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148 Gordon DrDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002956 Tax PIN/EH #: 5862-34-6398 Billed To: Van & Tanya Thomas Subdivision Info: Reference Name: Location/Address: Gordon Drive -27006 Proposed Facility: Residence Property Size: 1.71 acres ATC Number: 3605 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 CONST2//RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � �/� Date: ` 101 '21V - ,?� 3 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system de ibed on Improvement/operation Permit has been installed in compliance with Article 11 of G.S. Chapte 130echo 900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarapf at the em will function satisfactorily for any given period of time. It Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r• ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002956 Billed To: Van & Tanya Thomas Reference Name: Proposed Facility: Residence //,-00 DPW_ ( t - / 0---03 Tax PIN/EH #: 5862-34-6398 Subdivision Info: Location/Address: Gordon Drive -27006 Property Size: 1.71 acres ATC Number: 3605 **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 SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. �1 � Residential Specification: Building Type T✓ #People #Bedrooms ? #Baths -S Dishwasher: 2 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 Sizey2AL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth /_J Linear Ft.SUU IMPROVEMENT/OPERATION PERMIT LAYUT - APPROVED EFFLU FINISHED GRADE. ****NOTICE: Cont ct r esentativeofthe Davie system between 8:30 a.m. to 9:30 a.m. or 1:00.n to 0 p.m. on the da f inst f, T FILTER. RISER(S) IF 6 " BELOW Health Department for final inspection of this do elephone # is (336)751 0� 14, Environmental Health Specialist's Signature:X�4 -)Z Date: `j DCHD 05/99 (Revised) M OCT 2 1 2003 1 t. UPATZOVENTAL HEALTH DAVIE COUNiY )N FOR SITE EVALUATION/IMPROVEA1ENT PERMIT & ATC Davie County Health Department EnVir0n1nenta/flea/ih Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. r 1. Name to be Billed/d1s Contact Person / J _`�' -yam_ z 6 Mailing Address / / Home Phone City/State/ZIP 5 �� tL/J` anti M Bu�3se`ss hone �� ' �� ,S� 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Sittee Evaluation ❑ Improvement Perinit/ATC �th 4. System to Service: Lf House ❑ Mobile Honle ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: #People _� It Bedrooms #Bathrooms 'Mishwasher Garbage Disposal LlWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type It People It Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE:. # Seats Estimated Water Usage (gallons per day) .� 8. Type of water supply:County Gam` ❑ Well ❑ Community S. Do you anticipate JIditions or expansions of the facility this system is inti de serve? 1:1Yes No If yes, what type? ***IMPORTANP** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. d? 00 3_�7C, X `� 9XR� 1 ' 7 /( c Property Dimensions: [ TE DIRECTIONS from Mocksviilc) to PROPERTY: Tax Office PIN: it 5 Property Address: Road Name t - _ GtGZd't% / 1 city/zip C-0 / �(� /� If in a Subdivision provide information, as follows: 6-12 %'L " � Name: a) �Cl � 600 10 Section: Block: -?Lot: Date home corners flagged: - (o I+L 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 atu responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County I-Iealth Department to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE -�— /O "oC ! - SIGNATURE 1! GL 1 r 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). Sign given Revised DCHD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No.� y.� ✓ 333 DAVIE COUNTY HEALTH DEPARTMENT a Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002956 Tax PIN/EH #: 5862-34-6398 Billed To: Van & Tanya Thomas Subdivision Info: Reference Name: Location/Address: Gordon Drive -27006 Proposed Facility: Residence Property Size: 1.71 acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring 1.�/ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 6 - HORIZON I DEPTH e �� Texture groupL L Consistence Structure Mineralogy HORIZON II DEPTH 'Vo'• Texture group Consistence Structure k/ f Mineralogy 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: LONG-TERM ACCEPTANCE RATE: / REMARKS: EVALUATION BY: / ?/ // 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 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 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) ■ ■ ■ ■ ■ ■■ ■■■NOON■I■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■IZM ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■ ■ ■■■■■■■■■■■■■■■■■■■ NONE ■■N■ SOME