The URL can be used to link to this page

5262 Hwy 801SAccount #: 990002493 Billed To: Amy Wagner Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5766-58-8946 Subdivision Info: Location/Address: Hwy 801 S.-27006 Property Size: see map 12-Z Z ATC Number: 3308 **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. Residential Specification: Building Type #People �_ #Bedrooms #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine -P"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size (, Type Water Supply —&/j)j Design Wastewater Flow (GPD) Site: New W Repair ❑ System Specifications: Tank Size 1 DGAL. Pump Tank GAL. Trench Width,,—f �,"Rock Depth _ Linear Ft.,K �6 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.**** Environmental Health Specialist's Signature: n II Date: DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990002493 Billed To: Amy Wagner Reference Name: raciuty: Kesiaence ATC Number: 3308 P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5766-58-8946 Subdivision Info: Location/Address: Hwy 801 S.-27006 Property Size: see map 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, ection .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE CONSTRUCTION IS VALID FO PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:- Date: �� z 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 :�1 v ice.. <'/ Date: / DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmenta/Hea/th 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. 1. Name to be Billed Am n ' p Contact Person Mailing Address g DO1(�� J, Home Phone I ,� r ) City/State/ZIP _ ( dyaMci 1 I ( ai100 0y Business Phone 33 W - 1 5 1 - 5' { 34 2. Name on Permit/ATC if Different than Above Mailing Address City/State/zip 3. Application For: O'Site Evaluation improvement Permit/ATC ❑ Both 4. System to service: ❑ House Q'Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms _ FALshwasher O Garbage Disposal WWa% shing Machine ❑ Basement/Plumbing FI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE; # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City [U/Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes W o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: 5-C -e— u Tax Office PIN: # 5 7� G 59 a l 7 `p Property Address: Road Name �M 701 SoAlt City/zip ALG.m Zi COD If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 3 hlocb Un L'Akk. Date Property Flagged: Iola F/ b 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 am responsible for all charges incurred from 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 suitability. DATE � O ' ' OZ SIGNATURE ( Awl � 1 VVI v 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). Site Revisit Charge Date(s): Client Notification Date: F EHS: Revised DCHD (07/99)j� 1l —,7, _o Account No. �I 3 Invoice No. ^.+'r -rte n. .nawiw%.^ WWnn 00 ,.. 164 (360) A (4.94A) : 7536 (1202) (327) (4.68A) K700000063 (8.92A) 0 0374 3292 m & CAROL M DA WAGN O (4.23A) 7051 (24.08A) 8946 N JA) & CAROL M s� DA RL EDWARD WAGNER 300 5766588946" (1.71 A) (1.73A) A 831 9 (1371) - „n r ". m w (1 soA) 6346 j X260) N� (1.82A) 4374 -17) (1.56A) (a 2373 _ (250)so a (2.19A) 9259 _------ ... 4214) (254) N FACTORS 1 2 3 4 5 6 7 Landscape position . , �-- DAVIE COUNTY HEALTH DEPARTMENT ' J Environmental Health Section Texture group Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002493 Tax PIN/EH #: 5766-58-8946 Billed To: Amy Wagner Subdivision Info: Reference Name: Texture group Location/Address: Hwy 801 S.-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring 6�_ Pit Cut Texture group FACTORS 1 2 3 4 5 6 7 Landscape position �-- Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: 4�( 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S - Sticky VS - Very Sticky SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angul SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) ■■■See■■eSee■See■■■■■■■■■■i ■■■■See■■■■■eee■■eee■■■■■■i ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■See■■■■■■■■■■■ ■■■■See■■■■■■■■■■■■■■■E■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■■■■■a■N■■■a■■■■SSSS■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■eee■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ mom ■M■ ■■ SEMEN ■E■E■ ■■ES■ ■■M■■ ■■N■■ MEMOS ■E■E■ MEN son mom mom ■EM■■EME■■E■■M■■ ■■ME■■M■M■■E■■■■ ■■MEM■MEM■■M■■N■ ■■NSEE■EME■■M■N■ ■MUMM■N■EENME■■ on ■■■■■■■■■E■■ ■■E■■■■■■■■■■■■■ ■■■E■■E■■■■E■■■■ ■■■■■■■■■■■■■■■■ ■■N■■■■■■■■■M■■■ ■■■■■■■■■■■■■■■■ ■■■■■■NNE■■■■■■■ ■■nM■M■■■■■M■■■ no ■■■■■■■N■■■■ ■■■■■■■■■■m■■■■■ ■■■■■E■■■■E■■■■■ ■■■■■E■■■■■■■■■■ ■■■■■■E■E■M■■■■■ ■■■■■■■■■■■■■■■■ finUMM■■■■■■■M■■■ E■ ■■MEMS ■■■■ M■ M■MEN■■■■■ ■■EE■■■■E■E■■■■■ ■ME■■■■■■■■■■■■■ ■■S■■■■■■■■S■■■1 ■■■Nei■■■■■■■■■■■■■ ■■MM■MENEE■■■ ■■M■ ■E■E■■E■■EEM■■M■■M■ ■E■ME■MENMEM■■MEN■■ ■M■■M■ME■■E■E■EM■■■ ■■■■■■■■■■N\SSSS■■■ MEEMEMMMEMMEM NONE ■■■■■■■■�■■■l\SSSS■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■SSSS■E■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■EE■■M■■ ■■M■■MM■ ■M■M■■M■ ■N■E■■M■ ■■■S■■■■ ME■■■M■■ ■E■■■E■■ ■ME■■ME■ ■■MMEME■■ MENUMMENN ■M■■EMME■ ■E■■EMME■ EMMMEMMEM ■MEM■■■M■ ■EN■■■■E■ ■E■EM■■M■ ■E■■EMM■■ ■■MNEME■■ ■■m■■m■■■ ■o■■somo■ ■■■E■■■E■ MEN EMS ■■■■MONE■ ■mom■■m■■ ■EMM■M■E■ ■■MM■■ME■ ■■■■M■NE■ ■■■mm■■o■ ■■mm■■■M■ Som■■■■■■ ■MEN■MM■■ ■■ No ON �'e'eEeeeee ogeEeeE. oeee9::ee::::::�::::::::eeeeeeeeeMEN