310 Brangus Way Lot 31DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #:
5832-18-2692.31 SC
Subdivision Info:
Whip -c will Lot # 31
Location/Address:
Brangus Way -27028
Property Size:
5.68 acres
**NO�TQ*, 194R,rpro�Pi Rnt/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 CONTRACTQR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms #Baths
Dishwasher:: Garbage Disposal: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seaatts aa Industrial Waste: ❑
Lot Size Type Water Supply_ Design Wastewater Flow (GPD) Site: New ;217 Repair ❑
System Specifications: Tank Size L6b GAL. Pump Tank GAL. Trench Widd Rock Depth//f Linear Ft.4<5'v
Other:
Required Site Modifications/Conditions:
e_
r
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.****
Environmental Health Specialist's Signature: Date: Z /
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 #: 989900093
Billed To: Shelton Construction Services
Reference Name:
Proposed Facility Residence
Tax PIN/EH #: 5832-18-2692.31 SC
Subdivision Info: Whip-o_will Lot # 31
Location/Address: Brangus Way -27028
Property Size: 5.68 acres
ATC Number: 3920
**NOTE** This Improvement/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 6 ( f.
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTEM
E. YOUR Al
WASTEWATER SYSTEM CONTRA( OR MUST SEE THIS PERMIT BEResidential Specification: Building Type #People #Bedroaths _
Dishwasher: 42TI" Garbage Disposal: g Washing Machine: Basement w/Plumbingeo-*'� Basement/No Plumbing: ❑
Commercial Specification: Facility Type
Lot Size
Type Water Supply
#People #People/Shift
Design Wastewater Flow (GPD)
#Seats Industrial Waste: ❑
Site: Neve, Repair ❑
System Specifications: Tank Size.4G4 GAL. Pump Tank / GAL. Trench Width Riock Depth Linear Linear Ft.
Other: eL �'n ! ��I�.��/�Xi Asa f��{l'I `!✓� f �.� �
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. oRt
a—daQyof i?almla�ephone # is (336)751-8760.
,,j�G✓., ****
J -5U"
Environmental Health c
DCHD 05/99 (Revised)
X- � �'
V
Date: // r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name:
ATC Number: 3920
Tax PIN/EH #: 5832-18-2692.31 SC
Subdivision Info: Whip-o_will Lot # 31
Location/Address: Brangus Way -27028
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 CONSTRUCTION IS VALID FOR A PERIOD OF FIIVE YEARS.
Environmental Health Specialist's Signature: Ad Date: `f` e't,2
Y
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:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Dater 1�
Y.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
Environmental Heaitb Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE R'E�&"7
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruction{//y
1. Name to be Billed s- ✓ '_ ��L , Contact Person
Mailing Address �� S-��� f� �J Home Phone
City/State/ZIP _ uC� ✓ L C/l e— Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
4. System to Service: ❑ House ❑ Mobile Home
City/State/Zip
Improvement Permit/ATC
❑ Business ❑ Industry
❑ Other
❑ Both
5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
6. if Residence: # People # Bedrooms �U/tDr q
����'' �� #Bathrooms
--0Dishwasher Oage Disposals ing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify typ
# Commodes
# Showers
# Urinals
# People
# Sinks
# Water Coolers
IF FOODSERVICE: #��Seats Estimated Water Usage (gallons per day)
8. Type of water supply: i- County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***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: WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # (� ^�� ! Z3 (S A)
Property Address: Road Name" �.�0,ti ,,,,ag /
Q I d n r •,,
City/Zip
If in a Subdivision provide information, as follows:
Name: _Ay4,; r? -/) //
Section: Block: Lot: _:f
Date home corners flagged: D a
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 from
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 suitability.
DATE / 0 � SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dipKnsions, structures, setbacks, and septic locations).
�OV/1
b �
d, �..
Sign given
Revised DCHD (05/03
Date(s):
Account No.
Invoice No. /
�UTHc.RIZATION NO: 1938 DAVIE CQUNTY HEALTH DEPARTMENT
rEnvironmental Health Section PROPERTY INFORMATION
Permittee': P.O. Box 848 r
Name: Opp r�� SectiMocksville, NC 27028 Subdivision Name:
�,%L 1 /i 7L.) C_,t 46 Phone # 336-751-8760 ---ry•
Directions to property: on: Lot: --�
AUTHORIZATION FOR gZ
��+-7 WASTEWATER _ t> _ r � s7
SYSTEM CONSTRUCTION Tax Office PIN:#.
ITL Cn1 E �= Road Name: n�jr W)iy: x_ 70,—Z,
'**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G,S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
_� ��� IS VALID FOR A PERIOD OF FIVE YEARS.
EWVIR0f NAL HEALTH SPE -IALIST DATE ISS E
14,,. ' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�� Permi(lge' •� '`y�
-
tiame:.):;" Subdivision Name:
Directions to property: i.'' ' tN1 Section: Lot: --
'" ]MPROVEMENT
PERMIT Tax Office PIN:#.5,)f..� - I
Road Name:,' 4 -Ti p. .7
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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 I 1 of G.S. Chapter 130AI Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
tSYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRON?4ENTAL HEALTH SPECIALIST/ DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS �= # OCCUPANTS_ GARBAGE DISPOSA es No
COMMERCIAL SPECIFICATION: FACILITY TYPPE,,. '-1y (J # PEOPLE # PEOPLE/SHIFT # SEATS IINNDUSTRIAL WASTE: Yes or No
LOT SIZE `45' "' " TYPE WATER SUPPLY W + DESIGN WASTEWATER FLOW (GPD) NEW SITE ts" REPAIR SITE
1� #' Q
SYSTEM SPECIFICATIONS: TANK SIZE �-GAL. PUMP TANK ZQ . 3AL. TRENCH WIDTH , io ROCK DEPTH LINE -AR FT.
OTHER VI�'�rG1�1}j]or*1 I� L�7 jI�LL'Kt/J�► VQLI � QJ U1�U� L.rT'L t �/'�LT[�
REQUIRED SITE MODIFICATIONS/CONDITIONS: ALk, C0n IL)L)P i_`� ,�r(4{ {-�t�:. Vt:-`L-'` rD' cFF P_o(.L/a�
PERMIT LAYOUT
o
JU
• f y-
cO' .j� ,
o�
1(,0'
ICU'
/ 2''
tet`*—
*"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
*"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 03/96 (Revised)
0
DAME UNTYHEALTH DEPARTMENT
IMPRO 1 MENT AND OPERATION PERMITS PROPERTY INFORMATION
TamYY'Subdivision Name: I�+�r►1�'txa.. .
{ o
Duechons to piaortY''C ` Section: Lot:
�+»•+. IMPROVE11E1VT
�►* [, "!F`�i PERMIT Tax Office PIN
Road Name:
**NOTE** TbisImprovement Permit DOES NOT authorize the construction or installation of a septic.tank system or any wastewater system. An •
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be.obtained froi'di�Depagtinenf prior t&the .
r on/installation of a.system or the issuance of a building permit
(In compliance With Article 11 of C S c hapter i 30Ar Wastqwatea'Systems, Section .1900 Sewage Treatment and Disposal Systems)
+ ` ***NOTICE*** THIS PERMIT. IS SUBJECT TO REVOCATION IF SITE
,,;, PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER.
y r
"� t`�EI� VIRpNA TAL HEALTH SP CIALIST DATE I$ UE 'STEM CONTRACTOR MUST SEE THIS PERIVQT TiEI'ORE,
' INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION BUILDING TYPE BEDROOMS 44 #BATHS + #OCCUPANTS _ GARBAGE DISPOSAI,IYes of No
r
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT.SIZE' TYPE WATER SUPPLY C�t.�V I T DESIGN WASTEWATER FLOW (GPD)Q_ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: ' TANK SIZE IAL. PUMP TANK &C—�–IAL. TRENCH WIDTH, –1-Ro ' ROCK DEPTH JZ LINEAR Fr.
OTHER —SVi% A h)no/J r = _ c.�-Qu�J t t, , 4412vvO 09:7L
REQUIRED SITE MODIFICATIONS/CONDITIONS:
LAYOUT
/op
100'X fir' v 12V
'Co IrJc�lirS
xr.
V OF
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. '
u�nu w/yo �xevueal .
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
.
Davie County Health Deparbnent Q
Environmental Health SeWon
8 1999
P.O. Box 8413/210 Hospital Street 2
Mockaville, NC 27028
(336) 751-8760 ENVIRONMENTAL HFAITH
*'*IMPORTANT*** THIS APPLICATION CAMor BE PROCESSED UNLESS ALL THE REQUIRED I
INFORMATIw':N IS PROVIDED``. ((Refer to the INFORMATION BULLETIN for instructions. /)
Name to be Billed OG�C1 40\. C -s v`ICc�a�i Contact Person / OQD ott // L�uGG�[�%ee
Mailing Address ��Lp 1�\ �-r5 h V� t C� 8ome phone OAT— — 6 Q o(o
City/state/ZIp Ni" andOCO Business Phone rl �� 0L]11
Z. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: U Site Evaluation f'Improvement Permit/ATC 0 Both
4. System to service: id House 0 Mobile Home 0 Business ❑ Industry 0 Other
a. If Residence: # People Jr-% 6 # Bedrooms ._ # Bathrooms 3 YZ — �Z
6/Dishwasher D/Garbage Disposal U Nashing Machine a/Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: Specify type # people # Sinks
# Ccumodes # Showers # urinals # Nater Coolers
IF VWDSERVICE: 11 Seats Estimated hater Usage (gallons per day)
7. Typ.�, of, water supply: R County/C3.ty ❑ Well 0 Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes "o
If yes, what 13"
***IMP. R,rANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
111111.01 7. Either a PLAT or SITE PLAN MUST BESURMRITTED by the client with THIS APPLICATION.
'Oa 0 rty Dimer ions. 00 0I�� 1C 1 1 K � U3�"
a WRITE DIRECTIONS (from Mochsville) to PROPERTY:
Tax Office PIN: # S� 3'� — a(-Oq 2 (16-06T) 0 oaoa-
U,
Property Address: Road Name g('c«gUS 3l kc'(\ �(�71 l,.l`n i D — �— l� •
City/Zip `0noiE S�T1a�k- 6r,,\ bcatlr�US l y
If in a Subdivision provide information, as follows:
Name: W\,�-\D- o'�11�•
., IA 16 Pow A- 31 / q
Section: Block: Lot: 0: Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(O
issued hereafter um nwbject to suspension or revocation, if the site plans or Intended use change, or if the information
submitted lu tisaz 1pplication Is falsified or changed. I, also, understand that I ani rtVonsihlefor all charges incurred from,
this applicador.. I, hereoy;, give consent to the Authorized Representative of the Davie County Health Department
to cuter upon above described property located in Davie County and owned by C lac\ lA . born
to conduct all testing procedures as necessary to determine the site suitability.
DATE & J 7 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).
Revised DCHD (07/98)
Account No.
Invoice No. 'T
a�.,a {1.;, ...r,...::a Ic., - DAVIE county dr,.1 J Jppl.r.atav tfwt r
u .d tr.v bu..r�JJntl1 raw a...vCydJ aro uudny InU,Wlud a5 dfJ.`n IIJO11fdUrn:JGOn IJUI„7,n
GRAQY t,. TUTTERQW _.. ..aReplstefedt and
adlnowltldptld thtl
I I IE Ck H111 ICA It PASSE 1;
,a J,•p )�vi r da t•vca laa..v4 try trc [),Is -ll of 11•;;t,�.Jys p.dsuart to
(l.,
PJytl It JI U'•Y fJL4 Uf pf O(JSIOn df
.SI,Nurl.r pUl SOr1:11iy appuaftlJ bulold mf. this day and
—3'
NN
1..I.If. UI .IiU � uI-ur,.l ;):.1��•:� a '. ••1:.! l:l N,NtI• L.1f I,IIf•..1
vl.
I
30.000 11A I,,s pIJI Wds yr L•pJ•uJ NI dcc.,:.Ix-cu vv,tn G S
p
u•tic.,I-XI of Ind foregoing Instrument Warless my hand and official Stam O!
w t,u correct
l.l.••..IJ:.. •711
:% ,1•I ..1 J1.�1'..I.:.t i'i.l
•va111'y u,:U.i'JI S.y :J llJltl lvj;.1I'dwl111.1114-f Jf.A Sl•JI INS SI
bl:dl thl� 99 day Of Al�)?T 10 96
i;•.,b cat el
QECtAIM
A 0 10 96
1 ,r•bJtd Iva c yra Ilk
D3
Notary Public
HENRY L SHORE Meg 5161*, e,
Sl.rveyJf
Mi e•pues
oy
' DEPUTY
Upil t:i(dt GI PI r.tUlitl•;
1 S.:.d i,r Sid,np l
Hcy,straocn kL•:nbur '
sedl or Stam commission
�
r
'50'31 • E ��.
c^
LOT #30
AREA = 5.044 ACRES
S 82
227.97
a
33, 03' E
S 0619 �7 23566p6. V
r S
-76'
• E
S 06g0 '0
It 1/n1 ( k � AICt4T
WHIP-0_WILL
A LAND & CATTLE CO
172 pg. 122
N 08.09'29•
40.68 E
.P pig.
Cv`r1. y -_9 -0
p 9�ydy`rr. .�0
10 oy 66`s °N' 4-
LOT #29 °°
AREA = 5.006 AG•RES� u
•v
2
N �9521y6 a39. V
•1
/N ga52.51
. 15aV
'V t, 325 091
Iron found N Ol*32'15' E
70.97
S 22'26'51' E ,z
85.00 i NNI
a
1 J
,.JAI
S 22'28'51' E
228.95 1
S 35.44'37' E
65.04
S 81.50' 31 • E --a
940.67
LOT #31
= 5.681 ACRES
�,N 22.28'51' u
80.50
1
LOT #32
AREA — 5.460 ACRES
—
0
ty"IP—O—WILL
A LAND 3c CATTLE
N D.B. 174 P9 4340•
N
(PLAT BK. 6 Pg. 68
.� N•
69 r LOT #2 LOT #28
PLAT BK. 6 Pg. 69 Q AREA = 5.771 ACRES d'
d �s
�,`�-' s� LOT #33
O1 Na. AC S
LOT #34
AREA = 5.193 ACRES
1
w
fG
Nn
6
O
yoo �Du?
—3'
NN
o r6t
(P
Y p
c^
LOT #30
AREA = 5.044 ACRES
S 82
227.97
a
33, 03' E
S 0619 �7 23566p6. V
r S
-76'
• E
S 06g0 '0
It 1/n1 ( k � AICt4T
WHIP-0_WILL
A LAND & CATTLE CO
172 pg. 122
N 08.09'29•
40.68 E
.P pig.
Cv`r1. y -_9 -0
p 9�ydy`rr. .�0
10 oy 66`s °N' 4-
LOT #29 °°
AREA = 5.006 AG•RES� u
•v
2
N �9521y6 a39. V
•1
/N ga52.51
. 15aV
'V t, 325 091
Iron found N Ol*32'15' E
70.97
S 22'26'51' E ,z
85.00 i NNI
a
1 J
,.JAI
S 22'28'51' E
228.95 1
S 35.44'37' E
65.04
S 81.50' 31 • E --a
940.67
LOT #31
= 5.681 ACRES
�,N 22.28'51' u
80.50
1
LOT #32
AREA — 5.460 ACRES
—
0
ty"IP—O—WILL
A LAND 3c CATTLE
N D.B. 174 P9 4340•
N
(PLAT BK. 6 Pg. 68
.� N•
69 r LOT #2 LOT #28
PLAT BK. 6 Pg. 69 Q AREA = 5.771 ACRES d'
d �s
�,`�-' s� LOT #33
O1 Na. AC S
LOT #34
AREA = 5.193 ACRES
1
w
fG
Nn
6
CU �j
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI ATC `� r•
Davie County Health Department
Environmenaal Health Section
C P. O. Box 848 JAN —9
j Mocksville, NC 27028
y t� (704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
% ALL THE REQUIRED INFO TION IS PROVIDED.
/
1. Name to be Billed `�/t i �` l 7T'Contact Person
Mailing Address ' Home Phone
City/State/Zip " % � 2102L') Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: Site Evaluation
4. System to Serve: House ❑ Mobile Home
City/State/Zip
❑ Improvement Permit & ATC
❑ Business ❑ Industry
5. If Residence: #People i�kA--t
Bedrqoms
rk "
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing
6. If Business/Other:ecify ty e # People _
' ,e-
# Commodes # Showers # Urinals
❑ Both
❑ Other
# Bathrooms
❑ Basement/N'c: mbing
# Sinks
# Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
8. Do you anticipateradditions or expansions of the facility this system is intended to s rve? ElYes No
l
If yes, what type?
PROPERTY INFORMATI N REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �f' �'-2s E0 WRITE DIRECTIONS (from
1 Mocksville) TO PROPERTY.
1 " "�
Tax Office PIN: # t- -00 - 00 ._
Property Address: Road Name 1 R
_ ;
City/Zip Com_ �� 1 l =3, - i e - l
If in Subdivision provide information, as follows: 1 ��
Name: "' �,, 1
CAA Rr S7(
Section: i-- c?SS jZc > Lot #:
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, understand that I am responsible for all charges incurred from 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 1 - —too conduct all testing procedures
I X7
as necessary to determi a the site suitability. /) +
DATE SIGNATURE (/
Revised DCHD (06-96)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME �r '
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit—
SECTION_/— LOT
DATE EVALUATED a, / /V7
PROPERTY SIZE f�9e
ROAD NAME� !tr Zj/�
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Z_ .L
Slope %
gL--
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
/c C
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:
e—/4 !�/' /v_ -
EVALUATION BY: A,
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS: 611e/`
LEGEND
Landscaue 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 (01-90)
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Account #: 989900093
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Billed To: Shelton Construction Services
Reference Name: Con Shelton
Proposed Facility: Residence
Tax PIN/EH #: 5832-18-2692.315c
Subdivision Info: Whip-O-jWill Lot # 31
Location/Address: Brangus Way -27028
Property Size:
**NOTE* TTiis 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 #People _ #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: Z--"Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
L ❑
Lot Size Type Water Supply %% 6 Design Wastewater Flow (GPD) � Site: New�Repair ❑
System Specifications: Tank Size /0OCGAL. Pump Tank GAL. Trench Width 7,/ Rock Depth�%� Linear Ft.�dV
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.****
W
0
ye
Environmental Health Specialist's Signature: Ww!/ Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name: Con Shelton
ATC Number: 4409
Tax PIN/EH #: 5832-18-2692.315c
Subdivision Info: Whip -O jWill Lot#31
Location/Address: Brangus Way -27028
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 CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
/11121XEnvironmental Health Specialist's Signature: �2'`Z� Date: :S
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 I 1 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: Aq-)"
Environmental Health Specialist's Signature: /C r' � Date:
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
1 IAV
-2046
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax 336)751-8786
;ment Permit Authorization To Construct(ATC) ❑ Both
* ''*1L�7" ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed _ _ A A.. _ Contact Person
Billing Address 14 ,, G •A t,y Home Phone `79 6 - 2 o
City/State/ZIP /^') k ; _ ; j 1 7 c _ -1-?-2 y Business Phone 3 y s7" -
Name on Permit/ATC if Different than Above
Address
PROPERTY INFORMATION
NOTE: A surveyplat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Street Address i A :2 �"/ 1 �1 City -2!!! ,
„ - k- , i ) c Tax PIN#
Subdivision Name t,,)( --, _ u - w . 1 Section/Lot# I. Lot Size S', -7 j
Directions To Site
Date House/Facility Corners Flagged
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site? Dyes ONO�-
Does the site contain jurisdictional wetlands? Dyes B1lqb—
Are there any easements or right-of-ways on the site? Dyes 3N-6—
Is the site subject to approval by another public agency? Dyes EN -o-
Will wastewater other than domestic sewage be generated? Dyes ❑iia—
IF RESIDENCE FILL OUT THE BOX BELOW
# People t-/ # Bedrooms # Bathrooms _� Garden Tub/Whirlpool Dyes ❑No
Basement: Ates ❑No Basement Plumbing: es ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:unty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes .Fa'
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to determine compliance �} �th applicable laws and rules on the above described property located in
Davie County and owned by
Prope owner's or owner's legal representative signature
1-7 06
Date
Sign given Dyes 0 N
Revised 2/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
Invoice #
5-c-