Loading...
375 Howardtown Circle• t DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 Account #: 990002891 Billed To: John Lloyd Reference Name: Proposed Facility: Residence ATC Number: 4784 OPERATION PERMIT Tax PIN/EH #: 5861-22-1768 Subdivision Info: Location/Address: Howard Town Circle -27028 Property Size: 10 Acres **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. d System Type: S.T. Manufacturer Tank Date — Tank SizeA& a v Pump Tank Size / System Installed Ey:9' Of!�( 64K E.H. Specialist -Date: C iy Uw cc—G{ J Gfi✓ v DCHD 11/06 (Revised) 16 J Q s DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002891 Billed To: John Lloyd Reference Name: Proposed Facility: Residence ATC Number: 4784 Tax PIN/EH #: 5861-22-1768 Subdivision Info: Location/Address: Howard Town Circle -27028 Property Size: 10 Acres Site Type: egew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A . Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms # Bathrooms # PeopleA Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size 5.13 % c,,# Type of Water Supply: ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)%6�-�Iink Siz00�10- AL. Pump Tank AL. t t. � A/ / Trench Width G Max. Trench Depth3 G Rock Depth r't inear Ft. � Site Modifications/Conditions/Other: /,S -stated in 1:ti Nets �Sr1 19l;�31re �' P10 c�� OL -1 Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. -14 Environmental Health DCHD 11/06 (Revised) v- & r r � C c�gdd400 � J3 pal V' i �W, DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville NC 27028 �O✓ v ea l m 511 (336)751-8760 Fax # (336)751-8786 OW", /' 'AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002891 Tax PIN/EH #: 5861-22-1768 Billed To: John Lloyd Subdivision Info: Reference Name: Location/Address: Howard Town Circle -27028 Proposed Facility: Residence Property Size: 10 Acres ATC Number: 4784 Site Type: ,0?*w akepair ,Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms 4( # Bathrooms 3 # People_ Basement❑ Basement plumbing❑ Non -;Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: 76ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) q90 Tank Size 660 GAL. Pump Tank GAL. Trench Width Max. Trench Depth 3 ( Rock Depth Linear Ft. �d0 As stated in 15A NCAC 18A.1969(5) Site Modifications/Conditions/Other: eeeepted SYstemr. may Iso he asp Contact the Davie County Environmental Health Section for final insl 8:30 9:30a.m. on the'dav of installation. Telephone # -e -ejo YS O �. � M-6, �:: �l pwvH P Cf X51^ �\ w AIA \ e � �,tjQ ��.c• ,� � of this system between el .1eA .. T(., v.cti �) 0 -H C) V e"1 r N c`e a Environmental Health Specialist . Date: DCHD 11/06 (Revised) t4 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account M 990002891 Tax PIN/EH M 5861-22-1768 Billed To: John Lloyd Subdivision Info: Address: 158 Indian Hills Road Location/Address: Howard Town Circle -27028 City: Advance Property Size: 10 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a was system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: _iew RV epair DExpansion Permit Valid for: 13'5 Yeears ONo Expiration Residential Specifications: # Bedrooms 41 # Bathrooms 3 # People 4 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(G_PD): ' Type of Water Supply: t!]County/City DWell DCommunity Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: occepted Systems may also be usEgd site Plan System Type LTAR Initial Cce PA -eco Repair c c -t -t A 0, a- .�,�,el/ � b , F1 Environmental Health Specialist �� _ Date i.D.l 1-06 0 NOV 14 2007 13:59 FR WFUBMC 336 713 5145 TO 97513931 P.01 04AAqC AOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC is ONew System Davie'Coun'ty•Environmental Health P.O: B.ox•848/210 HospitaLStreet Mocksvilte, NC 274z8 (336)751•-876(1/P=To 786 anent Permit Construct(ATC) "oth Zepair to Existing System OExpansion/Modification of Existing System or Facility ***DdPORTANP** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT Name to be Billed Billing Address.Z City/Ste,eIZIF . Name on Permit/ATC if Different than ,Above. Mailine Address PROPERTY Contact Person Horne Phone *Date House/Facility Corners NOTE: A survey plat or site plan must accompany tris application. Included: 0 Site Plan (Permit is vah�-dor 60 months wi site plan, no expiration with complete plat.) Owner's Name Ye— Phor Owner's Address A, %..- ity/State/Zip ­� Property Address N City Lot SizeTax PIN# 0/OZ- Subdivision Name(if applicable) ection/Lot#__Z Directions To Site: 11; 9 9"A e* -E© !-(rsVAZ�(P r -__a-- 14c --� scale) If the answer to any of the following questildns is "yes", suppo'rting documcq6tion must be attiched. Are there any existing wastewater systems on the site? ON ! Does the site contain jurisdictional wetlands? ❑Y,�s f Are there any easements or righ"f--ways on the site? Q es ONO 0-V -s'i Aw.* — t�u��s�ttc- /°a�✓aic) Is the site subject to approval by another public agency? Dyes D Will wastewater other than domestic sewage be generated? Oyes 04 I IF RESIDENCE FILL OUT TIME BOX BELOW # people# Bedrooms # Bathrooms r Garden Tub/Whirlpool s ONO Basement: i7Y s o Basement Plumbing: O'Yes mit! IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of BuildinE # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons. per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested, onventional OAccepted ©Innovative ❑Alternative ❑Other Water Supply Type.+-EfCounty/City Water C New Well ❑Existing'Well 0 community well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0/10 If ves, what tvve? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permits) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if . the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County ealth Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I a responsible for the proper identification and labeling of property lines and comers and Iocating and flagging or staking the house iliry loon, proposed well location and the location of any other amenities. Property weer s oDate( r o er' le repres , Site Revisit Charge s)• Client Notification bate: Date EHS: Sign given ❑Yes ONo Account # Revised 11/06 Invoice # ** TOTAL PAGE.01 ** \ Tax Lot'E-g Tie line [flx ailie VN. N1en. et al , ---R- n f E 110. i DS -166 0 PG 48 3/4" tip Fnd p 5 86°47'29"E 918.73' o d • `� y Lot 1 5 Part of Tax Lot 81.02 °.36'49"W . PrCPQg6tI stem n � K 23: House -• p F�cISUng SepEic Sy Tax Map E`6 v 330.7 u� \ Area Lot 1. 3.364 Acres m �wInclusive of arca within S.R. t6J5 R/W) N CI -4 p N U -) CC) �y c» Well 7 PP 71G.OZ' 3/4" FJP F'nd ' ae S 87°•49'52"E 749.48 Tot01 Control Comer ¢ Ptc—tdoil set \ N 23%36'49"W 85.W NIAP\: o � Lot 2 Part of Tax Lot 81.02 Tax Map. E"6 5.763 We$ +/.. Area LDt 2- a' O N 23°11'04"W. (Inclusive of area w+thin S.R. ! 635 R/ul) W ow" �2r 1635 RAW 20'+�_ pavement . NMP N 559.07' Totol N $5124'071"4 SI Sst t" EIP Fnd • 4K—Na `ai i t:fir, .9/�"`�lf�'.- ' 3 .06' 5/8" EIR C=D -5X J�:itr39` - Fad In 11ne C 4' \ j U _ TaX fiat 1 o ra 1ifl& oil -Tax E r tins.ta Snier> _, �.- ti:i.7 ? Map Reid o� Fra Cilia Pemuttee'ss,e _. DAVIE COUNTY HEALTH DEPARTMENT Name: f (,��f�j�n� �,{/' Environmental Health Section PROPERTY INFORMATION A -6 P.O. Box 848 ''l 1. • _ Directions to property: /24- /'' "°� �� '" Mocksville, NC 27028 Subdivision Name: Y ' Phone #: 336-751-8760 pSection: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# a��d �- - wa SYSTEM CONSTRUCTION ��,% AUTHORIZATION NO: 002665 A Road Name: '' {l 1: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r3 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE_4!� #BEDROOMS - # BATHS �_ #OCCUPANTS _GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPES # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE,ONG TYPE WATER SUPPLY ( y DESIGN WASTEWATER FLOW (GPD) e7v-j NEW SITE REPAIR SITE _ --, SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH" LINEAR FT. /d0 REQUIRED SITE MODIFICATIONS/CONDITIONS: FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD cruvisadl Hca. j .�V0/C f 5Y33 k � • A vDAVIE COUNTY HEALTH DEPARTMENTeei i ! Environmental Health Section PROPERTY INFORMATION „ .,. P.O. Box 848 „Directions to prop ,"f' `' .'` "' Iv4ocksville, NC 27028 Subdivision Name: r.� Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: O 2 5 A Road Name: /`2ipl' . **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections `Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION ' ' = IS VALID FOR A PERIOD OF FJ,VE.YEARS:" ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEllROOMS# BATHS � # OCCUPANTS .. 9 --. GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION:,, FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEA' ` -JINDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( L7 DESIGN WASTEWJTER FLOW (GPD) `r Vd NEW SITE REPAIR SITE t� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 4V ROCK DEPTH 4110 LINEAR FT: `InDD OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1v .1140'' FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE .# IS (336) 751-8760. OPERATION PERMIT y ' SYSTEM INSTALLED BY: ,L`M1 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02102 (Revised) ,_�... �9a/ 1, Nvoiee -�f "5533 � , L J U N- 9 2006 L..i EWIRONMEfdTAL HEALTH v MCJ CE EVALUATION/IMPROVEMENT PERMIT & ATC (y` Z J I< wie County Health Department Fnvironmental Health Section P.O. Box 848/210 HospitalStreet Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Permit . ❑ Authorization To Construct(ATC) 5/Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed FV i2 m Aq 1.�v e -r Contact Person O x9t= rE T SAN C: Billing Address 2 SO vNT� d�/l E Home Phone City/State/ZIP5� _W)H,'a>S-SAL.OH'll NG Business Phone 9 3 & - 9196 - q73 27VC3 336-78 z- 9Co147 Name on Permit/ATC if Different than Above SA ✓13 r- A S /4 eo 1/r Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. 01 tt't S 1 o 4 1ev �'� > ✓1Z r 14 (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address x--07 1 City MoC 16,56 L u Tax PIN# - (0 1 Z Z 05,sY Subdivision Name 4 A A -CA -'f Section/Lot# Lot Size S A G -F Directions To Site:y S 1 5 i3 Ty . /17, ow .14aWAYL-OiOW#-A G1zer -Lv SI Tu= r 5 C2, 7' ✓YI c_t C 0 N i;T Date House/Facility Corners Flagged 2 — Z .3 - o �v If the answer to any of the following questions is "yes", supporting docuinep-cation must be attached. Are there any existing wastewater systems on the site? C�'%es ❑No Does the site contain jurisdictional wetlands? ❑Yes &-1<0 Are there any easements or right-of-ways on the site? 9(Yes _❑No Is the site subject to approval by another public agency? 2(Yes ❑No Will wastewater other than domestic sewage be generated? ❑Yes Boo IF RESIDENCE FILL OUT THE BOX BELOW # People _ Z # Bedrooms 14 # Bathrooms '3 Garden Tub/Whio rElYes o Basement: dYes ❑No Basement Plumbing: Rq'S'es ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: neonventional ZA- ccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 4ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to det mune compli��}}ce with applicabl laws and rules on the above described property located in Davie County and owned by !/, /�U>`lCz/I Site Revisit Charge r erty owner's or owner's legal representative signature / Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 2/06 Invoice # M I i ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street;` r 0j/d� Mocksville , NC 27028 Phone: (336)751-8760 NO ad 6 � I ON-SITE WASTEWATER CERTIFICATION FOR DWELLING to •(Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ Name: rcr Phone Number: 33& ' % &a " / S 17 —(Home) Mailing Address: 21501 ljv r•1+J4 m otlI r 33 2/9- 0113 w) w s ro w XhCYA I N N 210 3 c i w Detailed Directions To Site: 0:S 152 f 0� 14 0NM i/1 W&I %I (Z/G 0 , Ll n nl 14C WA v To wn) G 14_, tL E j S1 if LY Q, 7 ✓m 1 L.El ON U `=Y Property Address: i tJ 4 S8(0 I ZZ Z 5 5 1 LOT 1 0 t/1 5,oN (=JIZrnar4 AYLX% 2A P, ► vi2PMOP n7I) 10A& r 01P iAx Lc S 1,oZ I M % -U Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: CE V! a-4 IL& W `c )Z Type Of Dwelling: Date System Installed(Month/Day/Year): OIJXJ 61., iNumber Of Bedrooms: -k Number Of People: Is The Dwelling Currently Vacant? Yes ❑ No ❑ Any Known Problems? Yes ❑ No ❑ If Yes, If Yes, For How Long?. Please Fill In The Following Information About The New Dwelling: Type Of Dwelling:Aq,� (�c�_'r( Number Of Bedrooms: Ll ' Number Of People: Requested By Date Requested: Z 1y G ,6 ignature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Environmental Health 'The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: Y Y� DAVIE COUNTY HEALTH DEPARTMENT ` { Environmental Health Section PO Box, W/210 WANod Hospital Street /6lV Mocksville, NC 27028 ���' Phone: (336)751-8760 I ON STTE WASTEWATER CERTIFICATION FOR DWELLING �, '` • (Check One) REPLACEMENT 110, REMODELING ❑ RECONNECT~ION ❑ Name: j�'i �,� � . F '� ii J /t r Phone Number: ` /`� /I % '� S�o'l f +1G �i�� ��► ! ; ''^ �^,;�' �f '� .:Hme) Mailing Address: 33, (Wr c Detailed Directions To Site: V.S8 TO 4 ll : MW6j G ! 2 L lF i� r onl o AAjQ 70�a,,j C14,GL. rl71= I.1 0.%ell L% S ON PropertytAddress:'PI N 4. 158 �o,l ZZ Z S 5 � [,0T I 10141 -jJom 1=.I/ZmAt_�'- l3Jll j� .. _ A.yZ,A ' P. v 1Z T t �l 0 PF T•i . � pR LG% its of 'I Lo T S 1 t 0Z � MAI --7%5_U Please „,Fill In The Following Information About 1 e -Existing Dwelling. Name System Installed -Under: C UT Type Of Dwelling: '11 Date,System Installed(Month/Day/Yeaz)Number Of Bedrooms: Number Of People:.2 Is The Dwelling Currently Vacant? Yes ❑ No ❑ If Yes, For 'How Long? ' Any Known Problems? Yes ❑ No ❑ If Yes, Explain: 9 Please Fill In The Following Information About The`' New Dwelling: Type Of Dwelling: K494 rYl ��'rf Number Of Bedrooms: Number Of People: t Requested By-' '.-:•�:#' A Date Requested' � (Signature) '- For Environmental HealthOffice'Use Only Approved ❑ Disapproved ❑ // Comments:.' Environmental Health Svecialist�! _ — Date 'Me signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a I guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment:, Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: t, 1 23�v., itnlpl 14 48A) ��3 _`—~— O 2 (32 9-A) 3391 ..:.ash m 1.450A lo>AB aee 2934 d, vro N IRISH LIQ, 360— IrB —n85� � IrB A56 EnB 36'` A 57,n 15 _ N meaaA ` Q 2559 386 � 9430) ( 9.89A 116 G,� l t 77 (4'3154, 2 6758 b 9895 &. '^7--""._,_-_.... it --• 451 44�- 8 P99.A> ! c7 / 4359 448 452 --- 9549 �+ 475 Y557 �J...m................—........w-...-- - (2.87A) ` 9303 482 0145 41 1181 L � ...9023 F BLUEBIRD LN a� _ - __ :�N CN 81�- I rcxi _--- -i r �.., 509 sas> BLAKELY LN -. 518 - .-. 3830 522 o APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Reaith Section "IS .0. Box 848/210 Hospital StreetMocksville NC 27028(336)751-8760 ATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED efer to the INFORMATION BULLETIN for instructions. 1. ame to beH O Vl BOUfi /� Contact Person At3��l2r S-fUhI� Mailing Address Z -Z" M vpl'fj!G3 i i jugd YC City/State/ZIP VJ)*JS7014-,-54LC-yn , N L ZC7f o 3 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: �❑Site Evaluation 4. System to Service: N( House ❑ Mobil S. Type system requested: ❑ Conventional 6. IT�f/ Residence: # '0--n eo le 1 llQDishwasher P Home Phone Business Phone 3310 / - `7 77 City/State/Zip R(Improvement Permit/ATC Home ❑ Business ❑ Industry ❑ Other ❑ conventional modified ❑ innovative # Bedrooms Z2 # Bathrooms ❑Garbage Disposal R Washing Machine WeBasement/Plumbing ❑Basement/No Plumbing ❑ Both 7. If Business/Industry /Other: verify type # People # Sinks _ # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ]d 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 BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: L &T WRITE DIRECTIONS (from M11o��cksville) to PROPERTY: Tax Office PIN: # (012 Z 7, 5 S U S g -To 14 U VV 1Z0 rta U/& e 12GC.t; Property Address: Road Name 14D LVAtLQ'I' w m C C 1/Z �i , �� 4 t11 40 WA Y1101 O W Q PA1Cr,- 01 TAX- ai. v2. `-(,o city/zip M061 !841 LU: 0 C G ILCuT, 5) 7'G ! s O 1 tom: S z7oZt3 If in a Subdivision provide information, as follows: p it, Iz§ I o tv 0 T- FV R,,v pol - j Gal Name: —4 A ' )0- A r\j Section: Block: Lot: Z Date home corners flagged: Z 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 ani responsible for all charges incurred fro": 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 all testing procedures as necessary to determine the site suitabilit . DATE Z !/ �U 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). Sign given Revised DCHD (05/03 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No.O� Invoice No. t APPLICANT INFORMATION Account #: 990003921 Billed To: Furman Burt Reference Name: Robert Stone Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT _­Fnvironmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5861-22-2559,OZ Subdivision Info: Location/Address: Howardtown Circle -270 8 5 acres 'Date Evaluated: Property Size: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit ? Public Cut FACTORS L_ 2 3 4 5 6 7 Landscape position L L Slope % z2 576 HORIZON I DEPTH 3 V c: i/ / ,i // < <� Texture grow Consistence /- r Structure (�T Mineralogy/ 7;.17 HORIZON II DEPTH Zl</ </ Texture groupC Consistence (/ Structure . Mineralogy HORIZON III DEPTH Texture group Consistence G Structure ,. Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 4 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: - ,q LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: //� G/ 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 - Sand_ y clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE MQ1St VFR - Very friable FR - Friable FI -Firm VFI - Very firm EFI - Extremely firm 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 05105 (Revised) +' STONE LAND SURVEYING CO. P.O. BOX 307 MOCKSVILLE, NC 27028 TELEPHONE: 336-998-4733 FAX: 336-998-7343 MARCH 21, 2006 SUBJECT: SITE PLAN FOR FURMAN & AYLEEZA BURT CORRESPONDENCE TO: ROBERT HALL FROM: GEORGE R. STONE, PLS PER OUR RECENT TELEPHONE CONVERSATIONS, WE ARE SUBMITTING A REPAIR APPLICATION FOR THE EXISTING SEPTIC SYSTEM ON LOT 1, AND A NEW SYSTEM PERMIT APPLICATION FOR LOT 2. PLEASE CONTACT ME IF THERE ARE ANY QUESTIONS. { CC: FILE D"IE COUNTY, N. C. PROPERTY OWNERSHIP CARD "Map Group Parcel Property Location E-6 81 S. R. 1635 Township Subdivision Plat Bk. Page Block Lot Farm. Dimensions Acreage_ 46-.05 D OWNER: Date Book Page Brewery Thil lis Allen etydr-He BXewer. Eugene G.190- L-.15 �3 _ 6 �� —5AQ— 606 (A A a- sa •� 2- � �-oi � � 0 113 8 WEST MAPPING SERVICE, INC. 1.6 May 3, 2006 Mr. Furman G. Burt 2501 Huntington Drive Winston-Salem, NC 27103 Re: Site Evaluation: Howardtown Circle Tax Pin #: 5861-22-2559 Dear Mr. Burt, As requested, Robert B. Hall Jr., Environmental Health Specialist with this office on April 10, 2006 and April 21, 2006 evaluated the above -referenced property at the site designated on the plat/site plan that accompanied your improvement permit application. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: .1941 Soil Characteristics (3) -Expansive Clay Minerology .1942 Soil wetness (a) .1943 Soil Depth (a) .1944 Restrictive Horizons (a) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, this office has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVISIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor with this office. You may also request an informal review by the N.C. Department of Environmental and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, Environmental Health Section. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or from the OAH website at www.oah.state.nc.us/fbrrn.htm. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150-B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is August 14, 2003. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a.formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 15013-23) to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, NCDENR. Please call or write this office if you have any questions or need any additional assistance, as follows: Telephone number: (336) 751-8760 Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 Sincerely, '� �� Robert B. Hall, Jr. Environmental Health Specialist RBH/bml Enclosure(s): Soil -Site Report Rule .1948 Invoice LAWS AND RULES FOR SEWAGE TREATMENT AND DISPOSAL SYSTEMS 15A NCAC 18A.1900 Rule .1948 .1948 SITE CLASSIFICATION (a) Sites classified as SUITABLE maybe utilized for a ground absorption sewage treatment and disposal system consistent with these Rules. A suitable classification generally indicates soil and site conditions favorable for the operation of a ground absorption sewage treatment and disposal system or have slight limitations that are readily overcome by proper design and installation. (b) Sites classified as PROVISIONALLY SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules but have moderate limitations. Sites classified Provisionally Suitable require some modifications and careful planning, design, and installation in order for a ground absorption sewage treatment and disposal system to function satisfactorily. (c) Sites classified UNSUITABLE have severe limitations for the installation and use of a properly functioning ground absorption sewage treatment and disposal system. An improvement permit shall not be issued for a site which is classified as UNSUITABLE. However, where a site is UNSUITABLE, it may be reclassified PROVISIONALLY SUITABLE if a special investigation indicates that a modified or alternative system can be installed in accordance with Rules .1956 or .1957 or this Section. (d) A site classified as UNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956 or .1957 of this Section or a system approved under Rule .1969 if written documentation, including engineering, hydrogeologic, geologic or soil studies, indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SUITABLE if the local health department determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent will be non-pathogenic, non-infectious, non-toxic, and non -hazardous; (2) the effluent will not contaminate groundwater or surface water; and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people, animals, or vectors. The State shall review the substantiating data if requested by the local health department. HistoryNote: Authority G.S. 130A -335(e); Eff. July 1 1982 Amended Eff. April 1, 1993; January 1, 1990. ❑ ❑ ❑ ❑ DdC 3J 4 -s`•' r a moil •� �0 ... ko ° . sK 1 10 4 o P nj� 1 •�p;P•,'Qj, O 1 1 ! 1 I I " � I >r�t i vl I I A +�%Q i ��. Z 18- 'tI R; it 4 .. o- ° a J► O - 9s� 3 V� .+ o • �. e ° � G �aeos I IN F; O n �' Sad ® pO ,� 'I� " (?/off =.,. •. � rn C A y O I n r 8 w § Q 9 O ;v I 1 1 ( 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 ,. � � t NOS? ; v r _ v• it c �.r (A cr W _ N ?1 v m a, / Or .01 3 / oo / '' /0000, 0000 Cc z 90 _a rn w.. s ov y� o . ♦ / Moa�01� N � f a., ♦ ♦ �/ 0 w do z o = (A Z N 4O D N Q. 8- , N c O 5-°$ n Co x o Cb w 0 - itlit Z G='may.• T, r{p�IVpc iC< D p7 -1-i NNS .: � ♦ N. D m WAX x i r^ ' mo or 0 o ° X Oh O�oa a � a UU��ppN&. o N °, o Q r- a �,� f s NOOpV x ° c�?E01� t lit r+ 3 A rn 0 JZ �_ �o 0) oo + o o L4 \ N Wjr t0 i 366.51 $ _ 5 07.31'20"W '�. 2616.22' a � $ 07°31'20"W N>-n v $ w rn N �ovgc fmO��f0 IX x CD��x x Q #WNN ?c-gr v N 00• s � o o W p t7 r► c 0 � a CL b NOODd Q � D Os � pw a O RO O a (b J a � c e crn � < 2 > > o . o0 03 a N 0x I" = 7 W A v m - � S N 8 . CD m n 4 O F 'c z ol W `n '• Q A 0 o + + cn W i+V Ss I 40 7 ° til► � us �� $ pO d>*� p O a CJ t . v