Loading...
620 or 658 Fred Lanier Rd ' DAVIE COUNTY HEALTH DEPARTMENT �• Environmentcal Health Section �, � P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 .�'�, ,� (336)751-87G0 � ► N IMPROVEMENT/OPERATION PERMIT Q � Account #: 990003257 Tax PIN/EH#: 5719-29-9196 Billed To: Joe Gobble Subdivision Info: Reference Name: Location/Address: Lanier Road-27028 Proposed Facility Residence Property Size: 7 acres ATC Number: 3801 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION FOR WASTEWAT'ER 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 PERNIIT 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 L� #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�� Design Wastewater Flow(GPD)�� Site: New�Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widt�,�'� Rock Depth���Linear Ft.�` Other: �D� Required Site Modifications/Conditions: I1VIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FiLTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparirnent for final inspection ofthis 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(33G)751-8760.**** t � � Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) L , l . DAVIE COUNTY HEALTH DEPARTMENT �.l•- �v`� � • Environmental Heaith Section /� ' � �_ � p.�.Boa 848/210 Hospital Street - .. - . Mceksville,NC 27028 : . (336)751-8760 Account #: 990003257 Tax PIN/EH#: 5719-29-9196 Billed To: Joe Gobble Subdivision Info: Reference Name: Location/Address: Lanier Road-27028 Proposed Facility Residence Property Size: 7 acres ATC Number: 3801 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 Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONS CTION IS VALID FOR A PERIOD OF FIVE�YE . Environmental Health Specialist's Signature: Date: 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. � Septic System Installed By: �!L�'J�'J'l�l� n Environmental Health Specialist's Signature: ��� Date: � � d DCHD OS/99(Revised) d v , ;'�'� � � R .,' t�n � C1 �` � . �� C,1 :�jt �, E LICATION FOR SITE EVALUATION/IMPROVEhtENT PERMIT& �Q �f ,r,.,� Q 2��` : Davie Coun Health De artment " � � d.r • �Y p �` � --•il'�`'+ Environmenta/Hea/fh Section � �U J' , � A����i P:O. Box 848/210 Hospital Street N /�?QO " .�43"R��M�fA�t,n Mocksville, NC 27028 4 DA� (336)751-8760 �RONM • ---- . �a�iF�r�H�a� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIR INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN �or instructions. 1. Name to be Billed Contact Person Mailing Address � �� -(�""� �• Home Ph4+�v City/State/ZIP %��O�G/1/J?� h �•C•s �' f �2� Susiness Phone �,�����tL'�Z�•� • 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC �7 Both 4. System to servtce: � House Cl3" Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: t� Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People � # Bedrooms �_ # Bathrooms _�_ ❑Dishwasher ❑Garbage Disposal LF1Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing t 7. IL IIu�iness/Indu3try /Other: verify type 1{ People # Sinks` � N Commodes # Showers # Urinals $ Water Coolers _ IF FOODSERVICE: # Seats Estimated Water Usage (galions per day) _ a. xype ot water supply: tld' County/City ❑ Well ❑ Community 9. no You anticipate additions or CXpAi1S101]S 0�IIIC rlClllfy'tI11S SySlClll 1S(IifCI1�C(I f0 SCI'VC��Ycs 1�No If��cs,wliat typc? ***IMPORTANT'�**CLIGNTS MUST COMPLLTE THG REQUIXED PROPERI'Y INrORMATION RGQUCSTL'U I3ELOtiV. Cithcr a PLAT or SITE PLAN MUST BE SIIBNII7TED by thc clia►t tiviti�TIIIS APPLICATION. �.- Property Dimettsions: � �2LG. 1VRITE DIRLCTtONS(from 111ocl:svillc)to PROPIiIt'1'1': � ��'ax Of�cc PIN: �� .��i ����-�1 q.6' � .�� � f��- , ���o �����s � � � � �Q� /� �� �t j��/ I'roperty Address: Road Namc a�� !'�� _L�v�-G lri' ����Lv1 /"Y�! , � `/ "��� � .. , City/Zip Z �O Z O � ��-�G' ��►.�L, d31. i�l� Q � � _.. . If in a Subdivisiai providc information,as follows: :/IJ�w� .J`�� _ Namc: ` _ __ _ Section: Block; Lot: llate home corners tlagged: � " 7 � a �' Tl�is is to certify�ttiat tl�e information provided is correct to tlie best of m��Iccio�vledge. I uiiderstand tl�at any per�nit(s) issued liercafter are subject to suspension or revoc�tion,if the site plans or intended use change,or if the informatiou subu�itted in tliis application is falsiticd or clrmged. I,nlso,«�r�lerstanrl tlrat I rrnr respo�rsiGlc for nll clrargc.�s i�rccrr•red fr•a�r tltis applicnliar. I,l�ereby,give consent fo the Autl�arizc�I Representative of tlie Davie County Ileattl�llepartment to enter upon above described property located iii Davie County and o�vned by �e F G r�6 -z- to condurt all teslinb procedures as necessary�to determine the site suitability. DAT� b � j 7`� d � SIGNATUItE 1'IiIS AIt�A MAY BE US�D I+OR DRAtiVING YOUR SITE PL (Includc all of tlic followiiig: �sisting atid proposed property lines an�dimensions, structures, setbacks, and septic locations). � � _ Site Rcvisit Cl�nrgc_. / _ _ .. . _ . /� _. _ Datc(s): � `� , . ��� _ ; , � _ _ _. _ _ . . ._. _ _ _ � � Clicnt Notificatioli Datc: _. EHS: F\ . � Sign given �l ��, . ccowit No. ��� � V � � t/ Rc�•ised DC1 D (OS/03 .�((,� � Inv icc No. � I\ � \ ' r1k ' � .� �--�. . . . . . . � . .. . .. 1 , . . . . . . . . . . . .1" . ` ' ' DAVIE COUNTY HEALTH DEPART'MENT � ' �� Emironmental Health Section • : Soi�/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003257 Tax PIN/EH#: 5719-29-9196 Billed To: Joe Gobble Subdivision Info: Reference Name: Location/Address: LanierRoad-27028 Proposed Facility: Residence Property Size: , 7 acres Date Evaluated: p�2 `��`�� Water Supply: On-Site Well Community Public !/ Evaluation By: Auger Boring Pit 4 Cut FACTORS 1 2 3 4 5 6 7 Landsca osition ' Slo e% HORIZON I DEPTH Texture rou Consistence Swcture Mineralo HORIZON II DEPTH �l p� ' Texture rou Consistence .�'< ' Structure / ♦ Mineralo / t� : / HORIZON III DEPTH Texture rou Consistence � Swcture Mineralo . � `HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: EVALUATION BY: �G^� LONG-TERM ACCEPTANCE RATE: �' ' OTHER(S)PRESENT: REMARKS: 1 LEGEND ' Landsca�e 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 day 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-Slighdy plastic P-Plastic VP-Very plastic tructure . 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 otes • 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/ff2 DC�ID OS/99(Revised) ■�����������■■��■���s■�■�■■�■■��■■��■�■�■■��■�■��■�■■�■�■�ot�■���■ ■���■��■��������■�■�■�����■�����■■■�■�■��■�������■��■��������■ ■�■ ■�����■���■�����■�■����■■�■������■���������������■�■��■��■�� ■■ ■�■����■s�■���■����■����■�■s�■�■ ■��■�■��■����■���������■■�■��■�■ ■��t■�■�■�■�■■■����■■■��■�■■�����������■�■■■����■■■�■��■�■�■■�■■�■ ■����������■■�■■�■�■�����■■■���������■����■������������■�■■■■■■■�■ ■������■�■����������■�■■�■�■��■������■��■�������■��■■�■■��■■�e��■■ ■■�■���■■�■�����■�■�■��■�■■��■���■��■���■■■���■■■■�■������■�■���■■ ■■������■�■����■�����■�■�■■��■��■■■�����■���■�■�■■����■����o����■■ ■■■����■��■������������■■�■��������■■ ■��■����■■■■��������■�����■■ ................................�...C............................ ................................ ................................ .................................................................. .................................................................. ..................................�............................... ■��■�■��■■������o���■������■■��■■�s■�■�■■�■�����■�■��w���■�������■ ■■�■���■�■���■����■���■■�■�■��■�■■�o■�����■■������■�■��■��■������■ ■�■�■��■�■s��■■�■�■�■��■���■■■■�■■�■�■■�■�■■�■e���e■�■■����■�����■ ■■����■■��������■�■���■■�■��■■■��■�■�■��o■■�■����■■�■■�■�■■����■■ ■�■�����o�����■����■■�����■����■ ■■���■■��■�■����■���������■��■�■ ■���■��■■�■■��■�■�■�����■o■���■��■■�■■■����■■���■■■■�����■����■��■ ■�■�■���■�■■���■��■��■■�■��■���■�■■���■�■■�■��e����■■����■�����■�■ ■�■�■����■�■��■■��■■�■��■■�■���■��■����■�■����■■����■�ee■�������■■ ■���■����■�����■���������■�■■��■���■�■�■■■■��e■�����e����������■■■ ■■���■■■����■�������������■■■■��■���■���■�■����■■■■■■�■��■�■�■�■�■ ■■�■��■■�■���■�■�������■■■��■■■�����■������■��■��■��■��■■■���■■��■ ■��■���■■�■�������■������■■�■�■��■�o■■�■��■■�■■�■��■�����■�■■�■■■ ■��������■■■����■�■��■■�■����■�■ ■�■s■�■��■e�■e�e��■■�■■��������■ ■���■��■■�■���■�■�■■■■■■■����■■����■■■s���■■�■�■�■■��■�����■■■■■■■ ■�■�■�s���■■��■���■■�■■�■��■���■��■�■�■■��■����■��■■�■■■�����■■■�■ ■���■������■■�■■���■�■��■��00��■■���o�����:iO��������i■���■��■■■■■■ ■■■���■■■■���■■■■�s'■■■■■■��������������!%1+����■�����■■���■�■■■t�■ ■■�■��■��■�■�■�■��1'1���■■�����■■���������rr!■�■�����������■���■���■ ■■�■��■■�����■���ivl.l����■�■■�■■■��■■■�■■■I�����■�■■■■�■�■�■��■■■■ ■■�■��■■���v�■��■���a��■�■��■■■����■■�����e�����■■■��■��������■�■ ■��■���■��■���■�■■�����■��■���■■ ■■■■■��■�s■�■�■��■■e����■����■■■ ■�■��■�■■�■���■�■��e���■��■���■�e■■�■����■�■�������■■■�■�■■����■■■ ■����■�����■��■���■■■■�������■■���■��■�■�■o�■�■�����������������■■ ■�■���■����■��e■�����■■���■����■����e■�■■s■���■■�■�■�������������■ ■■�■�����■�■���■��■■�■■�■■�■���■��■■�■��■o■���■■■�����t����������■ ■������■�■����■■��■■�■��■■���■�■��■■����■�■�■��■�■■�����■�����■��■ ■■���■■■�����■�■�����������■■������■����■�■e■■�■■■■��■�■■■��■■■■■■ �iiiiii�iiiiiii�iiiiiii�iiiiiii�iiiiii�iiiiii�iiiiiii�iiiiiii� ■�■����■�����■�■������■■�■■■■■■���������������■��■■���■����■■■��■■ ■���■�����■�������■■■�■■�■��__===::::::■���■�:��■�■����■���■■����■ ■������e■�■����■■���■���:����■���■��■��������������■■��■����■���■�s ■�■■���■��■��������■���i��■��■■�������������■�■n�■�■■�■�■�������■�■ ■■��■■�■��■�������■�o��i��■��■�■�■■������������n��■�■■����se�■�■■■■ ■����■e���■■■���■■■�■��i���■�■��■�■■�■■■�■�������■����■���■■�����■■■ ■■■���■�■■■■��■�■�■�■��i�■�■���■■�■�■��■■�■���u■�■��■■�����������■ ■��■�����■�■�����■�����i�■�■����e ■■�■■■����������■�������■���■■��■ ■��■�������������■■�o■�i�■■■■����s■■■��■��������■�■������■�����■�■■ ■�����■��■�■��■■■■���■�i�■■■■���■��■����■�■��■�i■■�■�e�■���■■�■■��■■ ■�■■��■■�����■���■�■�■■i�■■�����■■�■■�■�■�����r���������■����■■���■■ ■�■�■������������■�����i■�■■■■■�����■���■■■�■�u��■�■��■■■■�������■■ ■■■�������s��■■�■�■��s�i�s■��■■�■■��■����■��■�i�■��■�■���������■■■■■ ■■e��■■��■■��■�■■�����■i�■■■�����■■....=���===�■�■■■■■■■�■�����■��■ ■����■■�■■■�������■�����::��■�■��ii������■�■�■��■��■■■■■■���■■��■ ■■�■�����■■■����■�■������■■■■�■■ ���������■��s■■■��■�s�■■■����■��■ ■■�■�����■■�����■■■������■■�■��������■■�■�■�■�■■■■■����■■�s����■�■ ■■�■�■��■�■���■�■�■�■��■�■■�■����:�■■■■■■�■�■��■■■■■■�■■■�■������■ ■��■�■■����■■�■�■����■�■����■■■���■■■�■�■�■����������■��■■■�����o■ ■��■�������■■�■�����■■■■����■�■���■�■■��■�■��■��■�■�■���■■��■�■■�■ ■�■■■������■■■■������■■■■�■���s��■■�■�■■■e■■■■�������■■���■■�����■ ■�■■■��■���■■■�■�■�■■■■■■�■�■��■�■■�■■��■��■����e��■�����■■�■■■■�■ ■�■�■■���������■�■■■�■■�■�■■�■������������■�������■s�■����������■ ■����■■�■����■�■■■■�■���■■■■�■■v ■���������■��■���■��■����■��■��■ ■■■��■■�■■■�■■�■������■��■�■■e�■�■■��■■■■■�■■■■■■■�■■■■■■■■■■�■�■■ ■■����■■�■■�������■�■�■���������■�■■�■■■�■��■����■■�■■■��■■■�■�■�■ ■��■■�■■�■�■��■���■�■�■■�■���s��e����■�■�■■������■■�■■■■■�■���■��■ ■�����■■■■�■������■�■�■■■■�����������■■■�■��■������■�s�■■■■����■■■ ■■■■■��■�■■■��■�■�����■■�■�����■���■�■■■�■������������■■�■������■■ ■������■�■����■�■�■�■�■��■�■���■���■��■��■■���■�����■�■■■■■�����■■ ■■���t�■�■�■��■■■■■■■������■■■■■��■�■�■■■■e■�■�■■�■����■■■�����■■ ■��■■����■�■�■■�����■��■�■�■■■�■ ■��■�■��■����■����■��■■�����■■�■ ■����������������������■�■��■■■■■��■���■■������■■�����������■�■��■ ■�■�����■�����■������■�■■�■���■�■■��������■���������■�■�■������■■■ ■■■�■■����■�■■�■■■■■�■■�■�■�■�■��■■■■■■�■�■���■�����s��������■��■■ ■�■��■■��■■��■�■�■�■�■■�■�■�■■■�■�■■■���■�■������■�■��■�■����■��■■ ■�����■������■�■�■���■��■�■��■■����■■���■��■�■����■���■�������■■�■ ■����■���■■��■�■■�■���■�■���■����■■�■�■������■■■■�■�■�����■�■■■■�■ ■�������■���������s�■�■�■����■■��■�■�■■���■���■■�■��■s■�■�■■�■�■■ ■���■�������■■������■■�������■■■ ■�����■�■■�■�■■�■����■��������■■ ■■■�■■���■■■����■�■���■�■��■�■■■�■��■�■o�■�■����■�■��■�so�■��■���■