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249 Mohegan Trail .. . ° � DAVIE COUNTY HEALTH DEPARTMENT • � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33(►)751-8760 Account #: 990003507 Tax PIN/EH#: 5754-03-2540 Billed To: William Smith Subdivision Info: Reference Name: Location/Address: Mohegan Drive-27028 Proposed Facility Residence Property Size: 15 acres ATC Number: 4017 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). T'his 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 WASTEW R-E N � N IS V ID F ERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ate: ` / 05 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 . . hapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in I�,O WA�be t en as a tee that the system will function satisfactorily for any given period of time. �N �� i� �!UI�-r /o r � (�,�,��5 ��/il'�`c-.�T l�q�` 4 ( ►B � 91 (�iG� '� �C�a�z �� E � -zp_v� Septic System Installed By: � Environmental Health Specialist's Signature: ate: C� � DCHD OS/99(Revised) . } DAVIE COUNTY HEALTH DEPARTMENT 2�� • � • Environmental Health Section g • P.O.Boz 848/210 Hospital Street O�- � ,/ �`S Mocksville,NC 27028 � (33G)751-87(►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003507 Tax PIN/EH#: 5754-03-2540 Billed To: William Smith Subdivision Info: Reference Name: Location/Address: Mohegan Drive-27028 Proposed Facility Residence Property Size: 15 acres ATC Number: 4017 **NOTE** 'This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AITTHOWZATION 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. CN��-�:�) Residential Specification: Building Type �� 10�� #People Z #Bedrooms � #Baths Z C�� Basement/No Plumbin � Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ' g: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 1� ��-�=S Type Water Supply ��-�-- Design Wastewater Flow(GPD) �d`� Site: New�Repair❑ r� ,� � System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width �ln Rock Depth �Z Linear Ft.� Other: �j ��STQ..1�1.,'�'1`��.J �.�� Required Site Modifications/Conditions: �a��l� �.� G��''r� �-G�:-�' �� i'�w—�c=1..� � �'� �Qt��+••- f IMPROVEi11E T/OPERATION PERMIT A O[T- APPROVED EFFLUENT FILT . RISER(S) IF("BELOW FINISHED GR DE. ****NOTICE: Conta a r pr se tative ofthe Davie County Health epartrnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m. o :3 p.m. on the day of installation. T ephone#is(33f)751-87C0.**** � � � �I�iV�-T�¢.��Ci�n �9� � � ° � �IF� -ro..�+�-}� �-► � �� fl' � � ��cS �a , , �c�,,,�7 � �-{o' � Q-- r e.�!` ��p�.'� I 7 1� �iAE, � � � � ��\ �J� � � Environmental Health Speciali ' gnature: e: O� DCHD OS/99(Revised) � � �.�iu>>l�F��-.��/,3,�3/y .� � d � • � � � �'/��e� Q � A L TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC C�// 2005 Davie County Health Department 4 � � � �Eg 2 2 Environmenta/Hea/th Sec�`ion � ��,� c � P.O. Box 848/210 Hospital Street �� S � �c, �`H�TM Mocksville, NC 27028 �, Fy- � �E��My (336)751-8760 � c��-S a ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. /�' �/I �� / /� M1 1. Name to be Billed _ ��i�� ///, ��jJ��f1 Contact Person G/��/��y�YI ,�� J�'�/� Mailing Addresa ��/~ 'm�!�i" ,�., Home Phone �(/'��` C�7: `-�C�_ City/State/ZIP `�,��:,�('?(�-/ /J� '��'��`� � Susiness Phon �(/�f Cy��(r" �l,`_�� '� d---`- �� /1 r ) 2. Name on Permit/ATC if Different than Above Gyi �i;'� .✓�'i �/12��/1 Mailing Addreas /�� Ct��/�C[�� [�r City/State/Zip ��/�;� ``,G - ,a'X�7 7 �/ I 3. Application For: �Site Evalu tion L.!" Improvement.Permit/ATC f�Both 4. system to Service: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type syatem requeateds �Conventional ❑ conventional modified ❑ innovative 5. If Residence: # People � # Bedrooms _� # Bathrooms � IY1Dishwasher ❑Garbage Disposal L"JWashing Machine ❑Basement/Plumbing ❑Sasement/No Plumbing 7. If Huainesa/Induatry /Othar: verify type # People $ Sinks # Commodea # Showera # Urinals # Watar Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gaiions per day) 8. Type of water supply: ❑ County/City �Well ❑ Community 9. no you anticipate additiona or expansions of the facility this system is intended to serve? ❑Yes [�No If ycs,�vhat typc? ***IMPOItTi1NT"'**CLIENTS MUST COd�PLETE THE REQUIRED PROPERTY INrORMATION REQUESTED I3CLOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by tlie client with THIS APPLICATION. Property Dimensions: /�� f''.�(Q� WRITE DIRECTIONS(from Nlocksville)to PROPERTY: Tax Officc PIN: # �7J`�GM_k��c.�G`� �� Si�c./�ti �/.�D l/�S l�,�i//� �,�('�� a�l% Property Address: Road Name�1�Q�1 �('. �✓„1��rI ,�l✓�'- �Y�l �jy��?'1�70/�q�rl p�. City/Zip ��I�SV'i f/r �✓l �7Q�`�Ci-,�'a-�, /�; �� aj1 ��f�s,.�� If in a Subdivision provide information,as follo�vs: ��Td� � Name: Section: Blocic: Lot: Datc homc corncrs ilaggcd: � 6 5 This is to certify tliat tl�e information provided is correct to tl�e Uest of my lcnowledge. I understancl tliat any permit(s) issued liereafter are subject to suspension or revocation,if the site plans or intended use cliange,or if tl�e information suUmitted in this application is falsi�ed or cl�anged. I, nlso, trnderstand that I�ui respaisible for n11 clinrges incrrrred fronr this applicatio�r. I,hcreUy,give consent to tlic Authorized Rcpresentativc of thc Davic County I-Ic�lth Departincnt to enter upon above described property located in Davic County and owned by to conduct all testing procedures as necessary to determine tlie site suitability. DATE Z/ o� �'/b � SIGNATUI2E THIS�It�A MAY BE USED FOR DRAWING YOUR SIT�PLAN(Include all of tlie following: �xisting and proposed property lines and dimensions, structures, se backs, and septic locations). Site Revisit Cl�arge � e��/ 6� . Datc(s): �i � Clicnt NotiFcation Datc: � �^ �l ��5: � �J Sign given � Account No. � Revised DCHD(OS/03 � Invoice No. ( L. �G S / � � �� lJ . 1NDEXED N 5744 � �631 F � � � c � ��1 � I ` --�,.� ti , , �� ' , t'�� a��.1Q � 890� ! ; � 1 t � ��:� PaD peC�Pc�2 �, PaD PcB2 ;, PaD � � PcC2 , � � 4 � �N�E��} �}� t ,�m�� ; f � *, 5754.Q3 ��.so� ► 2540 ' � I � rn I I I 'l ChA ,' � PCB2 , � PaD 1 �'I;�` � 9�' 4 � � j ; ii�,. 1 �� t '"� � ��,� '/ � � �� ,� \ � �� \ � ?�u� � � �_ / � J � (�o�p) �� .,� ' ' � f ,% / a � � ! 1 / / ° � � � � � , ,r�,��'�� '�i°�`�� - - � � l�Ral INDEXED N 5744 (6.52A) 6316 � , . 5393 ; 1741 121a1 (5.52A) : 5108 1583 l5yol � . � f � . (10.10 A) , 1' � ' . 8907 N . � 5A N 9963 ` (820) 1752 , ` : r : 1,�g01 869 . , � . 532 . . ' . 060000003401 . . � 'll `3� 5754032540 0 7.429A 5.00OA : ✓ 0670 ` 7660 � 15.600A I 2540 . . ,� �_ ___ - _ _ ___ _ _ _ _ _M E A 53, - _ _ __ _.______ _ _ __ _ _______- ` _ __._ _.___ _.2.304A . so� 6347--- — _ _ _ ._ _. __ _ ��vrg N � ss�.ss . . . . . . . � . . . . -: N l�Ot�e � 2.919A - 9295' 5A $� . 7262 574 �� (21.42A) �,� f�oyoJ _ 5924 � � - � b ' (718) 536 I V -•-+ •- �' ' DAVIL COUNTY HEALTIi D�I'ARTML:NT \ . Environmental Health Section Soil/Site Evaluation " AI'PLiCANT INFORMATION 1'ROPERTY INFORMATION „Account #: 990003507 Tax PIN/EH#: 5754-03-2540 � . ,'. Billed To,. William Smith ,Subdivision. Info: Reference Name: : Location/Address: Mohegan Drive-27028 / . Proposed Facility: Residence - Property Size: 15 acres Date Evalu�ted: _ � Water Supply: �. � On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L ' Slo e% � /,�1:� HORIZON I DEPTH �- . Texture rou Consistence Swcture � e Mineralo � HORIZON II DEPTH �,; Texture rou C"�.: Consistence - , ) Swcture Mineralo �1G HORIZON III DEPTH � 'S . Texwre rou Consistence � r� Swcture K S Mineralo �� HORIZON IV DEPTH X Texture rou "� � � Consistence Fr-- Structure 5,1�� Mineralo �'Z� SOIL WETNESS ` RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION " �� LONG-TERM ACCEPTANCE RATE p- SITE CLASSIFICATION: PS EVALUATION BY: ��>l—r�" �� LONG-TERM ACCEPTANCE RATE: �'� OTHER(S)PRESENT: ��'�''^'"�""'�'� REMARKS: ��.��',��a�I �� C��^-�P�"� `i�o, I r� ��S 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 ]nam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE ois VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky � � NP-Non plastic SP-Slightly plastic P-Plastic VI'-Very plastic tr ct rc 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic 1V_�ineraloEy 1:1,2:1,Mixed te Horizon depth-In inchcs 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-gaUday/ft2 , DCHD OS/99(Rcviscci)