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186 Chal Smith Rd.. . ' : ,., Account #: 990002521 Billed To: Robert Staley Reference Name: rroposea raciiity: Kesiaence ATC Number: 3336 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Tax PIN/EH #: 5850-35-1871 Subdivision Info: Location/Address: Chal Smith Road-27028 rropeRv size: see AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � � **NOTE** This Authorization for Wastewater System Construction MLJST 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 FIVE YEARS. Environmental Health Specialist's Signature: �!/Q�� Date: �„2 `�9"� Z CERTIITCATE 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 f G.S. Chapter ] 30A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be t�ke as a�u�ra�tee that the system will function satisfactorily for any given period of time. � � ��/i ��x�g �� Septic System Installed By: � � �v�X�-�X Environmental Health Specialist's Signature : �1,��,G�-�' Date: �'—`l L' L-�—�'�' v DCHD OS/99 (Revised) :. DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/Z10 Hospital Street Mceksville, NC 27028 (336)751-87Cr0 Account #: 990002521 Billed To: Robert Staley Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT ��a� � Tax PIN/EH #: 5850-35-1871 Subdivision Info: Location/Address: Chal Smith Road-27028 Property Size: see map ATC Number: 3336 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply l'� Design Wastewater Flow (GPD) � Site: Nevy� Repair ❑ � �� ,� � System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench WidthCf� Rock Depth � Linear Ft. �� Other: , �.�(r��,n ' ��t� Required Site Modifications/Conditions: IN[PROVEMENT/OPERATION PERMIT LAYOUT - FINISfIED GRADE. ****NOTICE: Contact a represen system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 I" EFFLUENT FILTER. RISER(S) 1F 6" BELOW `�Ie County Health Department for final inspection of this y/of installation. Telephone # is (33C)751-87G0.**** Environmental Health Specialist's Signature: / Date: �'' `� � .�! DCHD OS/99 (Revised) APPLICATION FOR SITE El/AL.UATION/IMPROVEMEM PERMIT & Davie County Health Department Environmenta/Hea/th Seciion P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �� _ N�1! �, 7 2= _ `� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed � ��QX� V I�P.(,� Contact Person ICJ �6YJN �1� �pY�' Mailinq Address j��• �Ox �pC.� Home Phone � JI �� p✓� City/State/ZIP � ��i�� Iej, �`,�_ oC, l ��_ Business Phone �U 3��,(�3� Ol� -` vl�'� (-1 � 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: '�ite Evaluation ❑ Improvement Permi.t/ATC Both 4. System to Service: C�ouse ❑ Mobi1Q Home ❑ Business ❑ Industry ❑ Other , 5. If Residence: # People �_ # Bedrooms � # Bathrooms p� Dish►rasher ❑ Garbage Disposal �hing Machine Ll Basement/Plumbing CI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks M Commodes ii Showers # Urinals H Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallons per day) 7. Type of water supply: �ounty/City ❑ Well C1 Community s. Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑ Yes No If yes, what type? ***IMPORTANT*** STCOMPLETETHE REQUIRED PROPERTY INFORMATIQN REQUGSTGD BELOW. Either a LAT or SITE P N MUST BE SUBMI7TED by the client with TH1S APPLICATION. /_ � � G�1 Property Dimensions: ��JJ �� J WRITE DII2GCTIONS (from Mocksvillc) to PROPF,RTY: � TaxOfficePIN: # 5�� / I �'IWy . (5$ �a5�'�' . �ASs Property Address: Road Name (�I lu �SYNF�1 f1�• c;ty�z.p tM o�tcsv�l (e . �.�02� lf in a Subdivision provide informatiou, as follows: IYame: Sectioa: Block: Lot: ��.rm i n�4on �d • - -� eq ZNd Roa� on (� i� �h�l 5��-t-.. � , �r��f� t5 0►� � � r�}' �r- ln� ��Sf �A� l�� C(n.�.C,�..2.�G. Date Property Flagged: I �'�uI ' C�Z. _ This is to certify that the information provided is correct to the best of my knowledge. I understand that a�y permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the anformation submitted in this application is falsified or changed. I, also, understmtd tkat I ant respo�rsible jor al! c/:arges i�rcrirred fran !ltis application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to entcr upon abovr dcscribed property located in Davie County and owned by � to conduct all testing procedures as necessary to determine the site suitability. DATE � I- Z7 � OZ SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of tl�e following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Chargc , Datc(s): Client Notification Date: ', EHS: Revised DCHD (07/99) Account No. �� Z / Invoice No. � � STALEY �G. 65 'ONG 66 iro�' ��in �`r p�U C(I or !'jL u..narked poin� \� or neor C% L roau f 9��6C� sl�. � r, o .r,. �� unrriarked pnint �� -"� j . Ifl C,�L �00!� �'•' � !^ A Y � `'� "�,� � , �� ! 6� s f��s A� � ^ 1 ^ �C�6. �l, � 6� �l. W � � p d � '�d O In +� O � � N N o N (t� Z � exis?iny ircn .�� } existinc iron r,xistiny j iron i I I fL O � unrt�ar�ed poirtt ��n C /L r,�c7�1 N � M v v ��ew iron AR�'A= 2.308 ACRES ' 1NCLUDES S.�#. i675 R,/NI N GO�l1G� D. C. SMI TH D. B. 44 , P existinq if0�1 s � _` . � —" ""-- --._.._ _,..._ m '— ~ M y� � Uj N 'P p �o H exisUny iron bA VrD L. BR � i3'N 0 � APPLICANT iNFORMATION Account #: 990002521 Bilied To: Robert Staley Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure DAVIE COUNTY HEALTH DEPART'MENT Environmentai Health Section Soil/Site Evaluation On-Site Well Auger Boring 1 SOIL WETNESS RESTRICTIVE HORIZON CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PROPERTY INFORMATION Tax PIN/EH #: 5850-35-1871 Subdivision Info: Location/Address: Chal Smith Road-27028 Property Size: see map Date Evaluated: �f �/Z LONG-TERM ACCEPTANCE RATE: REMARKS: ,f('!/`� �Si Z-� l'� /f��=r�dJ '`/�� < Public v Cut 3 4 5 6 7 EVALUATION BY: l`f!^y,= l � 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- 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 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) ■ ■ ■ ■ �� ■■ ■■ ■ ■ ■ ■ ■ ■ ■ ■ ■■�■ ■■■■ ■�■■ � ■■ ■■ ■�■ ■�■ ■■■ �� ■��■ ■��■ ■�■ ■■��■ ■■■■■ ■��■■ ■��■ ��■ ■■�■ i��■ ■�■��■ ■�■■■�■ ■��■�■■ ■��■ ■��■�■ ■■��■ C...... ...... ....... �■��■ ■■�� :�i�■■ ■��■■■ ■■��■■ ■�■��■ ■��■ ■�■�■■ �■�■■ ■■■■ ..�-�� ..��- ■�■■�■ ■■■■■■ PJ��■ ■\�■ ■■��■ ■��■■■ ■■■�■�■ ■��■ ■■ ■■ ■■ ■�■�■ ■��■ ■�■�■ ■��■ ■■■■■ ■■■■■ ■�■■ ■��■ ■��■ ■��■ ■��■ ■��■ ■��■ ■��■ ■��■ ■��■��■��■■ ■■��■��■ ■■��■��■ ■■■��■�■ ■■■��■ ■�■��■��■ ■��r��■ ===-��...... .....�..... ■�G�■�■��■ ■�■��■�■ ■■■��■■■ ■■■■�■��■■ ■��■ ■��■ ■��■ ■■��■� ■■■■�■��■��■ ■■■■��■ ■��■��■ ■��■■ ■�■��■■��■ ■��■ ■■�■��■�■■ ■��■�r��■�■ ■��■��■�■■ ■�■■��/�■■■ ■��■�■ ■��■■��■■ ■��■ ■��■��■ ■��■l��■ ■��■��■■■ ■��■■ ■��■■��■ ■��■ ■��■ ■■��■ ■�/��■ ■■�■��■■■■ ■■��■■ ■■��■��■■■ ■��■■■��■■ ■��■ ■■��■��■ ■■��■�■■��■ ■■��■��■ ■��■■��/�■�■ ■■��■��■ ■��■��■ ■��■■�■��■ ■■■��■ ■��■■��■