134 Parkway Court Lot 26 DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
' Mocksville,NC 27028
(336)751-8760
Account #: 989900571 IMPROVEMENT/OPERAiFjpff Woo 4§20.41-1803
Billed To: Shuler Building Subdivision Info: North Brook Lot#26
Reference Name: Location/Address: Parkway Court-27028
Proposed Facility: Residence Property Size: 7.8110 acre
ATC Number: 2900
**NOTE** This Improvement/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 #People #Bedrooms -? #Baths J
Dishwasher:: Garbage Disposal: Washing Machine:Oo" 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) -256o!� Site: New O'� Repair❑
System Specifications: Tank Size"GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft
Other:
Required Site Modifications/Conditions:
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.****
ld we
6 �led
e,
Environmental Health Specialist's Signature: D� Dater,,
DCHD 05/99(Revised)
rd
� t
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900571 Tax PIN/EH#: 5820-41-1803
Billed To: Shuler Building Subdivision Info: North Brook Lot#26
Reference Name: Location/Address: Parkway Court-27028
Proposed Facility: Residence Property Size: 7.8/10 acre
ATC Number: 2900
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 YEARS/.
Environmental Health Specialist's Signature: Lx'`� Date: oL lJ
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 aarantee that the system will function satisfactorily for any
given period of time. �°Z� 4 'w L
Septic System Installed By: 44W. - 01 VA,M101
Environmental Health Specialist's Signature: / j,9/�a Date: /Z F69
DCHD 05/99(Revised)
M
LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Health Department
JUN 2001 Environmenta/Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
ENVIRONMENTAL HEALTH (336)751-8760
DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer/�to.the INFORMATION BULLETIN foal instructions.
1. Name to be Billed j) Jer , L&%n Contact Person gen p S >Ine'r-
Mailing Address Home Phone
City/State/ZIPBusiness Phone 9!//
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation V�- provement Permit/ATC ❑ Both
4. System to Service: 8"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: �# People # Bedrooms 3 # Bathrooms
f4Dishwasher Q Garbage Disposal fYWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats �/ Estimated Water Usage (gallons per day)
7. Type of water supply: I3 county/City ❑ Well ❑ Community
�OU,��o�, idj /!ate�i l7c�.rr lJS�
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Imo
If yes,what type?
'IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �"7%D ! WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # SO c?� 7 ��Q d3 �o�� �0�7� �O.�S��irr , Tom.^•,�
Property Address: Road Name j"`�'lC�-�.r C a -'e.1
City/Zip /fr�yL O� /�/7G ia. C:a-
If in a Subdivision provide information,as follows: /l iy�4� z rq /4/.fu/ay C_vf- -7RL a
Name: ND!'70i16 .r
Section: Block: Lot: �_ Date Property Flagged: "o —o7c3
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 revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Day' ounty Health Department
to enter upon above described property located in Davie County and owned by.
to conduct all testing procedures as necessary to determine the site suitability.
DATE W"" SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
917 7 01)
Account No. 5-7/
Revised DCHD(07/99) Invoice No. ��
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM
Davie County Health Department
Environmental Health Section SEP 1 8 1995
P. O. Box 665
Mocksville, NC 27028
ENVIRONMENTAL
DAVIE COUc
1. Application/Permit Requested By ZrI4 4a&
Mailing Address xa,.e Na
Home Phone !?9,9#7 1 7 Business Phone
2. Name on Permit if Different than Above
3. Applidation/Permit for: IVGeneral Evaluation ❑ Septic Tank Installation
4. System to Serve: [P/House _ ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ In Other £1 erl ! El Unknown
5. If house, mobile home:Subdivision w03V Seton Lot#,
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No.of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
. . r
6.`If,business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
S
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ErPublic 7. ❑ Private ❑ Community
8. Property Dimensions (� 6keuz/ Sewage Disposal Contractor 7
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes,what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation,if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: ,
(J
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
DATff SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. 1 ❑ 2. 1 DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(12.90)
DAVIE COUNTY HEALTH DEPARTMENT ko \ b
+ Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED j 0 - 0
ADDRESS S� � PROPERTY SIZE �`-01 x 3Q��1
PROPOSED FACIILTY V`% o SQ LOCATION OF SITE 1 Ca— 10�00�
Water Supply: On-Site Well _ Community Public
Evaluation Bytom Auger Boring Pity Cut
FACTORS 1 2 3 4
Landscape position
Slope 6
HORIZON I DEPTH 1A It
Texture groupl.,
Consistence
Structure
MineralogX '
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy '
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS 5
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �'S " EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: t� 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 :lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vf.--y 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(01-901
MEN 0 MIEN
MEMMEMEMEMES no
■.■.■�....■■■■.■....\..i.111■ %.....■■..■.■..0..■■:■■■■■■■■■■■■■O■■
■....%.....■■.■...■■.■■■.Y.■/I.■1H SEEMS■■■■■■.■.■■...■■■■.■■■■■■■■
■■..■1\■■...■■■...■...■..■....■■■.■■■■■■■■■■■■■■ ■ �EEEEEOE■■EEE■■■
:.:.:.:.:.:.:.:H::■:■�■..:.:.:.:.:.:.:.:.:.:.:.:■O::.:■:.:.:.:a:::.■....:.:H:�s. ....:..:.:..E.m.m...m.. :EMO: : NuME:/I■■
■■....��.■■.■.■....■..u..■.■■...■..N■.■■..o■. .■■m MEMM■■■.■r/■�
;�EMEMEN
■■■M.►. _
.......,..................................�.■.... �.■_.. .._.■■► EEM
■..■■■\1■MM■Oc■..■■..■■.■■■..■..■.■■■EEE.E ■O■■■■E No ■■■■I ■■■�%.■■
■.■...\■.\79x1.O..■■ON..O.■■M.■�...OH■ONMHNNO.M■O. .■■■.■■■
■:::: \ ■N■ . s■:::'■�'::o■:::■ :H■M �H/1■■■I
MEN■.■....■■■■■■..■■■...■■.■■.■■■■■■.■ ■■ Hp� HOO ■■ EAMON
■■MEME :
■■■■■■ ■■■■■. ■E■O■O EE■■.■ ■.■■ .■.■■ ME'E: ■■II■■■ ,
■■■EMI."■MMEMMU■■EMME�IMM■ME MEMO ■ ■ ■■■■"■■11■■.
■.■■OE■11■.■■■■■...■■■■■EHE■■■■■■.■■■. OHME■■ ■MINEMEM■
■...■■■tl■■■.N.■■■■.■■■.■OH■.■■■■■.. ■■ ■MI/.MEMO
I:: ::E■ ■ O■ ■■Is■.�■■
::: 'C:: C:MENEM :
.......■I...O■O■.■...00■■■.■aO■.O
MOM!.N ■�■.w
No No ONIEN MI
■■.■■EEE�I■.EOEOE■HOO■ EMO
■I 1 M
SEE■:MEH■ H OE Oft■■.■0 mom
MMMMMM MEMO
O:
MEMEMEMEMEMEMMUM uMMMEM■EME ■ MOEMMIIMu■■■
....... ........... .... ■EEE : ■EIDE ORIMMEN M
■a.00■.E■11■.MEE■OE■■■■■■M■■.EMM.■:■ ■ ME OWNLEMME
MONo
■...■■■■■.iMM■■..■.....■...■■■.MI■E::: �MOMMO■MMMUMEMMUMMEMOM
■■.
MENEM
0 mom
■■■■O. ■EOMI\...�0■..■■:■■M■■H■■ ■ ■ ■ OH■■MEMMEMMEME :■HOME■OM■
MMEMEN m■■■