The URL can be used to link to this page

531 Gladstone Rd. r DAVIE COUNTY HEALTH DEPARTMENT --i� t Environmental Health Section % y P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003114 Tax PIN/EH #: 5736-73-4133 Billed To: Tammy Brown Subdivision Info: Reference Name: Bea Brown Location/Address: Gladstone Road -27028 Proposed Facility: Residence Property Size: 3/4 acre 20 **NOTE * Theis improveme t/Operation Permit DOES NOT authorize the construction of 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 I 1 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 '00w� #People #Bedrooms ,,f #Baths Dishwasher Garbage Disposal: ❑ Washing Machin 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 SizeJAP dGAL. Pump %Tank GAL. Trench Width caw' „ Rock Depth J,Z ' Linear Ft.ls' Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****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. t . on t e f installation. Telephone # is (336)751-8760.**** r 1 1i Environmental Health Specialist's Signature: �&11 Date: ,-- DCHD 05/99 (Revised) Account #: 990003114 Billed To: Tammy Brown Reference Name: Bea Brown ATC Number: 3720 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5736-73-4133 Subdivision Info: Location/Address: Gladstone Road -27028 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 CONSTRUCTI N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: / Date: a 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: Environmental Health Specialist's Signature: 41 1 / / Date: DCHD 05/99 (Revised) DEC N FOR SITE EVALUAT10N/IN111110MILYf I1L•11MIT Sc !l1'C ----�" Davie County Health Department fnYironmeota/Hea/t/1 Section FEAR 1� 2 04 .0. Box 848/210 Hospital Street Mocksville, NC 27028 EljVlRONMENTAL HEALTH (336)751-8760 ** THIS APPLICATION CANNOT DL•' PROCI;SSP:D UNLESS ALL HE REQUIRED - INFORMATION IS PROVIDED. Refer Lo the INFORMATION BULLETIN for insLructiorla. 1. Name to be Dilled /C.(./t�l T t7W/(7� ,1 ConLacL Person ��✓'� _[/_ /, G / Mailing Address % 2. y /^ 0,4 �^t[3c h R0, Itomc Plionc City/State/ZIP /190Ct7it,/ //l IU,(f 2702-.7"" Duuiness Phone cloq 2. Name on Permit/ATC if Different than Above Be C'_ � (O C.i Y\.— Mailing UMailing AddressG� /-10.4- 9 C C I— City/StaL-o/Zip M OCA 4 S 6,r '%1�-f Z.?O 2; 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC 11oLh 4. System to Service: ❑ House 00101ob.ile home ❑ Dusinets ❑ Industry ❑ Otllcz 5. Type system requested: n Conventional ❑ conventional modified ❑ iunovaLive G. If Residence: It People II Bedrooms 11 Bathroom;; E Dishwasher []Garbage Disposal II✓JWauhing Machine ❑Base:nenL•/Plumbing ❑Ba::ement/lto plumbing 7. If Business/Industry /other: verify type II People It Sinks & Commodes It Showers U Urinals 11 WaLer Cooler:) IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: Lf County/City ❑ Well ❑ Conununity 9. Do you anticipate additions or CXpallSiolls of the facility this systclil i5 ill(ell(le(1 to serve? ❑ Yes tl if ycs, what type? 'IAIl'ORTdN1' " CLIENTSAIUST C0AIPLLTLTI1E3 1U QU11tED PROPERTY INFORMATION RE'Q11ESTISU BELOW. Eithcr a PLAT orSITE PLAN AIUSTB—rSU11rlf17'TBD by the ciicut )1•illi T IIS APPLICATION. Properly Diuullsiolls: �C� tel(?, )YRITE DIR1;C1'IONS (frons 11•ludisi•illc) to PROP1;1('I.Y: ;1X Office PIN: 1157 3 i� 73 cl ! 3 3 (0 t S, o sacs S�m&e— (21 Property Address: Road Nal �' 10'J'540 m. N C��<zw+yv� � °c. O h Le -F4 1 City/Zip InoC b.S U i e %a�� /l 146 DOvbke U l a — beuk If in a Subdivision provide infornlalion, as follows: >\ze e kc Naulc: Oe- Section: Bloch: Lot: Date Ilonle corners flagged: This is to certify that Elle infornlatiou provided is correct to the best of illy kilowledge. I understand tliat any perwit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if Ulc iuforluatiuM subnlitted ill this application is falsified or changed. 1, also, understand that 1 aul re3ponsible fur all Charges ill eurn'11 /i•uul this application. I, hereby, give couscut to the Authorized Representative of the llavie County Ilcaltll Dep:u 'hies t to cuter upou above described property located in Davie County and ulvncd by to cunduct all testing proccdures as llecc55ary to determine the site suitability. DATE 3 — l -7 — Q �-/ SIGNATURE TI1IS AREA MAY BE, USED FOR DRAWING YOUR SITE PLAN (Include all of the fullolvillg: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). < v LSLer c— /Y Sign given Revised DMID, (05103 Site Revisit Charge Dale(s): Client Notification Date: EIIS: Account No. f 5'Q.u.Ln,v�-�ty `l �% Invoice IND. `233`w , 8468 7430 is ° 7 g` e 9390 r 828 88 i w4v t } 0861 J` (_ >A; , ' 3F1�;1 F (10 72A) (1.23 , � - °r'' ` 3513 (1 } 8689 (1.32A) y 4505 19 2554 L��`i 33Aj 77 15 rn W 1.030A a: X387 7333 . 4 p ' .70A) (1.119 !g 3229 ('�` 1 9 49z 1.01A 2129 A- 91 _ 4133 4 X— 484 ert 'S k�� 9015 �os a T C-D 41 r4 v./J 19045 28 ,78 � e 8 20085 (1. 1 r a t r V. 9 ,i9 ROAD ' sH 117e - " 14 m . 150 x x °2625 69A) a, 23�`A) q �^ ! $630 a �', x 4 11 i M O ( �� • 2.98 us a A- `ter• v 06sj sss G� ro oy � (2,2 A) i _ a! 42! 5481 ' '(1Ir Go a 03 ® �1 V, A G (1.41 A) 9198 , 9045 96 t (=✓ .:1 +tea (98 44A� ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003114 Billed To: Tammy Brown Reference Name: Bea Brown Proposed Facility: Rsidence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5736-73-4133 Subdivision Info: Location/Address: Gladstone Road -27028 Property Size: 3/4 acre Date Evaluated: Community Evaluation By: Auger Boring LZ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % " HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH it Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE r CLASSIFICATION LONG-TERM ACCEPTANCE RATE G SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: �Ah // 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 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 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) ■ ■ ■ ■ ■■ME■■ ■EMEM■ ■E■E■■ ■E■NE■ ■■■u■ ■■■ ■ ■■■■■■ ■E■ OMEN ■OO■ ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ONE mom ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 0 ■ -- - --- -- __ �r __ _ ____- - ----- -- __ _---------- _ --- --- _-- ------ 6 v __ .._ _... ------- --_ ___ _----- _ _ _-- _— _- -------_ ��r, - __ __��. _� reZ�'Zf'_ .�_ - -- _ --- - _. .-- - Q ��'� - - -- - - _ _ __ ___ _ __ ',