPTH Texture groupC(L W Consistence S Structure _.. Mineralogy; 1 HORIZON II DEPTH Texture group 4r oc*Pv Consistence - Structure SB Mineralogy HORIZON III DEPTH F - Texture group 4ir-+Srt Consistence. NS5 Structure Mineralogy1 1 HORIZON W DEPTH O Texture group'"::S Consistence Structure> ... - Mineralogy SOIL WETNESS, RESTRICTIVE HORIZON SAPROLITE .CLASSIFICATION UXQ S LONG-TERM ACCEPTANCE RATE C. O SITE CLASSIFICATION:_ 5 ' EVALUATION BY: " Jamil � LONG-TERM ACCEPTANCE RATE:OTHER(S) PRESENT: REMARKS:... LEGEND _Landscape Position R - Ridge S - Shoulder L - Linear slope y FS - Foot slope N - Nose slope CC -, Concave slope CV = Convex slope KT - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand. SL - Sandy loam L - Loam SI - Silt SILL - Silty clay -loam -SIL -'Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay - SIC - Silty clay . C7 ay CONSISTENCE VFR - Very f0tible FR -Friable FI - Firm VFI - Very firm EFI - Extremely firm"' Wet .. SS ... NS - Non -sticky - Slightly sticky S - Sticky VS = Very Sticky NP -'Non plastic r. 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 r 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) LIAR - Long -tern acceptance rate - gal/day/ft2 DCHD 05/99 (Revised)