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142 Idlewild Rd Lot 8 ov • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 � l,/� Account #: 990003354 Tax PIN/EH#: 5862-35-5173 Billed To: H&V Construction Subdivision Info: Idlgwild Lot#08 - t Reference Name: Eddie Hubbard Location/Address: Gordon Drive-27006 As stated in 15A NCAC 18A.1969(5) ATC Number: 4326 accepted Systems may also be used 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 WASTE CON N IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur Date: [�p too in 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. \0 / �Z MOAT )NAY, Septic System Installed By: Cy-7 Q- 'e') Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Moclksville,NC 27028 (336)751-8760 3 ( Y IMPROVEMENT/OPERATION PERMIT ✓ I Account #: 990003354 Tax PIN/EH#: 5862-35-5173 Billed To: H&V Construction Subdivision Info: Idlewild Lot#08 Reference Name: Eddie Hubbard Location/Address: Gordon Drive-27006 Proposed Facility: Residence Property Size: 0.738 acres **NOTES* Is�mprovement/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 ()sE7 #People #Bedrooms #Baths 2— Dishwasher: Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size h,•7�% L1 Type Water SupplyDesign Wastewater Flow(GPD) 60_ Site: New 2'*' Repair❑ System Specifications: Tank Size lOnQGAL. Pump Tank GAL. Trench Width&;' Rock Depth tZ' Linear Ft. 32-CO� As stated in 15A NCAC 18A.1969(5) Other; "U1STiZ.l421LOQ Bax& accepted Systems may also be used Required Site Modifications/Conditions: kr-tALI- dJ G00ty-04 14ZL--p �f 9 F 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.**** u 1pt-W I u7 C) _ - /,, o W Environmental Health Specialist's Sign tures Date: D DCHD 05/99(Revised) \ r r 4 TO too 2 c', `-77 1� `�rd's' �. ��, ��''► ,�, 24 1 fl'1 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department (� L' Environmental Health Section �1. P.O.Box 848/210 HospitalStreet 5 2006 Mocksville NC 27028 1 (336)751=8760/Fax(336)751-8786 ApplicatiPM t q E alu provement Permit authorization To Construct(ATC) ❑ Both DN 1 E *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 R 4 S ©� Contact Person Billing AddressO <-f o ,e r ,9-!;.— 14-ve - Home Phone City/State/ZIP .27/03 Business Phone 723-12E!' . Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is validfo ¢¢0 mont�s with site plan,no expiration with complete plat.) Street Address -ole-Wild 9(. City;,,fid uQNc4 Tax PIN# 5!b(-Z--355/7-,,- Subdivision 8(Z355/73Subdivision Name Zt) L E W O D Section/Lot# $ Lot Size & ,mac -f Directions To Site: T- ty -t,-) Vo 1 049Tg , L e.f-f aXJ Le40.- Date House/Facility Corners Flagged D to If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes ONo Does the site contain jurisdictional wetlands? ❑Yes RNo Are there any easements or right-of-ways on the site? ❑Yes 2No Is the site subject to approval by another public agency? ❑Yes OfIlo Will wastewater other than domestic sewage be generated? ❑Yes Bfto IF RESIDENCE FILL OUT THE BOX BELOW #People 7 #Bedrooms 3 #Bathjooms y Garden Tub/Whirlpool Vffes ❑No Basement ❑Yes o Basement Plumbing: ❑Yes 5No 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: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:V/County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Q 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 detee compliance with applicable laws and rules on the above described property located in Davie County and owned by d- IJ �yis�:� r tai e�j s�-�� • Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 06, Client Notification Date: Date EHS: Sign given ❑Yes ❑'No Account# 23`� Revised 2/06 Invoice# ..old N • Rap 08 04 107438 Gavle 44univ env088[pT 338 751 8788 .2 . i AYPLICAI V MA S(Mtalli81WSFLlOYdiLM"frf t On1,0otngllWd<C,p,�l lA1LffiO1MOflAd(lbSitJloB �, xx tum bow flat • ,rc t1D31 ._. � cuc»u•nco ,,,SIp0liilt�`�itR!ulleeirao CdelroS'to laaeassra D71Ltp Ice syl �cltozrar u>•aovmc5. Iola to U6 matarcmr>sou=ho>,HIIr3toEi O ,^�.• 1. aw w w n;u d ousfRaenyA Co. ef,saet tQ,r�b l6�k',Sd'J�+?b. ,,,,,,o,rh,,[afrOcovtrdAce ,4►'a ,raa.t • . . •. .� .-. 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DATL ,_, ffi4'rAI0Y6 L . • t�Alaati�zeaascDsoaD�.wmcto�anxs,��rt�l�rr�a�,rl�;vc�r� 4 t^Ia7Cucm1�+,+tssma+eAlda,saQsrytlaloatlos�, i SGhRcrllilEva. • CDxt if,DDoutu D,te j ilpdrm lcmolcYti,?�� [0•d £[£[[Zt9££ + + * Al. WW 9C:[0 t0—•[-42s r' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003354 Tax PIN/EH#: 5862-34-9883.08 Billed To: H&V Construction Subdivision Info: Idlewild Lot#08 Reference Name: Location/Address: Gordon Drive-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: IzID4 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 3 4 5 6 7 Landscape position Sloe% 2 J HORIZON I DEPTH —2�— Texture group1. Consistence Structure Mineralogy HORIZON II DEPTH 2' Texture group Consistence $ Structure Mineralogy HORIZON III DEPTH 34 — Texture group4 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE �( SITE CLASSIFICATION: EVALUATION BY: n LONG-TERM ACCEPTANCE RATE: 0.��rV` OTHER(S)PRESENT: REMARKS: 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) \ �k 0 J Z `r M M s s ry ry Lo-rk 8 cJ z�r ZDLew�1.D Ra T-bkr.w I LJh sssartJlsON lU I iu-s-r LrcYt- gSo7 I �D Davie County Health Department y ( [ �f [ onmental Health Section P.O. Box 848 r ,} �• r 210 Hospital Streep P 4S NOV242010 x Courier # : 09-40-0(rA► i (;t ?��' A 1 Mocksville, NC 270 ENVIRONMENTAL HEAITH BY: Phone:(336)1753-6780 DAVIECOUNNFax: (336)-753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: nd' V e O PJS_//-XC.//0 vt CO Phone Number (Home) Mailing Address: f5jy 'A)45;A6ra01F /711)Zh fir, 33&--72,3 /z-Sy _(Work) IM►us fen-57a lek-r, Abi I t�r9Bto 211Q 3 Detailed Directions To Site: Property Address:_ f 1f L 1b L e cur ldl Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: 9l" I V e-5 Type Of Facility: Date System Installed(Month/Date/Year): 1P + 30, 0( Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes (!!P If Yes,For How Long? Any Known Problems? Yes (90 If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:_pl� 11 oO yyT Number Of Bedrooms: y^ Number of People Pool Size: �, Z 4/, VA- y / Garage Size: Other: Requested By: e, ( �c/ Date Requested: �l (Signature) For Environmental Health Office Use Only (� Errient? oveDisapproved Environmental Health Specialist Date: Z&V.2010 *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 oney Order #___,67 7 2 Amount:$ Date: — 10 Paid By: 'l �. Received By1_A4 A4r_1 Account#: 33 Jr� Invoice#: 17525'