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262 Midway Dr ' � � ' . DAVIE COUNTY HEALTH DEPARTMENT � � ���� Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001079 Tax PIN/EH#: 4797-55-5124 Billed To: Steve Vestal Subdivision Info: Reference Name: Steve Vestal Location/Address: Midway Drive-27028 Proposed Facility: Residence Property Size: 2 Acres A'�C I�mb�r: 2396 **NOT ** 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 �i</`7 #People�_ #Bedrooms � #Baths�,�,_ Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) Site: New� Repair❑ � / System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth,�� Linear Ft.c�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER, RISER(S)IF G"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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(33G)751-8760.**** � r- , y/ ,_-- ,�;� _ , 7� Environmental Health Spec�alist s S�gnature: Date: vl- P�� DCHD OS/99(Revised) • � , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990001079 Tax PIN/EH#: 4797-55-5124 Billed To: Steve Vestal Subdivision Info: Reference Name: Steve Vestal Location/Address: Midway Drive-27028 Proposed Facility: Residence Property Size: 2 Acres ATC Number: 2396 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 WASTEWAT NSTRUCTION IS VALID FO PERIOD OF FIVE YEARS. s ,� Environmental Health SpecialisYs Signature: � 'Date: '7�=�l`� CERTIFICAT O COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletion s II i di e the system described on ImprovementlOperation Permit has been installed in compliance with Article 11 o G. Ch pter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken s a u ntee that the system will function satisfactorily for any given period of time. � ��de�� L �i Septic System Installed By: Environmental Health SpecialisYs Signature: � Date: � "f � � DCHD OS/99(Revised) � � . � , � � APPLICATION FOR SfTE E1�ALUATION/IMPROVEMEM'PERMIT&ATC Davie County Health Department Environinenta/Hea/th Seclion �� P.O. Box 848/210 Hospital Street r,;, r �� .�`' � r�o�ks�iiie, Nc Z�o2e ��y_ _ !��-.-ry-- (336)751 8760 ' ,1�` � '7 �f' ^;�r � /�'.' ***�ORTANT*** THIS APPLICATION C'.ANNOT 8E PROCESSED UNLESS ° �-�THE REQUIRED �' c INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN f r i�lhs�ructions�;,,tilTH i. x�a to be s�iiea _✓�ffv`�. //e,S�/4 � contact Person, ` � ���E. ���f TY / ' / _,_ �Cw6C Mailinq Addresa ��� � �.s ��✓� (!�y k/ Home Phone 3,/[C� " ?��l_��•2 0 0 �i�is��iZ=p _ �'�'I� �k,r✓,//� _.r/,� � � z a z� �S�ne88 Phone 336 -7.�1 - 7 73 y 2. Name on Permit/ATC if Different than Above ,�,q/!�/, Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC `�Both � � f a. syat� to ser,►ice: �'House ❑ Mobile Home ❑ Business ❑ Industry �Other-f�� 5. If Residence: � People ,�_ � Bedrooms � � Bathrooms � �DiahMaaher C] Garbage Disposal � Washing Machine ❑ Basement/Plumbing [J Sasement/No Plumbinq 6. If Bua3nesa/Induatry/Other: Specify type # People $ 3inka � Commodes � 3hoxera # Urinals # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage cg�iona �= a$y) �. Type of water supply: 0 County/City �Well ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? � �Na If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PI.AT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. 23�f���� t�.wE . /' Property Dimensions: f7s F' 1/OD l✓ -( � CI���� WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taz OfTice PIN: #�/��f'�-,5����� ltl�% (�L/ W 7"D Z U U Lcl 7'c� Property Address: Road Name m,`/,�u��4�i KAC� ,�,�.�" ���o%f �%y;9 S 7'�-��'�- City/Zip ��?i�C�c i1���/� ;��0�� �-�C�f t,t��es� ���.S�iaXF �fr `t� If in a Subdivision provide information,as follows: i r 5 f �/.� (S�'1 i(,ef�,1�4 �c� �`[Qicii�� �c�� Name: �r��.�c � �" E�vi.P �� I�� r9-n /4,� , Sectioa: Blcek: Lot: Date Property Flagged: ,3 �� �'�ad� � 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 revceation,if the site plans or intended use change,or if the information submitted in t6is application is falsified or changed I,also,understand that 1 am responsible jor all charges incurred from this appllcatlon. I,hereby,give consent to the Authorized Representative of the Davi ounty Health De ar ent to enter upon above described property located ia Davie County and own by��,w r/��� to conduct all testing procedures as necessary to determine the site suit ' � . DATE ��^' �DDD SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of t6e following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. /��� :?evised DCHD(07/99) / Invoice No. L// � i r.. . ,..� � t) .z f' �„ _,x�y.c��.r,�r. k .. �.. �.y 1 � S . .: , � ... . -. J. ti !'.� ...q..� ,: r,� r . �v 7. � +,y���.rq � �Kti�p y �lh ^�1'�,-�'' .,, }C r,..�-q � �.��.� Y+ L� .t'� � i. ..1' rNi tR, :� �.....� �f �}. I a ; ��s � .. ',.�„ ,,, ..� . . �.h. y �+: � '�� ,,Y u r��"i'� r`�+a .,' r v�-Y. R,�,,:� t. w. .a , • . �. ` . , � . . .. 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RnD ChA 1280 Parcel Identification Number :e�� ' ` 4797-55-5124 . :,� � �• �'-�" . � � DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001079 Tax PIN/EH#: 4797-55-5124 Billed To: Steve Vestal Subdivision info: Reference Name: Steve Vestal Location/Address: Midway Drive-27028 ) Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: '�/��/�a Water Supply: On-Site Well Community Public Evaluation By: Auger Boring C./ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition ,[.� Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH (� �' �� N Texture rou Consistence , Structure �c � Mineralo / . HORIZON III DEPTH Texture rou Consistence Structure Mineralo • HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION � LONG-TERM ACCEPTANCE RATE i � SITE CLASSIFICATION: O� EVALUATION BY: 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-Subangulaz blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed Notes Horizon 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