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575 Childrens Home RdAccount #: 990003619 Billed To: William Revels Reference Name: Proposed Facility Residence ATC Number: 4089 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5813-73-4677 Subdivision Info: Location/Address: Childrens Home Rd.-27028 Property Size: 1 acre AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST 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. i Environmental Health SpecialisYs Signature: 1�/�'f� Date: ��.� CERTIITCATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 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. Septic System Installed B Environmental Health Specialist's Signature DCHD OS/99 (Revised) ; •. . ,. . � . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C>0 IMPROVEMENT/OPERATION PERMIT Account #: 990003619 Billed To: William Revels Reference Name: Proposed Facility Residence ��/�� S c rc-� � r� � ��%C' �^---� C��gi-�Zl� ��r'�e Tax PIN/EH #: 5813-73-4677 ' Subdivision Info: Location/Address: Property Size: Childrens Home Rd.-27028 1 acre ATC Number: 4089 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATtON 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 o2 Dishwashe� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �� Design Wastewater Flow (GPD)Cy�1CZLL Site: New lQ Repair ❑ System Specifications: Tank Size DdDGAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width � Rock Depth ��Linear Ft.�ii(� I1�'IPROVEA1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" 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 130 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** s�' "� � �',Y�we�� s'Dfi � � Environmental Health S ecialist's Si nature: Date: �� ` C�� r L �7/� DCHD OS/99 (Revised) 0 � APPLICATION FOR SITE EVALUAT(ON/IhiPROVEM1tENT PERM1IIT �. � � l Davie County Heaith Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 � (336)751-8760 M AY - 9 2005 ENVi EVD �A �T U� TM ***IMPORTAN'l*** TIiIS APPLICATION CANNOT BE PROCES5ED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. l. Name to be Billed: 2. 3. 4. JeIS Contact Pernonl ��r 1� 1 ��s Mailing Addresa ��5 ��SC� (�, �iJ • Home PhonaC��01 ��/ J" 7i� 1 C..! City/State/ZIP �(�(�(j�\�\S � � `,C, �` �, �� ZO Businesa Phone Name on Pezznit/ATC if Different than Abova ��i�� n�(�r1 �(�.��Y�,,S Mailing Address )�_t�(1S I�il'�t� �1}1 City/�tate/Zip IUI��J�i IU�• IvC— 7/�� If Application For:�Site Evaluation ❑ Improvement,P,�rmit/ATC ❑ Both Syatem to Services •❑ House ❑ Mobile Home ❑ Business ^❑ Indu.stry ❑ Other I� 5. Type eyatam requested: ❑ Conventional ❑ conventional modified ❑ innovative �� 6. If Residence: # People � Bedr oms �_ # Bathrooms �� _ {dDiahwasher ❑Oarbage Diaposal �hing Machine aement/Plumbing ❑Sasement/No Plumbing 7. If Husinesa/Induatry /Other: verify type # People # Sinks # Commodes� # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallons por day) 8. Type of water supply: � County/City f�' Well ❑ Community 9. no you anticipate additions or expansions of tlie facility tliis s}�stenl is intended to serve? �1'es Ild�W'o If ycs, �vliat typc? ***Il11PORTi1N ** NTS AfUST COhiPLETE THL RE¢UIItED PROP�RTY INrORNIATION RGQUGSTGD BGLO�V. Githcr k� AT or ITG PLAN l�1UST BESUIlA11T'PL•D by tl�c clicnt witli TIIIS APPLICATION. P � itttcnsions: �L i� ,�`-C�� 1VRITE DIRECTIONS (from Mocicsvillc) to PROPCRTI': x Officc PI `� ��__.� �; / 3 7.3 � % l� I P�o ��ln, -�-c� �; rw,��, `n Property Address: Road Name �', �� lCivC f15 l� � �� (ln lC�`t"� a��7�'� D�l i�: h i K`� �9iS c;tyiz;p ` 1�� Z�YuZB .� 4� �- CZd � C r�r�:) � C h �(d �� r� � If in a Subdivision provide ii�formation, as follo�vs: Namc: Scction: Blocic: Lot: �-�o r�. Ql� df� ��t'. I�n � C��1-� , � Z atc liomc corncrs flag d: � "� � Tl�is is to ccrtify tl�at tlic information provided is correct to tlic bcst of my l:no�vlcdge. I undcrstand tl�at any permit(s) issued licrcafter are subject to suspension or revocation, if the site plans or intended use cl�ange, or if tl�e information submitted in tl�is application is talsiCed or chnnged. I, nlso, u�rdersta�irl t/rat I nur respo��srLle jor a!! cliarges iacurrer! jronr tlris applicc�tion. I, IiereUy, give consent to the Authoriud Representative of the Davie Cow�ty Iiealth Departmen to entcr upon abovc dcscribed property located in Davic County nnd o�vncd by ��', � �, �.m, S� t ZP�I ) Q�S to co�iduct all tcslir�g proccdures as nccessary� to detcriiiinc tlic sitc suitability. . DAT� _� — Q --O � SIGNATUIt� �� TIIIS AIt�A MAY B� US�D rOR DR�►WING YOUR SITE PLAN (Iiicludc all of tlic follotiving: �xisting a�id proposed property lines and dimensions, structures, setbacks, �nd septic locations). .L-�a.-e � � C-� . 1 s�e3 � �� _ g _ O �-�' ,(� 7_ ( S(gn given �� Rcviscd DC D (OS/03 DAVIE CO. EM/IRONMEN)-q� HE,q� Datc(s): Clicnt NotiCcation Date: Account No. � `� ` I►ivoicc No. ��y�� 0 471 125 \° 469 826 467 1a� a°'o `�Fr �'. (7.15A) l301 30� 2829 � 5 z� > �/, M N � � i I I I � N I � � 3.293A o � 0755 � I (8.60A) 4576 832 I/ \ V I � �D s� Zg+ �- 630 �.4 N W , 3673 i . : � - � DAVI� COUNTY I-ILALTII D�I'ARTMCNT , - � � Environmental Health Section Soil/Site �valuation - ' A['I'I.iCANT INI�ORMATION AGco�nt #�: 990003619 Billed To: ' William Revels Reference Name: Proposed Fac�lity; Residence 0 PROPERTY INFORMATION �Tax PIN/EH #: 5813-73-4677 S�bdivision Irifo: Location/Address: Childrens Home Rd.-27028 F�roper#y Size: 1 acre Date Evaluated: �,��Q,�C�� -- Watcr Supply: On-Sitc Wcll Community Public Evaluation By: Augcr Boring� Pit Cut M Slopc "/o .��n��nwr I lICUTL] MIt1Cf8I0�)' unvi�nnr n i��trru m�ncraiogy � 1/1111'7llAI 111 fli�llT[1 ivuncraiogy o�� v�r_•rwirrc 1(CJ l IVl„ 1 l V G fl SITE CLASSIrICATION: � LONG-TERM ACCEPTANC� RAT�: � I2CMARKS: CVALUATION BY: OTHER(S) PR�SENT: LLGEND � I,�ndscapc Position lt - Ridge S- Shouldcr L- Lincar slopc FS - Foot slope N- Nosc slopc CC - Concavc slopc CV - Convcx slopc T- Tcrracc FP - rlood plain H- Hcad slopc Tcxturc 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- Cl�y CONSIST�NCI: iois VI'R - Very friable Wct NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Vcry firm LrI - Extrcmely firm SS - Slightly sticky S- Stichy VS - Vcry Sticky SP - Slightly plastic P- Plastic V(' - Vcry plastic ,�.�ructurc 'SC - Singlc grain M- Massivc CR - Cnimb GR - Granular ABK - Angular blocky . 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