The URL can be used to link to this page

163 Landmark DrPermittee's //DAVIE COUNTY HEALTH DEPARTMENT Name: .N�441 a C t fJyi M Environmental Health Section PROPERTY INFORMATION Directions to property: b 4 \0 d v1 AUTHORIZATION NO: 0 0 2 9 0 9 A P.O. Box 848 Mocksville, NC 27028 Phone #: 336-751-8760 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Subdivision Name: Section: Q Lot: Tax ffiCe PINO�.#' �� Roa, : L 4L ---A vrla-t.1, ZiP• . f17 01.42 **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) ,yam ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION —d ? IS VALID FOR A PERIOD OF FIVE YEARS. HEALTH SPECIALIST DATE ISSUED Permittee' DAVIE'COUNTY HEALTH DEPARTMENT g Naitte: ,i7 PROPERTY INFORMATION nOf�'Gt�' n.1 Environmental Health Section �,r {,, P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 r {r� c+ +. • f, r' c� r�_t,,,,,,�. �- G✓1 Section: Lo[: / + AUTHORIZATION FOR 'E' VV c.i 7G • IL. rv WASTEWATER 6-) Ta r1�+ x - - t� SYSTEM CONSTRUCTION 9Qffice PIN://-- AUTHORIZATION NO: ,r 002909 A Road Name: 4 Zip: f' **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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .•4'' �% IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No i COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) J U NEW SITE - REPAIR SITE I--- SYSTEM SPECIFICATIONS: TANK SIZE �� GAL. PUMP TANK/4GAL. TRENCH WIDTH L ROCK DEPTH / "/LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT 1 TL� A{Y.� 9UT o� C y t r,I J t`-7 v L [/ � t� c� ►, : � }� � c, � P tom. y �� 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. V RATION PERMIT 0 ` - INSTALLED BY: ��'"' Cr— AUTHORIZATION NO. OPERATION PERMIT BY: k DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 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. Darn 02/02 (Revised) Permittee' DAVIE COUNTY HEALTH DEPARTMENT N e: .�'n(i�1 A 4"`''' riEnvironmental Health Section PROPERTY INFORMATION •r..�, �� ,..^j.. P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 - Section: Lot: o AUTHORIZATION FOR . VIA% ` 4j WASTEWATER G) ffl e I:� CONSTRUCTION Tax N SYSTEM AUTHORIZATION NO: 002909 A Road Name. �^ " a �'' ' � ' 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/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes o.010 COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) U NEW SITE REPAIR SITE t/ /f// 3 Ni1 3 a SYSTEM SPECIFICATIONS: TANK SIZE GA PUMP TANK LGAL. TRENCH WIDTH ROCK DEPTH INEAR FT. Q _ OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ,r IMPROVEMENT PERM T LAYQi G' ra 1 , . I i a 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. TION PERMIT 1 1 _fJ SY NSTALLED BY:GL D 2 •o C, C� u x l� 5 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: 1i "SS � ql f **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 02/02 (Revised) aqs- DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION • APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) // NAME�iiiiV� `(� /{'1 PHONE NUMBER 797.,' U4( ADDRESS �� A1C 1/��- /� IOC�%J V/`� SUBDIVISION NAME LOT # DIRECTIONS TO SITE y 1-1/6 d /4 ' 400d n A 1 Q 7 DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY 1 US& NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING 1"Jef DATE REQUESTED I277 -Dg 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 Hsv.1/93 . ?•1..::.. "r ,t ! ,.� ;.:=s a-�+ -s .=- .• ~.rig,, f"A �':f iti`q .a: 1'"n. a ., r..., 'r • r n� p DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section a PO Box 848/210 Hos 0 n Hospital Street j�� ilia, � • Mocksville, NC 27028 Phone:336 751-8760 ( ) VV V` f ` "ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑ q�o-gyq l Name: l� l��l��_ �i�Q F.l`� Phone Number: 3p ¢`� ? 2/9(Home) Mailing Address 1b3 i'1 LAa.& Dr Ydl)}- i1�/l _r �7lb�Y �,.. Detailed Directions To Site: �� CGLr�` Qx 1 ' ' -) 4 w 4h A �P ;s eV A,00d � roperty Address:... 5a / Yl Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: / / iK /' ` , A Type Of Dwelling:do� e,6 ,aj- Date System Installed(Month/Day/Year): ~' S Number Of Bedrooms: Number Of People: Is The Dwelling • Currently Vacant? Yes ❑ N9 If Yes, For How Long? " Any Known Problems? Yes ❑ If Yes, Explain: =' ( , e Please Fille n The Following Information About The New Dw' elring: Type Of Dwelling: Number Of Bedrooms: -� Number Of People: Requested By: ��a1 �G/,C�I' /"�!%C� �/a1{i% Date Requested: (Signature) For Environmental Health gwlb Use Only Approved Disapproved ❑ / / Comments: C, c �l / I ,rt Environmental Health Specialist '� - -Date Ger'( VV "The signing of this form by the Environmental Health Staff is 'in', way intended, nor should be taken as a guarntee(extended'or limited){ � t the on=site wastewater system 'function;properly for any given period of time. 1'amt.~ CI, a� E`'%� r, .{r Date: T •(5 -- Cash Check Money Order ❑ # ?' A17 mount: $�'�o� U(i T'aifl By N(�./1 / i r l \ i - Received By: Account #� t` t # ' InVoic6#:1 6640 r GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System zoom To Scale: OQ`as6rlo' Click Here To Start Over Quick Search: (County ID orOviner Name} l Ft' Active Layer. QUse tvap Tips GIS Dept Home Page I Contacts Department ( Irif �►pU',� L14j �' c �. 0 ' PARCELS (Map Tips Available) !�!✓ dap Layers I Results I Address/Name/Parcel Search I Tools' I200f 00005 62.0 C GODBEY RD s 0 356ft http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=4129&CFTOKEN=61640881 &initialize.... 3/17/2008 'Vn' � ,� � �a� � h�' �� . � -�" �� .____ _ � -_-_- �_ � �� J � � � � � � � � � � � �� .� � �, � � � � � s � � � � . i � � C �� ,�� j � �� f . / �� % � � �' �. •. . . � . �� , .� . � o - PLI ,�'I0 F R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ��RePt (336)751-8760/ Fax (336)751-8786 ipffTor: !Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***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 Billing Address City/State/ZIP Name on Permit/ATC if Different than Above Mailing Address Contact Person &16V -X-) Home Phone 5J& — 4!Z Z/ Business Phone Are there any existing wastewater systems on the site? l�-Ye's ❑No Does the site contain jurisdictional wetlands? ❑Yes,-B'go Are there any easements or right-of-ways on the site? ❑Yes �o Is the site subject to approval by another public agency? ❑Yeses Will wastewater other than domestic sewage be generated? Dyes 0 IF RESIDENCE FILL OUT THE BOX BELOW of # People 5 # Bedrooms 3 # Bathrooms a Garden Tub/Whirlpool es ❑No Basement: ❑Yes o Basement Plumbing: Oyes 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: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this syste 'is intended to serve? ❑ Yes IN o 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking ftthe house/facility location roposed well location and the location of any other amenities. LLQ? "' Z n Site Revisit Charge Property owners or owner's le -gal representative signature w o Date Sign given ❑Yes ❑No Revised 11/06 5. Date(s): Client Notification Date: EHS: Account# slot Invoice # APPL4WM t T114iFMt10MON Billed To: Chandra Swain Reference Name: Proposed Facility: Residence Water Supply: Evaluation By DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Tax PIN/EH #: 570E�ftZFTY INFORMATION Subdivision Info: Location/Address: Landmark Road -27028 Property Size: 1.100 acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H 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: -EVALUATION BY: 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 NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 05/05 (Revised) Davie County Health Department � 83 Environmental Health Section d P.O. Box 848 210 Hospital Street C? MAY 0 2011 Courier # : 09-40-06 YJ Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection A Name:Phone Number(Ho Mailing Address: 13 CLCJ�. r.0 rli� +�G1 70 �/ `�4 0- %Z 9y Iuioales Email Address: Detailed Directions To Site: la 4 -fes alch Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility:_ A/7 Date System Installed (Month/Date/Year): Number Of Bedrooms: 3 Number .Of People: Is The Facility Currently Vacant?Yeshio If Yes, For How Long? Any Known Problems? Yes (No) If Yes, Explain: Please Fill In The Following Information Ab The NEW Facility: Type ,Of Facility: i�6 Number Of Bedrooms: Number of People Pool Size: arage Size: '-' K 3 r � Other: Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: . *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 Chec Money Order # 5 o Amount:$ lQ0.0c) _ Date: `2''J Paid By:,AJ(1 Received By: Account #: 5-101 Invoice