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128 Beaver Branch Trail, DAVIE COUNTY HEALTH DEPARTMENT � ' � Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 � � y GG Z;� IMPROVEMENT/OPERATION PERMIT Account #: 990001012 Tax PIN/EH #: 5800-41-6482 Billed To: David Baity Subdivision Info: Reference Name: David 8� Sheila Baity Location/Address: Calahaln Road-27028 Proposed Facility: Residence Property Size: 5.70 Acres **NOTE�"�'i�i�ibgmprov3em�ent/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 _�� 'T Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing:� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � Type Water Supply �_ Design Wastewater Flow (GPD) �� Site: New � Repair � System Specifications: Tank Size /�lJ GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �_��Rock Depth �,��Linear Ft.��j �� 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)751-87G0.**** 1� F Environmental Health Specialist's Signature: � . Date: ..� —!� 9 jf v DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990001012 Billed To: David Baity Reference Name: David 8� Sheila Baity Proposed Facility: Residence ATC Number: 2350 P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5800-41-6482 Subdivision Info: Location/Address: Calahaln Road-27028 Property Size: 5.70 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 FIVE YEARS. Environmental Health SpecialisYs Signature: VJ •�i(� �7`J• Date: (,L�'�'%�—�d 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. � �C !;./i.. L'i? +� � �Dv �- / Septic System Installed By:`�- Environmental Health Specialist's Signature : DCHD OS/99 (Revised) Date: �� —9 '"Q�� APPLJGATION FOR SITE EVAWATION/IMPROVEMFM PERMIT & Davie County Health Department Envir+vnmenta/ Hea/[fi Se�ciion P.O. Box 846/210 Hospi�al Street Mocksville, NC 27028 (336) 751-8760 FEB 2 8 �0�0 ***IMPORTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED INFORt�iTION IS PROVIDED. Refer to the INFORMATION SULLETIN for instructions. 1. Name to be Hilled � i �� Q �J T 9 Q V �� Q ��S/ Contact Peraon � f� ii � L+ �� ,S l t� G� Mailing Addrese L� �� OI �\l t� f �( � Home Phone � 1�— � l� b City/State/ZIP � (� C �S V�/ li� � / � Z� Buaineas Phone 1 ' O �v ` `/�3 �' S � � y � ' 2. Name on Permit/ATC if Different than Above Mailiuq �ddreas City/State/Zip 3. Application For: �lYSite Evaluation ❑ Improvement Permit/ATC B�Both a. syat� to sernice: C�House ❑ Mobile Home ❑ Business ❑ Industry 0 Other s. if Residence: � People �+ � Bedrooms _� # Bathrooms �_ (�/bishnasher C�Garbaqe Diaposal Washing Machine FYHasemant/Plumbing ❑ Basement/No Plumbinq 6. IP Hueineas/Induatry/Othar: 8pecify type �j People 11 3inka # Commadea # Shorers Y Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallona per asy) �. Type of water suppiy: Q'County/City ❑ Well ❑ Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑ Yes I�To If yes, what type? ***IMPORTANT'ti** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: � t %� C Taa O�ce PIN: ' # .; �1�� — �t� CO `� O� Property Address: Road Name C ct � q�� r� `1 � c�tyiz;p � � %sv;� f I,�,_ ,IIT c � �o � If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (trom Mocksville) to PROPERTY: b`I ��0�,5 T Lakc M�.�,�s _ f�C44�� R �L �s �� R;� �,T .. l. �j .,�! IeS � f� �rOPI`�y � S B r, R7 � Z' BeavP♦ � ,^ c ., c � _�^ r.� : 1 Date Property Flagged: 2'��'� d 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 jor all charges incurred Jrom 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 a- 1'g - p p . / � �� . � : THIS AREA MAY BE USED FOR DRAWING YOUR S1TE PLAN (Include all of the following: Ezisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) � �� Site Revisit Charge , Date(s): I Client NoNfication Date: I EHS• Account No. �� Invoice No. � � �� CeB2 � �. � � 36I�, '4�,,•,�..i14ti, / �,�CL � ) � \ \ � � s�� 513 T �2`s This map is for PERC TEST and BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office assumes no liability for any information contained on this ma COUNTY-ID: G20000001001 PaD �� I �bruary 28, 2000 10:26 AM Parcel Identification Number 5800-41-6482 DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section Soi1/Site Evaluation APPLICANT INFORMATION Account #: 990001012 Billed To: David Baity Reference Name: David & Sheita Baity Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5800-41-6482 Subdivision Info: Location/Address: Calahaln Road-27028 Property Size: 5.70 Acres Date Evaluated: G�3 '� $�7�� Water Supply: On-Site Well Community, Evaluation By: Auger Boring_o/ Pit Public Cut REMARKS: 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- Tenace 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very frm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineralo�v 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 Classiiication - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gaUday/ft2 DCHD OS/99 (Revised) ■��■■ ■��e ■�■�■ ■�■�■ ■■��■ ■��■■��■�■■�■ ■��■■�■��■o■��■�■ ■■�■■■■��■■■��■��■ ■■��■■■■��■�■■�■�■ ■■��■■��■�■�■ ■��■��■■��■��■�■ ■�■■��■■�■■■��■ ■��■�■■■■�■�■��■■��■ ■■�■��■■�■■■■��■ ■��■�■�■��■�■��■�■�■ ■��■��■■��■�■��■■ ■■■��tt�■■�■�■�■■��■ ■�■��■��■�■��■■ ■�■■■■��■�■�■■■�■■■ ■��■■■��■��■■■■■■ ■■��■■��■�■��■��■ ■■�■■■��■��■e��■■ ■��■��■■��■■■ ■■��■■■■■�■�■��■��■■ ■■��■�■�■�■��■�■ Ziiiiii�iiiiiii�iiii ■��■■��■o�■■■�■�■■�■ ■■■��■��■�■�■��■ ■■■��■��■■■�■��■�■ ■�■�■��■■�■■■�■�■■�■ ■�■�■��■��■■■��e��■ ■■�■��■��■■�■�■ ■■��■�■�■�■��■�■ ■■��■■��■�■�■��■�■ ■��■■�■�■��■■■ ■■��■��■�■�■■�■■va■ ■■��■��■�■�■N�■■�■ ■■�■■��■��■��■�■�■ ■��■��■■■��■■��■ ��■��■■■�■■■��■ ■■��■�■��■�■ ■■��■■■�■�■��■�■ ■■��■��■■�■�■��■■�■ ■■��■■■�■�■■�■ ■�■��■�■�■�■�■ ■��■�■��■ ■�■■■■��■■�■■ ■■��■ ■■■■��■■�■■��■ ■■��■�■■■��■ ■��■■��■�■�■�■■ ■��■■�■■■��■ ■■■■��■��■�■ ■■�■��■■�■��■■��■��■■��■��■ ■��■��■■�■��■�■�■��■�■ ■■■�■ ■��■��■��■■�■■��■��■ ■■■��■■�■��■�■��■�■■ ■��■��■��■��■��■s ■��■��■��■��■��■��■■ ■■�■■��■��■■■■■■�■■�■ ■��■��■�■�■■■■��■■�■ ■■■�■��■�■�■■■■��■■■s■ ■�e��■�■■�■��■��■�■ ■��■�■■�■��■��■��■�v ■��■■ ■��■�■■■��■■�■ ■��■�■�■��■��■��■��■�■ ■�■��■■�■�■■��■■��■ ■■��■■��■�■�■��■�■ ■�■�■■��■■■�■��■�■��■ ■■■��■■■■■��■■��■�■ ■�■��■��■��■��■�e■�■ ■�■�■�■■�■�■■��■■�■��■ ■�■�■ ■■�■�■■��■�■��■ ■��■��■■■�■■��■■�■��■ ■��■■�■��■■�■■�■��■ ■■�■�■��■■�■�■■�■■�■■�■ ■■■■�■■�■■��■■�■��■■�■ ■■�■�■■�■■�■��■��■ ■��■�■■�■■��■■��■��■ ■■�■��■��■■��■ ■■��■ ■■■��■■�■■■■��■ ■■■N■�■■■■�■��■■��■■�■ ■■��■��■■■■�■��■��■■■�■ ■■��■■�■■��■�■�■■■■�■ ■■��■■��■�■��■■■�■ ■■��■■�■�■■�■■■��■��■■■�■ ■��■��■�■��■��■��■��■ ■■�■_��=====�■■��■�■■�■■■�■ iii�iiiiiiil�iiiiii�iiiii ■■��■��■■■��i■��■��■■��■ ■■��■■��i■■��■�■■�■■��■ ■■��■■■�■■��■�■■��■�■ ■■■�■■�■�■■��■��■■�■��■ ■■■��■■■■��■�■��■■�■■■■ ■�■��■��■��■■��■�■■��■■■ ■■��■��■■��■�■■■�■■■ ■�. ■��.��:i■■�■■�■■��■■■ ■■�M ■■s�■ ■■■�■ ■��■ ■��■ ■■■�■ ■■■�■ iii� ■■��■ ■■��■ ■■��■ ■■��■ ■■■■■■■■■■■ ■��■��■■■■■ ■�■■■■■■■■■ ■�■■��■■■■■ ■��■■■■■ ■��■ ■�■■��■■�■■ ■�■■■■��■■■ ■�■■�■■�■■■ ■�■■�■��■ ■■■■�■��■ ■��■ ■■■■■■��■ ■��■ ■��■■�■ ■�■��■��■ ■�■��■■�■■■ ■■■�■■��■ ■��■��■�■ ■�■��■■