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141 Tulip Magnolia Dr Lot 18 FermitteesDAVIE COUNTY HEALTH DEPARTMENT �1 lYanie: y»V, �,.,c�r,'�"P3:1►j �,< kr; t Environmental Health Section PROPERTY INFORMATION \tiA� . Ut 5 .L �� ' P.O. Box 848 Directions to property: 1Gt�I f Mocksville,NC 27028 Subdivision Name: 46 Yh G ( + r_+ S /• Phone#:336-751-8760 6_1 .✓ �� ��G' j!,c•-�� ren ;V4 G? c=�•u Section: Lot: ) _ AUTHORIZATION FOR 1111 L,H �• WASTEWATER C + : Tax O SYSTEM CONSTRUCTION Office PIN:# )5g G _ _56-1 {, � Ictt 5C AUTHORIZATION NO: 002766 A Road Name: �1''+�',h r`r�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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) -�' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 3-;747 IS VALID FOR A PERIOD OF FIVE YEARS. E fI ONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE 5y�+. #BEDROOMS #BATHS a• 'r#OCCUPANTS - GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes /or�No LOT SIZE 10C"LfiYPE WATER SUPPLY �! DESIGN WASTEWATER FLOW(GPD)�I�t�U NEW SITE REPAIR SITE i : . 1� SYSTEM SPECIFICATIONS: TANK SIZE E'ya GAL. 7UMP TANK GAL. TRENCH WIDTH ' _ ROCK DEPTH LINEAR FT.W OTHER M u 51 ti-5X f ILt -V n G Yt REQUIRED SITE MODIFICATIONS/CONDITIONS: I IMPROVEMENT PERMIT LAYOUT C� 16`�'rV"`r/ JtSCQh ✓Ie �k r� 1ih5 Q Q ��1Gin'�a �✓t SSI t C_"I 'A VIA 1(6, n J) o �Y C-P-t ID I-r—t 6$A '1c -Pvc-U rv� 1 /S� wo+;„ 5`ts� �..+. Clue/ loo , i 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. OPERATION PERMIT -P, Y `� SYSTEM INSTALLED BY: ,J !Mf w 3 �X�51� s a• 3 � 3- y q n v C()KCie•efy okt C, AUTHORIZATION NO. 4r02 740OPERATION PERMIT BY: DATE: .707 — **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. ncHD 02M(Revised) jN v L� ;i" t-.:�' -ti-.._-.:z.->i•: =.,r.,-N R.. -.; -.r�.�-r:-:t�v,w T'-�.. ....re,,. -�.�-°_is iY-;_ -. . - . „ ,_ � r �:i {. s'.>- .. ^.} Ferttdtt t „_ DAVIE COUNTY HEALTH DEPARTMENT r p'arrir,•p.- �� 5�.,.[1.; y` ,.•""^'.1i.•�d��.r-.� ,I�kt� `` Environmental Health Section PROPERTY INFORMATION ti P.O. Box 848 _ections to rd a �'�X-XL7 I -5 (''r , p i P rtY` ' _ h1ocksville,NC 27028 Subdivision Name: /1-16 tl t't G l t ci �! v •r'`:> Phone#: 336-751-8760 Section: Lot: _-tea AUTHORIZATION FOR i_Wfps +,��e..�.c o t ry l 14 1 T,$1 �. WASTEWATER Tax Office PIN:# r SYSTEM CONSTRUCTION ti AUTHORIZATION NO: 002766 A Road Name: f_ �'' ,r+ 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 Pen-nits. (In compliance with Article 1 I 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. ENVik6NMENTAL HEALTH SPECIALIST DATE ISSUED f^ RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHSOCCUPANTS ~GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE10 Cr c" l (' �� TYPE WATER SUPPLY�� DESIGN WASTEWATER FLOW(GPD) /-6 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE—`,GAL. UMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 14 dd OTHER ti 15 L_L< C 1 r CA T• i REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT `r AJ 15# cln 'JA 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. OPERATION PERMIT (/ SYSTEM INSTALLED BY: w 13 ,M 4 is U y AUTHORIZATION NO. / OPERATION PERMIT BY: DATE: — "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 0202(Revised) "j"•, i �j lam/ DAVIE COUNTY HEALTH DEPARTMENT r Environmental Health:Section PO Box 848/210 Hospital Street - ` Mocksville,�NC 27028 3' Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING RECONNECTION ❑ Name: Willll n m 1J��1 �_�,�/�/S Phone Number: (Home) MailingAddress: (Work) WS AgN,011'a A Detailed Directions To Site: Property Address: Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: IO/1/ Q q A0 (_ 21511 W61 Type Of Dwelling: & _ Date Syste mInstalled(Month/Day/Year): Number Of Bedrooms: Number Of People: Is The Dwelling Currently Vacant? Yes❑ I4of( If Yes,For How Long? Any Known Problems?Yes❑ NP If Yes,Explain: Please Fill In The Following Information About The New Dwelling: �. Type Of Dwelling: 00 l Number Of People: /Requested ByA ,)1/�t Cvr's ` Date Requested: (Signature) For Environmental Health Office Use Only Approved$�. Disapproved ❑ J" Comments: W 41\A n e- G (-r c, CA .ate -1 n CLA1/ a f C G V%`f ck —� Environmental Health Specialist *'Me 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. FOPayment: /C/as)h❑ Cfheck❑ Money Order❑ # ��z, Amount: $ .Q() Date: LO Paid By: W // / kcl N Received By: �R Account #• 7 Z7 Invoice # S. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH #: 5880-51-5022.18 SC Billed To: Shelton Construction Services -Subdivision Info: Magnolia Acres Lot# 18 Reference Name: Location/Address: Tulip Magnolia Drive-27006 ProQQsed Facility: -Residence Prn,pPrty,1;i7e* 130'x 233' ATC Number: 3730 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YE 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 1 I 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 Date: DCHD 05199(Revised) .• - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section pot • . P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900093 Tax PIN/EH#: 5880-51-5022.18 SC Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot# 18 Reference Name: Location/Address: Tulip Magnolia Drive-27006 I UI Proposed Facility: Residence Property Size: 130'x 233' **NOTE*This Improurh : vemeent/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 TIM PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type T/ #People #Bedrooms _ #Baths J. S Dishwasher: ?( Garbage Disposal:21-"' Washing Machine:Fr Basement w/Plumbing: e Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) ZeP Site: New a"-Repair❑ System Specifications: Tank Size-dOPGAL. Pump Tank GAL. Trench Width� 'Rock Depth /-2 Linear Ft. Vf� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPR FFLUENT FILTER. RISERS)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representaf o e Da ' 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 1:3 P. on d installation. Telephone#is(336)751-8760.**** �t 1sel r 6D� p� l � A i r Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ��-- P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH#: 5880-51-5022.18 SC Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot# 18 Reference Name: Location/Address: Tulip Magnolia Drive-27006 Proposed Facility: Residence Prope[b�Si7e- 130'x 233' ATC Number. 3730 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YE S. 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. 1b° Septic System Installed By: AA Environmental Health Specialist's Signature: Date: /4 - —,O 5!� DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900093 Tax PIN/EH#: 5880-51-5022.18 SC Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot# 18 Reference Name: Location/Address: Tulip Magnolia Drive-27006 Proposed Facility: Residence Property Size: 130'x 233' Date Evaluated: 0 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut_ FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH i Texture group Consistence Structure Mineralogy HORIZON II DEPTH is c y Texture group G Consistence Structure /L 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 17 L SITE CLASSIFICATION: L` EVALUATION BY: �1/ LONG-TERM ACCEPTANCE RATE: _ 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) DEC E O V E I I ICATION 1=011 S17E EVALUATI0N/IhIPII0V0IL•Yr 111:11) IT&A'I'C Davie County Health Department MAR 2 5 2004 Eavironmentalffea/t/r Section P.O. Box 848/210 Hospital Street Nocksville, NC 27028 OMRONMENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IDIPORTIINT*** TIiIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRE]) INFORMATION IS PROVIDED. Refor to the INF1ORMATION BULLETIN for instrucL-ions. I • 1. Name to be Dilled —sk l l�-- _ _.��..'F: -. Contact Person �• „S.�� ��•" Mailing Address 2.S 7 V S Home Phone -7�1 -_2; b.d City/State/ZIP / • l D i -+: C .41-C - 2.-704knuuinenn Phone 3 T S ZOO (c 2. Name on Pcrmit/ATC if Different than Above ____......... Mailing Address City/State/Zip _,.._ . 3. Application For: �Si-te Evaluation l Improvement- Permit/ATC Ll 11oLh 4. System to Service: C9-4f01:fse ❑ IS013ile Home ❑. Buninctn ❑ Industry ❑ Otilar ti. 5. Type system requested: 22-fonventional ❑ conventional modified ❑ innovative G. If Residence: it People _ u Bedrooms It Bathroums 2Ti-shwasher 06rXr-bage Disposal (ung Machine �asement/Plumbing ❑Dascment/Ito Plumbing 7. If Business/Industry /Other: verify type tt People it Sinks i Commodes 0 Showers 0 Urinal: II Water Cooler: IF FOODSERVICE: # SeatD Estimated Water Usage (gallons per day) a. Type of water supply: CI-County/City ❑ Well ❑ Comluunity 9. Do you anticipate additions or expansions of file facility tilts systcn,is intendc(1 t0 serve?❑Yes If yes,11•11at type? ***lAIPORTdIVT***CLIENTS AIUST COA111LIETL••THE REQUIREW PROPE10•Y INFORNIATION REQU1:STI-A) BELOW. EiUlera PLAT orSITE PLAN J1fUSTBESUIIt1lITTLD by the client 1yiffi l,1IIS APPLICATION. r I'1'operty Dimensions: 3 b X Z 3 1VRITI:ll11ZEC1'IONS(rrulu A-luelisville) to I'ROPE'I('1'1% Tax Off►cc IM 11 0 Property Address: Road Name A I'17,c /•� D.;,. _ ��Y r..: o e'��' /?'��,. .1:, i4...► Ci tylvii /4/f✓. < < Z70o 7—,1:42 I�'i /.•. D—:.., If in a Subdivision provide information,is follows: Name: /�'] w •• . l: c 1 Section: ! Block: Lot: 1 Date Monne corners flagged: This is to certify that file information provided is correct to the best of Illy knolvledgc. I understand that any pernlii(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if file infurluaiiun submitted in this application is falsiIIcd ur changed. I,also,understand that I alit responsible for rill chut3es iacurred•%t•utn this upplication. I,hereby,give consent to the Authorized Representative of file Davie Cuuufy Ile:dfll 1)ep:u Uu�nt to enter upon above described property located in Davie County and olvucd by to conduct :111 testing proccdures as necessary to determine lite site suitability. DA1'i:_ 3 A /y q SIGNATURE TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of file following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 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