Loading...
204 Bailey Rd . , . DAVIE COUNTY HEALTH DEPARTMENT ' � • Environmental Health Section �. � � �' . � � P.O.Boz 848/210 Hospital Street � Mocksville,NC 27028 L�;�G,� /l�� �p (33G)751-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B Billed To: Jake Miller Subdivision Info: Reference Name: Location/Address: Bailey Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3581 **NOTE** This ImprovemendOperation 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 P�RMIT BEFORE INSTALLING SYSTENL /� �J Residential Specification: Building Type C ��'#Pe�e�_ #Bedrooms� #Baths� Dishwasher� Garbage Disposal: 0 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(GPD)_�� Site: Ne�Repair 0 System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width����Rock Depth���Linear Ft.�� Other: Required Site Modifications/Conditions: IIFtPROVEI�1ENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis 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.**** . � '�. 1- � - � Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) . , , � 1 . ' `� / ' ' ' ' DAVIE COLJNTY HEALT'H DEPARTMENT �Jv` � ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (336)751-87G0 Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B Billed To: Jake Miller Subdivision Info: Reference Name: Location/Address: Bailey Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3581 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 T UCTI N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: � Date: �%���� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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. `. � 'l � � ' ' ` , � (��' 1 ) � � , _ . • � � � � � — � ��� r I"!P Septic System Installed By: ��� � Environmental Health SpecialisYs Signature: Date: �`"����� DCHD OS/99(Revised) .�. ,• . . . . �no���o��ti� ��'�u������1� APP CATION FOR SITE @VALUATION/IMPROVEh1F1VT P[Rh11T&ATC Davie County Heaith Department ��� Z Z d3S Environmenta/Hea/th Section 4 P.O. Box 848/210 Hospital Street . � � ` � MocY.aville, NC 27028 " � R � (336)751-8760 ��U� ***IDSPORTANT*** THIS APPLICATION CANNOT BE PROC�SSED UNL�SS ALL TH� REQUIR�D INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instrucL-ion�. l. Name to be Billed .Sa�,tL � y 1,\�C'�'' Contact Person ��,c,Y C� Mailing Address L` 1 � Homo Phono s��6-' � I�i� '�%C�__ City/State/ZIP � Business Phone ��(�_; ���j `p�J_L�_ 2. Nnne on Permit/ATC if Different than Above — Mailing Address City/State/Zip 3. Application For: �Si • . Evaluation ❑ Improvement Permit/ATC Both 4. System to servico: L17 House b 'Mobile Home ❑ Business ❑ Induatry ❑ OLher 5. Type system requested: lrJ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People �_ # Bedrooms �_, t� nathrooms � 3 h(1Diahwasher LlaGarbaga Dispo�al LhWashing Machina ❑Dasement/Pliunbing ❑IIasement/No Plumbin� 7. If Huainess/Industry /Other: verify type �# �eople 4k Sinks # Coamiode3 # Showers # Urinal3 A #{ Water Cooler:� IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay> __ __ 8. Zype of water supp�y: �County/City ❑ Well ❑ Community 9. no You anticipata �dciition3 or cxpansions of tUc facility this systciii is i�itendcd to sc►•ve? ❑Ycs L�No x. . 3: If ycs,���l�at typc? j �;�, ***IMPORTAIVT'`**CLICNTS AfUST CObIPLL•TB TII� RLQUIRED PItOYLIiTY INI�ORMATION RCQUGS7'GD BGLOW. Eithcr a PLAT or SITE PLAN h1US'l BE SU6�YIITTED by tlic clicnt �vith TII IS APPLICA'1'ION. Property Dinlcttsions: ,�1�t� (.�i��l WRI'CG DIRGCf10NS(from Modcsvillc)lo PKOPI;K'1'1': `_._�`.. ``Tax OfCcc PIN: > # ��S�SI�C�c������� ._.(�'�/(� �A"'o!,►.lrL� r,fJir���dl �' lt�C�✓� � --:— � Property Address: Road Namc��jC-�;���I �� . ,.rX �� ��d - ��Ya�►� Clty/Zip (�(1,Y1r � GC��� ,10.�� C>n ��/lCXri����.S .C.�Cr�� If in a Subdivision providc ii�forniation,as follows: � . ...� nn � i�C V ��, Namc: '�(��� .����/ -%��-5SC>� � ,,� , - � n�� �` �0;�5 u�-�-��c��• Sectio�i: I31ock: Lot: Datc lionic cornci•s tlabecd: g'-�a-�� Tl�is is to certify tl�at tl�e inforination provided is correct to tlie bcst of my kiiowlcclgc. I uiidcrstaitd tlint any peru►il(s) issucd hereafter are subject to suspension or revocatioti,if the site plans or iutended use change,or if the inforinaliou suUmilted in tl�is applicatiou is falsi6ed or clianged. I,also, u�tderstaud tltnt I aut res��u��siGle for al!c/tr�rges irrcrrrrcc!fi•nnr llcis applicalio�r. I,hereby,givc conscnt to thc Authorized Represcntativc of thc Davic County IIcalth Dcp.u-t�nenl to ci�tcr upon abovc dcscribcd property located in Davie County aud owned by �p�Q.��_ G. �LiGLr-I t�,�'1 to conduct all testing procedures as necessai•y to determine the site suitability. DATE I �`�,�'O�� SIGNATUItE O _4'(_' ,}'�-,,�('J� �(_�����/��� THIS AItEA MAY BE USLD rOR DRAWING YOUR SITE PLAN(Includc all of thc follotiti�ii�g: �xisting and proposcd property lines and dimensions, structures, setbacks, and septic locatioiis). ��� ;� ��t � ��,i�---�:_�.��- � Sitc 12cvisit Cliai•bc ' )atc(s): � ���_� . Clicut Notification Datc: � �'�� G� c � �HS: �� /�>� /� �--�- a-2�.�..; � � Sign givcn S Accouut No. �;����„�--� Revised DCHD(OS/03 (�'������C � s`s Iuvoicc No. d ✓ � �---� � � _.� . � � '- ` : . , r.h � . . , . . . . - . � . ' . . .... . .. .�.,�. �&t. - . ;',.. . 3/4�� aP 20.�' �.*� � � - . Bent/Fnd 417.1 a. . y ,F`, – ..-...�.. —.�..�. '• -.. . s . �:":,_ ��`. . , '` ` 5/Fnd�R N 00°2 '41"E 437.16' Total , , , . , � ._,, , �N 02°50'54"E -- --- _ _ � ,r.5 . �� �s P�o�ed �n i,rneJ , 12.sa `, : - . . m � , � , � , � . �r t, . . .- � . . .-.. :. . ': .. � . � . �" - . . . ' —_'-�-_--'-,. .___._ ��i0� ^2 z � � TOX,LAt 6.�� o� _ � ` + , Tux Map:G-9 � �- � . �F:° : : . n/f Metiasa Knox . � _ ����+. � DB 25. O PG .3.2, .,__ , N _ . I , - ._ ,: ,n : - !��`�; - � _ ; �r o u I � � �� , �, � �� ' Z I � ' `' J ; r �__ , � �ys�' - `.._ ` 1dc1/2° EIP � N 76°27'23"f , f`" , Fnd 489.67' Totci �� - �� �y�` - ' _ R� .P ,��,:_.' � . �(_`{1 _ LOt 2 r r . . � 0 �.. � . . � ,��' _-:: _ - � ` o Part of Tax Lot 4 ��.-:: � � �, r:' ` 3�,.� aP � Tax . Map :G--9 � �- Fnd in Une op ; � z . _ N. 5.548 Acres+/= x� ,� 3 ; �,., . o ' • M t ' . � b - i � � � �...' � . . � � � � M . `' Q lU ;�. . . . . . Q z . . ��'':".(.. . n , 't:a�:� . . a`.i-..`.:� . .. . . � . ± �:i..:: ' : 559.11' Totdl S 00°� 27'05"W I 1&5/8" E1P Fnd . by o Stone 414.71' . Y.-_ . . 1" Elf fn L Tax Lot 8 Tax Map G-9 . n/f�Jcy H.�Mintz, Trustee of the _ Jay H. Mlntz - Revocable Trust � DB 195 O PG 87 ,; , • ' . ' - •,� , � DAVIE COUNTY HEALTH DEPARTMENT � �� ' . ' ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002927 Tax PIN/EH#: 5880-62-0927 B Billed To: Jake Miller Subdivision Info: Reference Name: Location/Address: Bailey Road-27006 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 Landsca e osition L Slo e% HORIZON I DEPTH �< ci Texture rou L. Consistence Structure Mineralo HORIZON II DEPTH `� % Texture rou Consistence Structure � - �' Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo • HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE s � 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 firtn 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 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) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/99(Revised) ■�������������������■���������■���■■�■���������������■■��������■�■ ■■�����■������■���■���■���■��■�����■�■��������■�����\�����/������■ ■�����■������■������■��■■����■�■�■■�������■�■■������������������■ ■���/��������������������������■ ■������������������������������■ ■����■�■��■�■■■��■������■■■����■\�■���■�����������■■���■�������■�■ ■■\������������■�■�����■■��■��■���■■���■��■����■����\�������\����■ ■�����■■�■■��■����■��■■��■■��■�■������■��■�����■�������■���■�����■ ■�����������������������������■������■���������������������������■ ■�����■■��������■�����■��■��■�■����■�■����■�\����■�■���������■�■�■ ■���■�����■���■��■�■�����■��■�■���■��■���■��������■����������■�■�■ ■■������������■��■���■�■■��■�������\■�■��■������������■�A������\■ ■�����■��������■������■��������■ ■�����\■������■��■��■■���■ ■���■ ■����������������������������������������������������������■ ■���■ ■����■����■���������������■��■���■■■��������■����■������������■�■■ ■■����■�\�■������������■���■������r����■������������������/���■��■ ■�����■����■��������■����■■��������■�■������������■������■���■■■�■ ■����■��\����■����������������■��������■�■■■�■����■��■■�������■■�■ ■���������■������������������■���■■������■����e�������■�����_����■ ■���������������■��■�■������������������■����■�����■■�����■ ■���■ ■���������■����■���■��■��■����■■ ■����■�■���������■�■����t����■�■ ■����������■���■���������������������■�■��■■���������������������■ ■�������������■��������������������������������������������������■ ■����������■�������■��■■��■■�■�■�������������■��■��■��������■����■ ■����■�■�■■�■������■��■��■��■�■��■■���■■��■����■�■��e��������■■��■ ■�����■���■��■��������■��■���■■���■��■■���■������������������■���■ ■��■�■�■���■���■�������■��■��■�����■����■���■���������■����������■ ■�����������������■��■���������■ ■������������������������������■ ■■���������������■���������������ii�������������■�■�������■■���■■�■ ■�����■����������■���■�■�■■�■����■���������■����■■��■■������■����■ ■��■�■��������■������■���������■�����■�������■t■���■������������■■ ■��■��■����������������������■�■������■�■��w�����������■���■�����■ ■■���■����■���■����■�■■���■■�■�■�����■���■��ri��■������������t����■ ■�■���■■����������■■�■■��■■������■����■�������-.���■■��■����������■ ■■����■����■������■���■■�■■����������■■��■■��■i��■����■����������■ ■��■�■�■�����■�������■�■�■■����■�■�����■�■�■�■��■■��■�����������■ �������������������������������i--��.�iii:�����������������������■ ■��-�� _ ■■�■�■��■����������■���■ ■���������■■���■�■�■��■���■ii�■■�■����■■�■�■�■�����■■��■■��������■ ■�����■■■��■���■�■�����■�■EI��■■������■���■■��■�����■����■��������■ ■�■��■����■��■�����■�■■����I��■����■■�■��■■�������■���■�����������■ ■�������\������������������I�����������������������������/�/������■ ■■�������■■�■����■�■�����■�I������■����■���,■��■��■■�■��■�■��������■ fi���������������������1��������������1��������������������� ■����������������/���������/�/������������il��������������������■■�■ ■�����■■������■������■�����■���■■��■�����L������■������■��������■�■ ■■�������■■��■�����■�■�������■��■�1��.=:C�J���■�■��■■����■■�������s ■����■���■■��������■�����l��iii��■�■������■������■���■�����■ ■�■�■ ■�������■����■�■���������■�����■���■�■�����������■■��■�■�������■�■ ■��������������������������������i�������������■�����������������■ ■■�����■������■���■■�������■�����■������■�����������■����■������■ ■�■■��������������■■/�■����■��■■ ■■���■��■■��■■�■���������������■ ■�■��������■���■�■��o����■■���■��■���■■■��■��������■���■�����■■��■ ■■���������■���■�������■��■■�■�■��■■��■��t�■■��■���■■��■■�������■�■ ■��■����������N�������������������■����i�'li�l/������������■ ■����■�■ ...........................................�.............C........ .................................................................. ........................................................�......... ................................�................................ ................................ ................................ .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. ................................ ................................ ................................�i................................ .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. ................................ ................................ ................................�i................................ .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. ................................�................................ ................................ ................................ ..................................................................