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533 Davie Academy Rd� , ' . DAVIE COUNTY HEEALTH DEPARTMENT . ' Environmental Health Section P. O. Boz 848/210 Hospital Street Mceksville, NC 27028 (33G)751-87G0 Account #: 990002095 Bilted To: Walter Austin Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT � i.� _� .� Tax PIN/EH #: 5727-05-4950 Subdivision Info: Location/Address: Davie Academy Road-27028 Property Size: see map ATC Number: 3046 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALITHOWZATION 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 2. Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size `r�c Type Water Supply � Design Wastewater Flow (GPD) � Site: New �Repair � System Specifications: Tank Size� GAL. Pump Tank GAL. Trench Width��Rock Depth � Linear Ft.��% Other: Required Site Modifications/Conditions: INIPROVEMENT/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 of this 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 (33C)751-87(►0.**** � i� � ✓ Environmental Health Specialist's Signature: Date: ��/��'�? DCHD OS/99 (Revised) �6 (� � Account #: 990002095 Biiled To: Walter Austin Reference Name: ATC Number: 3046 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5727-05�4950 Subdivision Info: Location/Address: Davie Academy Road-27028 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). 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 WASTEWAT O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Si�ature: �� Date: .% ��d '�L-- CERTIITCATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. � �� n� �� Septic System Installed By: Environmental Health Specialist's Signature : DC�ID OS/99 (Revised) ��Date: "� ��j � �/ • , . ,� • ��' � APPLJCA710N FOR SITE EVALUATION/IMPROVEMENT PEIi611T & ATC Davie County Health Department � Environmenta/Hea/th Se�fion P.O. Box 848/210 Iiospital Street Mocksville, NC 27028 (336)751-8760 ��v(ia '� ***IMPORTANT*** THIS APPLICATION GANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOF2MATION IS PROVIDED . Refer to the INFOF2MF.TION BL3LLETIN for instructions . 1. Name to be Billed G✓,�-/�e� P�-f % Gt� �USi./1/ Contact Person (,(//�,�T �j � Mailing Address �'S� � �/l� U% P �/�%r L°'!Ll 1/ � Home Phone �3GP -- ��'j Z— �%3%Q -�JD �_� City/state/2�P '��.�LSlitl�e /1�C �%42� Business Phone ��/-S`/� -s�� y �� 2. Name on Permit/ATC if Different than Above�.�p[�r /�- f��12 L�� !/S /-� �✓ Mailing Address City/State/Zip �� g -� �. c� 3. Application For: L+1�5ite Evaluation ❑ Improvement P rmit/ATC ❑ Both a. syst.�m to ser�ice: O House �obile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _�_ # Bedrooms _� # Bathrooms 2- ►.i'Dish�rasher U Garbage Disposal C�}'iiashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industxy/Other: Specify type # People # Sinks # Co�odes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Tjtpe of water supply: H�ounty/City p Well ❑ Community e. Do you anticipate additions or expansions of t6e facility this system is intended to serve? If yes, what type? ❑ Yes �'� ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRCD PROPERTY INrORMATION REQUGSTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITT'ED 6y the client with T1iIS APPLICATION. Property Dimensions: l y�� l� �� .J�/,�-,�it" Tax Office PIN: # �� — � S '�` / �d Property Address: Road Name 11i4 � i e !�' c�' �!� City/Zip lf in a Subdivision provide information, as follows: WR(TE DIItEC'I'IONS (from Mocksvillc) to PROPGRTY: l � l�/ �'r� �r�-��Pr.%h n 7�v �dl/�i'��t-fjPen/�il� �'v.F'N /`jsh� %�/� bi C/'�1�t'A� Y�C S�'it ts/S � ds✓ �� Name: Section: Block: Lot: Date Property Flagged: ` ! b�-- This is to certify that the information provided is correct to the best of my knowledge. I undcrstand that any permit(s) issued hcreafter are subject to suspension or revocation, if the site plans or intended use changc, or if thc information submitted in this application is falsified or changecl. I, also, uitderstmrd t/iat I Rm respo�rsih[e jor nll charges incurrerlfro�s ilris application. I, hereby, give consent to the Autl�orized Representative of the Uavic County Iify� Ith Department to cnter upon above described property located in Davic County and owned by ��/�� /`: L� to conduct all testing procedures as necessary to detcrminc the site suitability. DATE ��0.2- SIGNATURE GL/G•c�t �/'J�.c�� 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). Revised DCHD (07/99) �S-- 6 � � � � Q� L - �t'�v(- ` c. ii'',,--,-�' /� o 0 �i�v �0�7�,�,� � Sitc Revisit Chargc Datc(s): Clicnt Notification Date: EHS: Account No. ` Invoice No. � 7� i � � � (250) (4.72A) 1915 (148) � (1.90A) �- 2�80 SR 1147 (148) K300000020 (1.90A :�� (290) -,-- . .' . . 3.28A i ) 780$ (166) (1.88� 983� , ' ' ' DAVIE COUNTY HEALTH DEPARTMENT �� '' Environmental Health Section sECTiorr LOT SoiUSite Evaluation � / ` APPLICANT'S NAME S" ��" DATE EVALUATED /�-S �� PROPOSED FACILITY �tt� PROPERTY SIZE / T'��/ SUBDIVISION ROAD NAME ��G �� Water Supply: Evaluation By: �.i.H��iri�.H i iviv r rovr._T�uTvr err On-Site Well Community, Auger Boring � Pit SITE CLASSIFICATION: � LONG-TERM ACCEPTANCE RATE: . REMARKS: DCHD (O1-90) Public 1� Cut EVALUATION BY: OTHER(S) PRESENT: LEGEND � Landscape Position R- Ridge S- Shoulder L- Lineaz 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 Mois 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 - gaUday/ft2 ■ ■ ■ ■ ■ ■■�■��■�■■��■�■ ■��■��■�■■��■�■ ■��■ ■■��■��■�■��■■ ■■�■��■■��■■�■ ■ ■ ■ ■ ■ ■ ■■■ ■■��■ ■■�■■ ■�■�■ ■��■ ■■��■ ■ ■ ■��■ ■■��■ ■�■�■ ■�■■■ ■�■■�■ ■��■ ■��■■ ■■�■�■ ■�■■�■ ■��■■ ■��■■■ ■■ ■�■■�■■��■■��■��■■��■��■�■ ■■�■��■��■�■■��■��■�■�■�■\■ ■��■�■��■■��■�■��■■��■■■��■ ■��\�\�� ■■�■��■■��\��■��■■��■■��■��■■■�■ ■��■��■��■■��■■��■��■■��■��■ ■��■�■■�■�■��■■��i■��■■��■■��■�■��e ■■■��■��■��■��■�i�■■��■�■�■ ■■■��■■��■��■��■��■■��■■��■��■ :��►i��■ ■��■ :�:�.�■��■■��■��■�■■■��■ ■■�■ ■■��■��■-��i�■��■��■��■��■ ■ ■ ■■ ■■ ■■ i�i ■ ■■ ■■ ■ ■ ■ ■