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271 CV Smoot Ln 12.014 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003345 r Tax PIN/EH#: 5801-78-9210 Billed To: Mary Lou Coley Subdivision Info: Reference Name: Location/Address: 271 C.V.Smoot Lane-27028 Proposed Facility Residencec Property Size: 2 acres ATC Number: 3867 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 Treatm t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA S VAL FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION i **N(ift * The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit Iton 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. p � 6-� � I S� 1 c' x 3r, t I p to .-ten/ Yom, Cr I O of 1v�� t � Septic System Installed By: L Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section a-01 .6 P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003345 Tax PIN/EH#: 5801-78-9210 Billed To: Mary Lou Coley Subdivision Info: Reference Name: Location/Address: 271 C.V.Smoot Lane-27028 Proposed Facility Residencec Property Size: 2 acres ATC Number: 3867 **NOTE** This Improvement/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 SM PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �l�M 1� #People 2 #Bedrooms #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine: Mr"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift /,�j#SSe�atts Industrial Waste: ❑ Lot Size 2 A6("S Type Water Supply V`'�- Design Wastewater Flow(GPD) (�lJ Site: New Ge" Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width(Rock Depth Linear Ft.n, Other: _q h uTn�) �t V� Required Site Modifications/Conditions: !2�mux- e3r� left, W-6o, �� t St ox duo, IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 i°BELOW FINISHEDGRADE. ****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)T 1-8760.**** 48 Iso' 1� i� Environmental Health Specialist's Signature: Date: t Ulf DCHD 05/99(Revised) PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC WJ `� Davie County Health Department DEnvirwmeiita/Hea/fh Section too P.O. Box 848/210 Hospital Street AUG 3 Mocksville, NC 27028 N (336)751-8760 , * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED TION IS PROOVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed motr U l 1 Contact Person Mailing Address O? l I lea V °yy -Smoc, (L17 Home Phone 336 L62- No J City/State/ZIP 6060;Ile /V C 2-70 Z 0�jBusiness Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �te Evaluation / } ,Mtnnp,+�ront Permi /ATC ❑ Both 4. System to Service: ❑ House Mobile Home 13 Business E3 Industry ❑ Other S. Type system requested: IA Conventional ❑ conventional modifiedE3 innovative u 6. If Residence: # People # Bedrooms 1 # Bathrooms *ishwasher .❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) s. Type of water supply: ❑ County/City [ Well ❑ Community 9. . Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes No If yes,what type? 'IMPORTANT***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: ' WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN. # 7 I )-( O Gel N � �►- �-( /� � � �t ' �c rk Property Address: Road Name�',(l S ( f.1 © '� C City/Zip �� If in a Subdivision provide information,as follows: 1' -e c--,- C 7) "�`� C�' Name: . T Section: Block: Lot: Date home corners flagged: I 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 for all charges incurred frons 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.alllttesting procedures as necessary to determine the site suitability. DATE D ��/'0 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge 0 0 Client Notification Date: EHS• Sign given 4 Account No. 'Y5 Revised DCIID 5/03 Invoice No. 74 5 ' 108 5.13A ° 9564 (4.70A) r- 9210 A 271 N M \ 1 1. l� t DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003345 Tax PIN/EH#: 5801-78-9210 Billed To: Mary Lou Coley Subdivision Info: Reference Name: Location/Address: 271 C.V.Smoot Lane-270 8 Proposed Facility: Residencec Property Size: 2 acres Date Evaluated: C� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring 1r� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON-1 DEPTH. ®— Texture ou S,c t- �`GL Consistence % �� Structure. Mineralogy HORIZON II DEPTH t Z -Li 1& Q Texture group C_ 01 Consistence s Structure Mineralogy7C HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 4_ut %'10T1 L.4fl(:p 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 Mineralogy 1:1,2:1,Mixed Notes Horizon depth-In inches 1 1 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 05/99(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■eww■w■■■■■■■■■caw■■w■■■�w■■■■■■■ell■w■e■■■■■/■■■■■■■ ■■■■■■■■■■■■■s■www■■■ww■w■�■■��a■■■■■e■■■■■■■w■■Ilw■ew■■■w■■■■■■■■■ ■■w■■■w■ww■■ww■w■w■w■■■■■■asses■■■a■�:e■w■■wsw■s■■■w■■■■■■w■■w■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■erns■s■■°r�i■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■Irl■■■■e■■■■■/■■■■■■■■■■■■■■e■■■■■■■■■■■■■ MENNENEMMEMMEAMEMsi5,iiiiii iiENNEN iMENNEN ■■■■//■■/www■/■■■s■w■■■■■■■■■■■/■■■■ww■■ww■w■■■■■w■sw■■■■■w■■■■■■■ ■/■■■■w/■w■e■■w■■■■■w■■■■■w■■■w■■■■■■■w■■■■w■■■■■■■■w■■w■■ww/ww■w■ ■■■■■■■■w■w■■■■w■■■■■■■■w■■■■ww■■■www■w■■■■w■■■■■■w■w■w■■w/w■ww■■■ ■/■■■■■■■■■■■■■■w■■w■/■■■■■w■w■■■■■■■■■■■■■■■■■■www■■■■■■■■w■■■■e■ ■w■■■w■■w■w■■■■■■■■ww■www/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■w■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■■w■■■■■w■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■w■w■■w■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ J ^ .. , . « © 5 9'64MnB2 . \ \ § . � . . . m a, . « y ^\/ }��