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893 Howell RdI., DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003795 Tax PIN/EH #: 5823-62-6954 Billed To: Bobby Shelton Subdivision Info: Reference Name: Location/Address: Howell Road -27028 Proposed Facility Residence Property Size: 41 acres ATC Number: 4253 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 TRU T ON IS VALID FOR A PERIOD OF FIVE YEARS. 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. , , g0ILV- 4 S-ra I,o,rjK -I>4i e t —2 Septic System Installed By: ", Y M, I. Environmental Health Specialist's Signature: DCHD 05/99 (Revised) ►. DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003795 Billed To: Bobby Shelton Reference Name: Proposed Facility Residence IMPROVEMENT/OPERATION PERMIT M / *116 6 --- Tax PIN/EH #: 5823-62-6954 Subdivision Info: Location/Address: Howell Road -27028 Property Size: 41 acres ATC Number: 4253 **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 CONTRACTOQRrJ'IUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �12 'eople #Bedrooms #Baths _Z Dishwasher: 0 Garbage Disposal: 0 Washing Machine: ❑ Basement w/Plumbing: 0 Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply Design Wastewater Flow (GPD) 1-20 Site: New 0— Repair 0 �•� �. U System Specifications: Tank Size QDDGAL. Pump Tank GAL. Trench Width ` Rock Depth 1Linear Ft Other: AA stated On 15A INICAD 18A 1969(5) accepted Systems may also be use 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. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** r / Date: Environmental Health Specialist' s Signature: �� PS DCHD 05/99 (Revised) �..: APPLICATION FOR SITE EVALUA710N/Ibii'IiUVL•AtFM PL•RM1 VE Davie County Health Department Environmental Healtly Section P.O. Box 848/210 Hospital Street NOV 15. 2005 tt �) Mocksvilla, NC 27028 (336) 751-8760 DMRONMENTALHEAI,I}1 ***XlfPORTANT*** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TH. INFORI•IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person Mailing Address /� Ifomo Phone City/Stato/ZIP _ _ [ /D GIiU/ ux ` Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATCBoth 9. System to Service: ❑ House ❑ Mobile Homes ❑ Business ❑ Industry t_ Other, 5. Typo system requested: XrConventional ❑ conventional modified ❑ innovative I3accepted 6. If Residence: It People # Bedrooms It Bathrooms % ❑Dinhwasher ❑Garbago Disposal ❑Washing Machine ❑Basamen t/Plundbing ❑Basement/No Plumbing 7. If Dusineus/Industry /Other: verify type 9 People 0 Sinks / it Commodes 1l Showers tl Urinals li Water Coolers IF FOODSERVICE: it Seats Estimated Water Usage (gallons par day) G. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes to If•yes, 11•l:at type? ***IAfPOR7WN7*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUES'T'ED nELOR'. Either PLAT or SITE PLAN AMSTRESURMITTED by the client lvith'ClIIS APPLICATION. Properly Dimensions: WRITE DIRECTIONS (from Mockwille) to PROPERTY:, Tax Office PIN: it 2�,G2�1`� tely ��l /��L� �/t� C/� Gill Properly Address: Road Name (, / el- city/zip y L( -e 9Y Z-;ro 4 2. s A, If in a Subdivision provide information, as follo}ys: r dJYll% Nanlc: Section: Blocia Lot: Date home corners flagged: 'I'liis is to certify that the information provided is correct to the best of lny I.nowledge. I understand that any pernlit(s) issued hereafter are subject ;to suspension or revocation, if the site plans or intended use change, or if the info•nlaflon submitted in ibis. application is falsified or changed. I, also, widerstand that l au: responsible for all churges facurred franc this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcat(11 Department to enter upon above described property located ill Davie County and oyt;v;i by to conduct all (e ting procedures as necessary to determine the site shit. i t ' DATE ) SIGNATURE TIIIS AREA MAYBE USED FOR DRANVING YOUR SITZ; PLAN (Includ all of (hc following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EIIS: Sign given 'Account No. Revised llCIIll (05/03 Invoice No. 883 867 \t9l>9 39 1 Q N 96 �� 150 � 857 APPLICANT INFORMATION Account #: 990003795 Billed To: Bobby Shelton Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5823-62-6954 Subdivision Info: Location/Address: Howell Road -27028 Property Size: 41 acres Date Evaluated: `/116, On -Site Well ' Community Auger Boring Pit Public 1Z Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % o HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group Consistence r Structure 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 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 F1= 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■e■■e■■■■■■■■■eee■■■■■■■■■■■s■■■■■■■■■■■■■■■e■■■■■■■e■■■■■■■■■e■■■ EMMONSiiiiiiiiiiiiMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■