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145 Sheffield Road Lot 10Dav !017 All data In provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the G�l1O 8`)r3;7 Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shell hold harmless the County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and all claims or "uses of action due to CUUN't NC or arising out of the use or inability to use the GIS data providad by this webelta. WARNING: THIS IS NOT A SURVEY I'arce1Ufoimation . Parcel Number: H2O50B0017 Township: Calahaln NCPIN Number: 5719552321 Municipality: Account Number: 8304390 Census Tract: 37059-801 Listed Owner 1: HEINER JANE R Voting Precinct: NORTH CALAHALN . Mailing Address 1: 145 SHEFFIELD ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag. District: No Legal Description: LOT 10 SHEFFIELD PARK Fire Response District: CENTER Assessed Acreage: 0.35 Elementary School Zone: WILLIAM R DAVIE Deed Date: 8/2014 Middle School Zone: NORTH DAVIE Deed Book/Page: 2014EO284 Soil Types: CeB2 Plat Book: 0004 Flood Zone: - Plat Page: - 098 Watershed Overlay: DAVIE COUNTY , Building Value: 71210.00 Outbuilding & Extra 2930.00 Freatures Value: Land Value: 25000.00 Total Market Value: 99140.00 Total Assessed Valuer 99140.00 All data In provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the G�l1O 8`)r3;7 Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shell hold harmless the County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and all claims or "uses of action due to CUUN't NC or arising out of the use or inability to use the GIS data providad by this webelta. Applicant: Jane Heiner/Kristie Heiner Address: 145 Sheffield Road City: Mocksville StatefZip:. NC 27028 Phone #: (336) 926.4730. Property owner. Jane Heiner/Kristie Heiner Address: 145 Sheffield Road City: Mocksville Staterzip: NC 27028- - Phone #: (336) 926-4730 OPERATION PERMIT R„* Davie County Health Department 210 Hospital Street 145 Shffield Road P.O. Box 848 Mocksville NC 27028 27028 Phone: 336-753-6780 Fax: 336.753-1680 Applicant: Jane Heiner/Kristie Heiner Address: 145 Sheffield Road City: Mocksville StatefZip:. NC 27028 Phone #: (336) 926.4730. Property owner. Jane Heiner/Kristie Heiner Address: 145 Sheffield Road City: Mocksville Staterzip: NC 27028- - Phone #: (336) 926-4730 Property Location & Site Information Address/Road #: Subdivision: Sheffield Park Phase: 145 Shffield Road Mocksville NC 27028 Directions 71A- structure:SINGLE FAMILYHwy 64 West right on Sheffield Rd. o # of Bedrooms: # of People: Supply: WA ed by atan/Description: 'System Classification/Description: TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) ued by: 2140 -Nations, Robert rDesign SeproliteSystem? OYes @No Flow: 3 6 0 *Distribution Type: GRAVITY -SERIAL Pump Required? OYes *No plication Rate: 0 3 'Pre Treatment: Drain field Nitrification Field 1 1 0 0 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 7 Installer: Brian McDaniel Total Trench Length: 2 7 5 ft. Certification #: 1118 Trench Spacing: — 9 • Inches O.C. Feet O.C. *EHS: 2140 -Nations. Robert Trench Width: — 3 Zeal: Zeet 0 4/ x 1/ 2 0 1 6 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 2 4Inches Approval Status Maximum Trench Depth: 3 6 I' Approved ❑ :Disapproved Inches Maximum Soil Cover. 2 4 Inches CDP File Number 201967 -1 Manufacturer. STB: Pump Tank Gallons: Installer. Date: Certification #: *Filter Brand: *EHS: ST Marker. ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No County ID Number: f Let. Long: Installer. Certification #: *EHS: Date: Approval Status ❑Approved❑ Disapproved- ." Pump Tank Manufacturer. Installer. PT: Certification #: Gallons: *EHS: Date: Date: Riser Sealed ❑ Yes ❑ No j RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: C] Yes ❑ NO m' Approves!❑tDlsapproyed� •' 1 PieceTenk: ❑ .Yes ❑ No Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification #: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings [IYes 11No Approval Status ❑ Appioved ❑ ;Disapproved Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification #: Drew Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approver status •, PVC unions ❑Yes ❑ No ❑ Approved ❑ ,'Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ NO CDP File Number 201967 -1 NEMA4X Box or Equivalent ❑ Yes ❑ No Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2140 - Nations. Roberl *Operation Permit completed by: Authorized State Ag l; _ County ID Number: Installer. Certification #: *EH S: Date: / / Approval Status ❑rApprovt d❑, Dlsapprovel Date of Issue: 0 4 /" a 1/ 2 0 1 6 Owner/Applicant Signature: ..This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for .. _._. _'Sewage Treatment and Disposal, -15A NCAC 18A .1900 at, Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE II A sewage septic system. TYPE It A — ` — Y: Rule.1961 requires thata Type- septic system meet the following criteria: Minimum. System Review ByThe Local Health Department: WA _ Management Entity:, OWNER Minimum System Inspection/Maintenance Frequency ByCedified Operator: NIA Reporting Frequency By Certified Operator. NIA Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a codified operator for the life of the septic system. Rule.1961 (2) (a) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. ft shall also bee condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** t'' OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 201967-, 1 County File Number: 27028 Date: W W ` O Inch Scale: , OBlock ON/A ■ MM.® MMM ■.■■■■ ■■■■M ■ ■ ■ .II ■I .®� ■.■■M. IM ■ ■ ■ . ■ .■■.EMMM . ■ ■■�■■■ ■■■■■ ■ ■ JIM ■ . . . ■ +, ■ ■ ■ ■■ ■.■.■■.. + COMM ■ ■ ■ III 1■ ■ ... ■. ■. ■ ..■ ■ ■MEI!• �=■■■.■ CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street � P.O. Box 848 Mocksville NC 27028 For Office Use Only `CDP File Number. 201967 -1 County" ID.Number. Evaluated For: REPAIR Township: J M=MRIIT \/AI Ill I ILIT11 . Phone: 336-753-6780 Fax: 336-753-1680 0 3 I a H I a 0 a 1 Applicant: Jane Heiner/Kristie Heiner Property Owner: Jane Heiner/Kristie Heiner Address: 145 Sheffield Road Minimum Trench Depth: Address: 145 Sheffield Road City: Mocksville City: Mocksville State/Zip: NC 27028 3 6 0 State/Zip: NC 27028 Phone #: (336) 926-4730 Phone #: (336) 926-4730 Address/Road #: Subdivision: Sheffield Park 145 Shffield Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: # of People: `Water Supply: NIA Phase: Lot: 10 Directions Hwy 64 West right on Sheffield Rd. on the left Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches \Site Sap rolite System? Q Yes ® No Minimum Soil Cover: 1 .a Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches *System Classification/Description: 'Distribution Type: GRAVITY - SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons `Proposed System: 25% REDUCTION 1 -Piece: OYes 0 N Pump Required: Q Yes ®No Q May Be Required Nitrification Field 1 a 0 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: OYes ONo Total Trench Length:3 0 GPM --vs-- ft. TDH ft. Trench Spacing: _ 9 O ® Inches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: 3 O Inches Feet _ ® Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01011 0111 O N / Page 1 of 3 CDP File Number 201967 - 1 County ID Number: 'w ; ' - ❑ Open Pump System Sheet ® No O No, but has Available r�cwau vr�amu Trench Spacing: Inches O. *Site Classification: — Feet O.C. **** 15A NCAC 18ftw"45 **** 8Feees Design Flow: t Soil Application Rate: *System Classification/Desc,,R: pair *Proposed System: Nitrification Field No. Drain Lines \ Total Trench Length: Aggregate Depth: inches Minimum Trench Depth: Inches Area a it pt Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches Sq. ft. *Distribution Type: Pump Required: Oyes ONo OMay Be Required ft. Pre -Treatment: ONSF OTS -1 OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe Issued at the same time the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature, Date: / *Issued By: 2140 -Nations, Robert Date of Issue: 0 3/ a 8/ a 0 1 6 Authorized State Agent: Malfunction Log O Yes K' ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.* Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization . ............�:� . .... ................... ............ . . . ....... . ... .. ��....._. 00 CDP File Number: 201967 - 1 County File Number: Date: 03 /28 /D016 0 Inch Scale:. 0 Block 0 N/A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 201967 - 1 P.O. Box 848 Mocksville NC 27028 County File Number: Date: 03/ 0 88 /2016 Click below to import an image from an external location: Drawing Type: Construction Authorization /at' -ta` te to to 5r 4�C Q 1 Page 3 of 3 P1 P2 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account # Tax PIN/EH #: Billed To 6 Subdivision Info: Reference Name: Location/Address: Proposed Facility: Property Size: Date Evaluated: LQ Water Supply: On -Site Well Community yll*� Public Evaluation By: Auger Boring Pit Cut FACTORS I 2- 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH (y Texture group Consistence rl Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVEHORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 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 SI: - 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 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) BIZ PHONE NUMBERz NAME LOT If DIRECTIONS TO DATE SYSTEM IX01 ED/ 72 NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED__ TYPE WATER SUPPLY P/i SPECIFY PROBLEM OCCURRING hN6 610; DATE REQUESTEDa Dlo INFORMATION TAKEN BY Am///i0- This / ////i0This is to cerliy that the Information provided is coned to the best of my knowledge, and that I understand 1 em responsible for all charges Incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT 'Rev. 1193 •, y:.; A/f//i/!W - � Cr ag APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environinenhil Health.Section P.O. Box 848/210 Hospital Street. Mocksville, NC .27028 (336)751=8760/ Fax (336)751=8786 Application For:ite Evaluation/Improvement Permit D Authorization To Construct(ATC) D Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. AYYL1k,PAN 1 11Nr UB NL k 11V1N Name to be Billed P� Billing Address City/State/ZIP Name on Permit/ATC if Different than Mailing Address PROPERTY INFORMATION Person //� Phone `� /— 7 % s Phone NOTE: A survey plat or site, plan must accompany this application. Permit is valid for 60 m with j 1 y nq ex ' 'on with qte Iat Street Address c>/1 P '"d�C ty ; S p / t° Tait PINS Subdivision Name cs'Ao Sectio/n/Lott#�—��Lot Size Directions To Site: i„ U iAJ ns � �/) S`/P T /�Cr7 1 ,4 . �Iia_i�, Date House/Facility. Comers 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? ❑Yes RM6' Does the site contain jurisdictional wetlands? DYes gNt_� Are there any easements or right-of-ways on the site? DYes PN� Is the site subject to approval by another public agency? DYes;;; Will wastewater other than domestic sewage be venerated? DYes IF RESIDENCE FILL OUT THE BOX BELOW # People ---f # Bedrooms # Bathrooms % GardenL!�Wbirlpool Wes DNo Basement: DYes 2Nr Basement Plumbing: DYes DNo---- 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: ❑Conventional DAccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D County/City Water D New Wellsting Well . ommunityWell Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes 9 PdD� 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 inspectione�etermine compliance with app 'c le laws and rules on the above described property located in Davie County and owned by / Pig z/ �Jle A �i9 rK— Site Revisit Charge Pr owner's o owtir leg 1 representative signature Date(s): Client Notification Date: Date' EHS: qq 2 Sign given DYes GNo Account # 3 !2 2 Revised 2/06 Invoice # :°, CONSTRUCTION AUTHORIZATION ' Davie County Health Department a� 210 Hospital Street � P.O. Box 848 Mocksville NC 27028 For Office Use Onl Phone: 336-753-6780 Fax: 336-753-1680 0 3/ a 8/ a 0 a 1 Applicant: Jane Heiner/Kristie Heiner (Ard pertyOwner. Jane Heiner/Kristie HeinerAddress: 145 Sheffield Road dress: 145 Sheffield Road City: Mocksville State/Zip: NC Phone #: (336)926-4730 P Address/Road #: 145 Shffield Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: # of People: 'Water Supply: NIA City: Mocksville 27028 State2ip: NC 27028 Phone #: (336)926-4730 lerty Location & Site Information Subdivision: Sheffield Park Phase: Lot: 10 Directions Hwy 64 West right on Sheffield Rd. on the left i 'Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: 1 a 0 0 Sq. ft., ep is an Gallons 1 -Piece: OYes ONo Pump Required: OYes *No OMay Be Required Pump Tank: Gallons 4 1-Piece:OYes ONo 3 0 0 ft_ GPM—vs— ft. TDH Feet O.C. 9 Qlnches O.C. g — Dosing Volume: _ Gallons >y Inches — 3 . gFeet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -II Septic Tank InstallerGrade Level Required: OI 011 OIII OIV ewe Minimum Trench Depth: a 4 Sfte Classification: Provisionally Suitable Inches Seprolite System? OYes ®No Minimum Soil Cover. 1 a Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover. a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY -SERIAL TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S f T k' 'Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: 1 a 0 0 Sq. ft., ep is an Gallons 1 -Piece: OYes ONo Pump Required: OYes *No OMay Be Required Pump Tank: Gallons 4 1-Piece:OYes ONo 3 0 0 ft_ GPM—vs— ft. TDH Feet O.C. 9 Qlnches O.C. g — Dosing Volume: _ Gallons >y Inches — 3 . gFeet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -II Septic Tank InstallerGrade Level Required: OI 011 OIII OIV ewe CDP File Number 201967-1 County ID Number. No ONO, but has Available 3 � � ❑ Open Pump System Sheet Trench Spacing: 0 Inches 0. 'Site Classification: Q Feet O.C. **�`* 15A NCAC 18Ah.'^'19l'945 ** * SFeet 9 Design Flow: Soil Application Rate: Aggregate Depth: inches Minimum Trench Depth: 'System ClassificationlDescri�Nelnepair Area e ii pt— Inches R Inches 'Proposed System: Maximum Trench Depth:_ Inches Maximum Soil Cover. Nitrification Field Sq. ft. Inches No. Drain Lines "Distribution Type: Total Trench Length: ft Pump Required: OYes ONo OMay Be Required Pre Treatment: ONSF OTS -1 OTS -II J 'Site Modifications - __ No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. i "Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe Issued at the sametime the Improvement Permit Issued (NCO3 130A-336(blj If the Installation has not been completed during the period of validity of the Construction Permit, the Information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become ImAlld, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant(Legal Reps. Signature- Date:, 'Issued By: 2140 -Nations, Robert Date of Issue:. 0 3/ 2 8/ x 0 1 6 Authorized State Agent: Malfunction Log OYes *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 201967 -1 County File Number: Date: 03/28/2016 W W Olnch Scale:. . .OBlock ON/A J MEE No M NNE MEE MEE MEMORM No MOMMONE ME No 1 0 MEN ON MMOMMO NEENo 010100MEMO=0 MEEM MENoMEM ME EMMEM NEEONENONE OMEN NEE J CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 201967 -1 P.O. Box 848 Mocksvllle NC 27028 County File Number: Date: 0 3 1 2 8 1 2.0.1 6 Click below to Import an Image from an external location: Drawing Type: Construction Authorization i Perrmnee sLI-/�I�1 IZ DAVIE COUNTY HEALTH DEPARTMENT ,Names I' Environmental Health Section PROPERTY INFORMATION �o P.O. Box 848 n/ Directions to property: n Mocksville, NC 27028 Subdivision Name: IL• �tr l �� D PI re 1 41 L, FF i L`L-1) Phone #: 336-751-8760 'U Section: Lot AUTHORIZATION NO: 002630 A 'AUTHORIZATION FOR o WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: /414; Lr�F-FIWn **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 Of ice when applyigqg for Building Permits. (In coinphartc� kith A 0e 1 I/bf G.S. Chapter 13OA. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION (7(/ IS VALID FOR A PERIOD OF FIVE YEARS. RESIDENTIAL SPECIFICATION: BUILDING TYPE fWS: #'BEDROOMS _-,i # BATHS # OCCUPANTS L GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE _&)-C 1054E WATER SUPPLY 1Ir iqJ-- DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE t SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH-_ LINEAR FT. ®O ' OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: I � I I C -P to IMPROVEMENT PERMIT LAYOUT ' FRRoNT to %10 s D ;� rJEW ILS I,J -TA ri j< 4lAA X iRE ! Gt 1 ice. {'til 3( �p �EMbV�- OI.D WPM StV rAQ TlE l �x ISTII.tC� ua>i FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9a3 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT E AUTHORIZATION NO. f-l� OPERATION PERMIT SYSTEM [NSTAI.LEBY: � I I I 41C **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S CR ED ABOEV.2 WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND, DISPOSAL SYSTEM GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD Obit (Revisal) DATE: qjK�,11 AS BEEN INSTALLED I COMPLIANCE ', BUT SHALL IN NO WAY BE TAKEN AS A t/A:na