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972 Hwy 64W (2) OPERATION PERMIT or nice use ny s; * Davie County Health Department *CDP File Number 194431 -1 210 Hospital Street 14-000-00-055 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: F ant: Lynne Hicks Byerly Property Owner: Lynne Hicks Byerly ss: 972 US Hwy 64 West Address: 972 US Hwy 64 West y: Mocksville CRY: Mocksville State/Zip; NC 27028 State2ip: NC 27028 Phone#: (336)751-3312 Phone#: (336)751-3312 Property Location & Site Information rAddress/Road#: Subdivision: Phase: Lot: Hwy 64 West le NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 west on right just past Steelman Rd on left #of Bedrooms: 1 #of People: 3 *Water Supply: EXISTING WELL *IP Issued by. 2140-Nations,Robert *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes *No Design Flow: 1 a 0 : GRAVITY-PARALLEL d-box Pump Required? Distribution Type: ) OYes ONo Soil Application Rate: 0 - a a 5 *Pre Treatment: Drain field (No. t ification Field Sq.ft. 'System Type: INFILTRATOR QUICK 4 STANDARD Drain Lines 1 Installer DonnieLakey otal Trench Length: 1 3 6 fl- Certification#: 1107 Trench Spacing: _ Olnches O.C. Feet O.C. EH S: 2325-Mitchell,Brittany (*)Inches Trench Width: _ 3 6 OFeet Date: 0 7 / 2 9 -210 1 5 Aggregate Depth: inches Minimum Trench Depth: a 4 . Inches r v; 7: Minimum Soil Cover. 1 a 'Approve l'Status Inches Maximum Trench Depth: .4 9 ®'Approved O Dlspproved Inches Maximum Soil Cover. Inches CDP File Number 194431 - 1 Septic Tank County ID Number: 14-000-00-055 Manufacturer. Shod Let. STB: 760 Long: Gallons: 1000 Installer. Donnie Lakey _ Date: 0 4 / 9 1 / x 0 1 5 Certification#: 1107 'EH S: 2325-Mitchell,Brittany "Filter Brand: ST Marker. El Yes El No Date: �0 / a 9 / a 0 1 5 (einforcedTank: ❑ Yes ❑ NoPTank ❑ Yes ❑ No ® Approvetl❑` Dts�pproved Pump Tank Manufacturer. Installer. Donnie Lakey PT: Certification#: 1107 Gallons: 'EH S: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ ,NO (Min.6 in.) Approval Sfetus `- Reinforced Tank: ❑ Yes ❑ No ❑ A roved❑:Otsa pp pproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line CPipe Size: 3 inch diameter Installer. Donnie Lakey Pipe Length: 6 feet Certification#: 1107 'Schedule: 40 'EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO Approval Status ® Approved❑ Disapproved x p Requirement Pump Type: Installer. Donnie Lakey Dosing Volume: — Gal Certification#: 1107 Draw Down: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check valve ❑ Yes ❑ No Approval Status - ..= PVC unions ElYes ❑ No ❑ Approved O Disapproved vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ YeS ❑ NO CDP File Number 194431 - 1 County ID Number: 14-000-00-055 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ElNo Installer DonnieLakey Box 12 inches Above Grade ❑ Yes El No 1107 Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No '"EHS: Pump Manually Operable ❑ Yes ❑ No =Activation Method: Date: Alarm Audible ❑ Yes ❑ NO Appro+lal status .❑ Approvetl❑ Dlsapproved�� Alarm visible ❑ Yes ❑ No 2325-Mitchell,Brittany 'Operation Permit completed by: Authorized State Agent: '✓ wuh, Date of Issue: 0 7 / a 9 / a 0 1 5 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A,Rules for Sewage Treatment and Disposal, 15A NCAC 18A.1900"ef. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE 11 A. sewage septic system. Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator. NIA Reporting Frequency By Certified Operator:WA Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator forthe life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entily prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shalt require specific requirements for maintenance and operation, responsibilities of the ownerand systems operator,'provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. it shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.**'` OPERATION PERMIT 194431 - 1 Davie County Health Department CDP File Number' 210 Hospital Street 14-000-00-055 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 7 /. 2 9 / 2 0 1 5 Olnch • Drawing Drawing Type: Operation Permit Scale: , OON/A k ► OV f �1 I l I� FTF 7- I � f tt N Ij 'q ( � — I 6t Tax Map: a Address: • �O, Installer: Ua im t pj 1167 U EHS: Date: Operation Permit Inspection Checklist Location and Separation Distances f 1. Distance from septic tank/pump tank to foundation/basement feet 2. Distance from system to well if applicable feet 3. Any other setback(.1950)requirements Supply line 1. Material supply line is constructed of diameter inches 2. Length of supply line(2'min.) 3. Amount of fall in supply line(1/8"per oot min) 4. Distance from ST/PT to the nitrification field/dist.device) feet Septic Tank/Pump Tank 1. Visually inspect top of tanks(s),interior&exterior walls,baffle wall and bottom 2. Any honeycombing or exposed rebar present? Circle: YES or NO 3. Visually inspect sanitary tee,lis and air vent for}Rroper installation and sealant 4. Tank Serial Numbers:STB U 5� 10a� PT 5. ST Win 6"finished grade?Cir 1 : or NO 6. Date of manufacture:ST T PT 7. Liquid capacity of tanks ST41U0 UPT 8. Effluent filter type 9. Pipe penetration seal present?Circle: or NO 10. Riser(s)present?Circle: YES or No Riser Type 11. Pump Tank riser 6"above finished grade?Circle: YES or NO 12. Riser approved?Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation 2. Trench Depth Readings(inches) Z4 ►/1 3. Number of Trenches a Distance between trenches 4. Trench Width ?J 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth(inches) k 7. Nitrification lines installed on contour?Circle: YES or NO 8. Innovative system type Installer certified for installation?Circle: YES or NO 9. 2'earthen dam between ST(or d-box)and beginning of nitrification line?Circle:YES or NO 10. Stepdowns a. 2'undisturbed earthen dam(s) Circle: YES or NO �� L b. Proper rise over stepdowns?Circle: YES or NO ! c. Solid pipe used? Solid,Corrugated or other? d. Elevation of each stepdown e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO Distribution Devices 1. Type Is the device watertight? Is it level? 2. Distance from Dist.device to trenches feet 3. Record elevations:Inlets Outlets �pe,�CS � a P CONSTRUCTION For office Use Only ` AUTHORIZATION CDP File,Number 194431 .1 U.- O- 40, Davie Count Health De artment 14-000-00-055 Y P County ID Number.210 Hospital Street Evatuafed For. NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 6 / 1 6 a 0 a 0 Applicant: Lynne Hicks Byerly Property Owner: Lynne Hicks Byerly Address: 972 US Hwy 64 West Address: 972 US Hwy 64 West City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)75 (336 Phone.1-3312 751-3312 #: ) Property Location & Slte Information rAddress/Road#: Subdivision: Phase: Lot: wy 64 West e NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 west on right just past Steelman Rd on left #of Bedrooms: 1 #of People: 3 "Water Supply: EXISTING WELL System Specifications I/ Minimum Trench Depth: a 4 Inches rSiteClassirication: Provisionally SuitableMinimum Soil Cover:System? OYes @No 1Inches esgnlow: l a 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . a a 5 Maximum Soil Cover: a 4 Inches "System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 _ Gallons "Proposed System: 25%REDUCTION 1-Piece: Oyes @No Pump Required: OYes ®No OMay Be Required Nitrification Field 5 3 3 Sq.ft. Pump Tank: Gallons No.Drain Lines a 1-Piece: OYes ONo Total Trench Length: 1 3 3 ft GPM vs- ft. TDH Trench Spacing: Inches O.C. - 9 . 8Feet O.C. Dosing Volume: _ Gallons Trench Width: QInches 3 CEJ Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 011 0111 OIV Dann I of Z CDP Fite Number 194431 - 1 County ID Number. 14-000-00-055 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: Ei Inches 0.ification: Provisionally Suitable — 9 Feet O.C. Trench Width: 0Inches w: 1 a 0 _ 3 . @ Feet Soil Application Rate: 0 - a a 5 Aggregate Depth: inches Minimum Trench Depth: a 4 Inches "System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR480 GPD OR LESS) Minimum Soil Cover. 1 a Inches "Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 5 3 3 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain lines "Distribution Type: GRAVITY-PARALLEL(eq.d-box) a TotatTrerich Length: 1 3 3 ftPump Required: OYes @No OMay Be Required Pre Treatment: ONSF OTS-1 OTS-II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System,Constructlon shall bevalld fora person equal to the period of validity,of the Improvement Permit,not to exceed five years,and may be issued atthe same time the improvement Permit Issued(NCGS 130A-336(b)�If the installation has not been completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction Authorization is found to have been Incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall became Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair Applicant/Legal Reps.Signature Required? Oyes ONo Applicant/Legal Reps.Signature: Date:, !Issued By: 2140-Nations,Robert Date of Issue: . 0 . 6 / 1 6 / a 0 1 5 Authorized State Agent: Malfunction Log OYeS OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION • Davie County Health Department CDP File Number: 210 Hospital Street 14-000-00-055 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 06 / 1 6 / 2 0 1 5 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QQN�Ak ft. V V 1 -17 Ilk I �tr � b ai CONSTRUCTION AUTHORIZATION , Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 14.000.00.055 Mocksville NC 27028 County File Number: Date: .0 .6./ 1 6 1 2 0 1 5 Click below to import an image from an external location: Drawing Type:Construction Authorization • IMPROVEMENT PERMIT For Office Use only • "CDP File Number 194431 -1 Davie.County Health Department County ID Numt�er;14.000-00-055 210 Hospital Street P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 6/16/2020 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Lynne Hicks Byerly Property Owner: Lynne Hicks Byerly Address: 972 US Hwy 64 West Address: 972 US Hwy 64 West City: Mocksville City: Mocksville State)Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)751-3312 Phone#: (336)751-3312 Property Location & Site Information rddressfRoad M Subdivision: Phase: Lot: Hwy 64 West le NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 west on right just past Steelman Rd on left #of Bedrooms: 1 #of People: 3 "W\�7ater Supply: EXISTING WELL System Specifications nitial S stem "Site asst ica ton: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? QYes @No Maximum Trench Depth: 3 6 Inches Design Flow: 1 a 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 a 5 1-Piece: QYes QNo Pump Required: QYes ®No'QMay Be Required "System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) `Proposed System: 25%REDUCTION 1-Piece: QYes QNo Repair System Required:®Yes ONo ONO, but has Available Space Repair System "Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: - a a Maximum Trench Depth: 3 6 Inches C "System ClassificatiWDescription: Pump Required: QYes (E)No Q May be Required TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 194431 - 1 County ID Number: 14-000-00-055 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. a Site Plan Tne Improvement Permit shall be valid for 6 years from date of issue with a site plan(means a drawing not necessarily drawn to :scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the 1teforthe proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a scale of one inch equals no morethan 60 feet;that includes:the specific location of the proposed facility O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision tots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article.This permit Is subject to revocation ifthe site plan,plat,or Intended use changes(NCGS 130A-335(%The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring, reporting,and repair(1938(b)) Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 6 1 6 2 0 1 5 � ..s��f OValid without Expiration? Authorized State Agent: "reate CA? @Hand Drawing Olmport Drawing n , **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 194431 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 14-000-00-055 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Improvement Permit Scale: . OBlock ON/AI __TT t TA_ ft. ,t 7:4- QIJA a�b J4'4Cr I -ins l• � I yv IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 194431 - 1 P.O.Box 848 14-000-00-055 Mocksviile NC 27028 County File Number: Date: LO.L6../ 146.j/ 01 5 Click below to import an Image from an external location:Drawing Type: improvement Permit 05/26/2015 14:01 3367514835 LYNNE HICKS #3547 P. 001/002 c7EDAPPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT& ATC /-PAID C��r AAViR CPp11tyoviropmeotal tjealth � Cf� / P.O.Box 8481210 Hospital Street g@g1P�b a Mocksville,NC 27028 Pal (336)753-6780/Fax(336)753-1680 Application Far: a Site EvsluationRmprovement Permit ❑Authorization To Construct(ATC) Both Type of Application:XNew System ORcpair to F-xisting System ❑Fxpansion/ModiPeation of Existing stem or Facility ••*IAfPaRT4NT"'1'THIS APPLICATION CANNOT BE PROCESSED UNLESS AM.OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions, APPLICANT INFORMATION l�A 9 Namo to be BillcdF�_Contact Pcrson_ Billing Address 'Home.Phone City/Statc/zIP usincss Phone 75T 26:51-2, Name on Permit/ATC if Different than Above — {✓�� Mailing Address_ City/staterLip PROPERTY INFORMATION *pate House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included:g Site Plan ❑Plat(to scale) (permit is valid roe 60 mod:iSw th site plate,no expiration wt h co ple lat.) Owner's Namc CJI-M�_I.�S Gts1P_ AeJl.(V �j Phonc Number _ Owncr's Addres� Ciry taI rZ, Property Address City $ I.ot Size ap tcapl ) ax.P # _ Q Subdivision Name(if Scct'onlLot# -1000 Dio S1 T1 W t !f the ynswer to any of the following questions is`yes",supporting documentation must be altarfied. Are there any existing wastewater systems on the site? IYes ONo an0 Does the site contain jurisdictional wetlands? ❑Yes Vo 3 NPS rAyl Are there any easements or right-of-ways on the site? OYes o Is the site subject to approval by another public agency? f7Yes Nwo Wi 11 wastewater other than domestic sewage be generated? OYes-VNn /�,,/ /�.� 1F RESIDENCE FILL OUT THE BOX BELOW /7l/t i A J0 A'Se/'�1e "� #People #Bedrooms III If #l3athrooms�L Garden Tub/Wh' (pool l.:Yes Vo Basement: es 'I IN Basement Plumbing: ns ONO IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Tota!Square Foo Ve of Buildiog #People #Sittks— #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats,__ Typo system requested: ClConventional DAccepted 01anovative ❑Altcmative ❑Other Water Supply Type:0 Coynty/City Water ❑New Well ,Misting Wdl ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?O Yes VN0 If yes,what type? This is to cervi ry that the infnnnation provided an this application is true and correct to the best of my knowledge. 1 understand that any pennit(s)or ATC(s)issued hereafter arc 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 Health Department to conduct necessary inspcctionsto determine compliance with applicable laws and rules. I understand t4 1 am responsib the proper identification and label ins of property lines and corners and locating or th ouselfa 'ity ion, opo c11 location and the location of any other amenities, Prope o o s presen re Site Revisit Charlie 15 Client Notification p$tC: ;,Ltegib� ERS: Sign given ❑Ycs❑No Account# I Revised I IAM Invoice# Cl off-- - o' ` N 1Rl�S1v O] N O r CJI � � o co CO Ul .� 00 . , w Ul PAa r m H C7 W ca W Ch T O � N 1� i DAVIE COUNTY HEALTH DEPAR NT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION I PROPERTY INFORMATION u,�ff w W Lqlvve' P q7z /_/0 ' I i i i I , I I I Water Supply: On- ite Well /Community Public Evaluation By: Aug r Boring -Pit Cut FACTORS { 1 2 3 5 6 7 Landscs a position L Slope% HORIZON I DEPTH Texture group <Z j Consistence Cr.51 ti I Structure f ( I Mineralogyj I HORIZON II DEPTH 4,- Texture fTexture groupj I Consistence < PVVi ! Structure MineralogyI j I HORIZON III DEPTH I I Texture groupI Consistence } Structure r I I Mineralogy lI I HORIZON IV DEPTH { I Texture groupj Consistence I Structure 1. I MineralogyI I SOIL WETNESS RESTRICTIVE HORIZON C I I i SAPROLITE CLASSIFICATION I LONG-TERM ACCEPTANCE RATE dj S ala a I SITE CLASSIFICATION: _ EVALUATI! N BY: Q • Uyl� .2 � LONG-TERM ACCEPTANC .'RATE: �'� S d� � I OTHER(S)PRESENT:' l I I RE1vIaRxs: � LEGEND i � , Landscape Position R-Ridge S-Shoulder' L-Linear slope FS-Foot slope N-Nose slope) CC-Concave slope CV- onvex slope T-Terrace FP.-Flood plain H f Head slope Texture S-Sand LS-Loamy san SL-Sandy loam L-Loam SI ,Silt ; SICL-Silty clay loam SII -Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay ; CO STSTENC� VM-Very friable FR-Flable FI-Firm VFI-Very firm IEFI-Extremely firm NS-Noit sticky SS-.Sligl tly sticky S-Sticky VS -Very Stich I NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plasltic Structure I SC-Single grain M-M 'sive CR-Crumb GR-Granular ABK-Angular blocky. SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy I 1:1,2:1,Mixed Notes i Horizon depth-In inches Depth of fill-In inches i Restrictive horizon-Thickness and inches from land surface i Saprolite-S(suitable),U(unsu�table)• I 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 rovisionally suitable),U(unsuitable) py"�).frr:yrs,.�� ,-.,....:iiw s/fw�,.,��LJnr sj �yhi� r•✓�4•i:.. �y �,s{, t`.y, 'his� ;i.�7wt �+;F.7;r jiav r x 1 IAUTH(.,°A1IZATION:NO: ` DAVIE COUNTY HEALTH DEPARTMENT ., Environmental Health Section PROPERTYINFORMATIONermi _ • J' Namettee's ��" { MocksOl Box 848 NC 27028 Subdivision Na x Phone# 336-751-8760 " ` Directions,fo property: Section: Cot; AUTHORIZATION FOR f r r', WASTEWATER vi, r7'C, i/'`iI; �f r J Tax Office PIN# - SYSTEM CONSTRUCTION Road Name Zip: **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/Authorizafion Number should be presented to the Davie County Building Inspections' Office when applying for Building Pen-nits. X . - (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � ***NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION dJ /�t•t" �? � `/:.S" 7 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL'HEALTH SPECIALIST: DATE ISSUED rt:, ' r , /:r�-r. } t„�: F ..1 S a,.Yt--,& r�r�'� "t ri' r DAVIE COUNTY HEALTH DEPARTMENT - Y48 aMPROYEMENT AND`OPERATION PERMITS PROPERTY INFORMATION,- m» 1 dr Nain V t fJ �ti!+'�' /i.{ Subdivision Name - rte' Directions fo property: / x `' �� Section: Lot: t r IMPROVEMENT PERMIT Tax Office PIN:# r s t Road Name: Zip: **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or"any wastewater system.An' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained frdm this Department prior to'the construction/uistallation 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) r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE ` PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER - —Y ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE y .INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS---)—_#OCCUPANTS GARBAGE DISPOSAL.Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE L TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD � NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE -GAL. PUMP TANK GAL. TRENCH WIDTU-I? ROCK DEPTH It LINEAR FT.1 OTHER1uC REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISH[ GRADE* "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS V"19444Y�80R (336)751-8764 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 r WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEMfASA 'r GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) F"ib�V.hJNO - c w w bs sa.� v ='"Sr '�`v r'Scw erg+ a '�v:..'t`�.; "^w— , 5 w � � r•+ s.•z+h t DAVIE COUNTY HEALTH DEPARTMENT � 4 s , IMPROVEMENT AND 61 ERATION.PERMITS PROPERTY INFORMATION dk Pet'Irntte's ¢ '• / , Namd:" Subdivision Name: Direction�-to property: /' f r` Section: Lot: PYWROVEMENT E y PERMIT Tax Office PIN:# - - '+r } Road Name: Z p;' **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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) ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE ; PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 'RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS L_#OCCUPANTS_L_GARBAGE DISPOSAL.Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIA ASTE:Yes or No � F LOT SIZE �G�/��' � TYPE WATER SUPPLY�_ DESIGN WASTEWATER FLOW(GPD).J�i'�� NEW SITE REPAIR SITE j/•• ` SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH T': ROCK DEPTH LINEAR Fnza OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLU04T FILTER* *RISER(S) IF 6" BELOW FIHISI':ED GRADES = z �4 s "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THISSYSTEM f BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(tNJ63�+1$�db?r j OPERATION PERMIT SYSTEM INSTALLED.BY: i 1 a AUTHORIZATION NO. f OPERATION PERMIT BY: DATE: i i "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIAN9i " WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKENtAS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. i DCHD 05/96(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME PHONE NUMBER — g -7 7 ADDRESS —SUBDIVISION NAME 42 �i✓fryP,�fJ LOT # DIRECTIONS TO SITE ��fi � i — �� ilS C-C-42) -0 yLl -o DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED r TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING�I je 4rg_ d_�_ � DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 � � �Q�•f- �e2S a � �-yn � �-tc.�s � Z ' DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C) OWNER OR CONTRACTOR CZ<- —1 rrN, DATE i;k Zir PERMIT LOCATION N° 1200 .rC",it-, r r{ C--A', is e'.•.c... S.R. NO. SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. HOUSE ❑ MOBILE HOME IN BUSINESS ❑ House Trailer 800 Gal. 400 Sq. Ft. NO. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑. NO ❑ Three Bedroom House 900 .Gal. 900 Sq. Ft. AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE YES ❑ NO ❑ SITE SUITABLE YES ❑ NO ❑ SIZE OF TANK 1100 gal. NITRIFICATION FIELD sq. ft. c DEPTH OF STONE IN LINES: WATER SUPPLY: Individual Public ❑ IMPROVEMENTS PERMIT BY INSTALLED BY CERTIFICATE OF COMPLETION ByDate (8/16/73) *Construction must c ply with all other applicable State and local regulations LOT AREA t O QC t r- 5 J '(1 Parcel#:I400000055 Page 1 of 1 oP�r� Davie County, NC - Basic Estate Search ®riv, Davie County Web Site Basic Search Real Estate Search Tax Bill Search Sales Search Q View Property Record for this Parcel View Map for this Parcel View Tax Bill Information Parcel#:I400000055 Account#:35620000 Owner Information Tax Codes ICKS JUNE M ESTATE ADVLTAX-COUNTY TA /o LYNN H BYERLY FIREADVLTAX-FIRE TAX OCKSVILLE NC 27028 Property Information Township nd(Units/Type): 41.060 AC MOCKSVILLE ddress: 972 W US HWY 64 Deed Information Local Zoning ate: 09/1963 Book: 00066 Page: 0627 Plat Book: 0003 Page: 019 Legal Description PIN 50.76 AC HWY 64 5738086362 Property Values uildin 350,46 BXF: 12 81 nd: 322,96 Market: 686 23 sseS. 392,38 eferred: 29385 Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price 00066 0627 09 1963 WD Unqualified Improved 0 View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information « Return to Basic Search All Information on this site is prepared for the Inventory of real property found within Davie County. All data is compiled from recorded deeds, plats,and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the Information.All information contained herein was created for the Davie County's internal use. Davie County, its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or Implied, in fact or In law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at(336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnet/View.aspx?prid=1470275 6/30/2016