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186 Shore Ln . ' �' � • DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Heaith Section P.O.Boa 848/210 Hospital Street � Mceksville,NC 27028 (336)751-8760 Account #: 990003853 Tax PIN/EH#: 5803-39-4724 Billed To: Michael Shore Subdivision Info: ��(� �'(ta���wL Reference Name: Michael Location/Address: 2691 Liberty Ch Rd-27055 ATC Number: 4309 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 WASTE O ON I OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: tt, CER MPLETION '`�2�- � ii **NOTE** The issuance ofthis ertificate of omp e�on shall indicate the system described on Improvement/Operation Permit �° has been installed in mpliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"b WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. �— � � '� � h � � ti1 D��� �� l� � � � _ '.___ _ -�-- - -� � ♦ • cDv ; yA �q�' 3 � ������ '�►�9) �3 ``� �vwc y s�m u�Aw.� ` Z . �A�Jti,�q�� 4-3,� �, . Septic System sta l.L.: Environmental Health Specialist i e: e' `� �'�d� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT r ' ��-�• Environmental Health Section pd. � ' �r ; � � � P.O.Boa 848/Z10 Hospital Street t Q Mceksville,NC 27028 q I�'� � ' (336)75]-87G0 U� IMPROVEMENT/OPERATION PERMIT Account #: 990003853 Tax PIN/EH#: 5803-39-4724 Billed To: Michael Shore Subdivision Info: Reference Name: Michael Location/Address: 2691 Liberty Ch Rd-27055 Proposed Facility: Residence Property Size: �n **NO'I'��*�iisImproveme9iit/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WAS7'EWATER 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 PERNIIT BEFORE INSTALLING SX,�T� �j lg�� ,y � A7�-� `� Residential Specification: Building Type nE7l�% #People� #Bedrooms ✓`I � ' #Baths �� Dishwasher: � Garbage Disposal: ❑ Washing Machine: �" Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size "'�Q�=S Type Water Supply� Design Wastewater Flow(GPD) 1��� Site: New�Repair❑ I� �� System Specifications: Tank Size��� GAL. Pump Tank GAL. Trench Width c� Rock Depth tJ L� Linear Ft.� o�h�: 5 Disre�b��n� ��s . �'C - ��� 25%12��T��I ���rc:�� �� � , Required Site Modifications/Conditions: ��STp�,.1_ C�•-3 Gf�TO��Q C-l�� �C� �OM.1•�r7�1� �. INIPROVEMENT/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)751-87G0.**** - '��� ,� � � �� �� � " •� � � � �� - � � � � -�} � �. _�. ���� z �� � ����-� -� ►�� I i LL � � � ��'`� �r«z,.,��,. ���r,�T ' ���C..'��!�1-{2 � ��� �G I . � �� i� c��Z cx�k ��T�C� ���=�� 1� � �'N „ �����-��N��--I�� c�'�I� . I Environmental Health Specialist'� i�eu� �� ���� � ��!L� l.�V DCHD OS/99(Revised) `l2j /�x� � Jan 18 06 03:45p davie county envhealth 336 751--8786 p,2 j!�' '' • _,., � � .t• :a , � • � � APPLIC1l7lON FOR SRL EVALUA770N/IA1PII;IVFh1ENT PC[iA11T d ATG � ��' � Davie County Health De{:artment {��--�"' � EnvironmentalHea/d�,yecGon D ��� P.O. Box 848/210 Hospil:al Straat � Mocksvilla, NC 27028 ` ^ G ���6 (336)751-876C �� � ;' ' ��` *�*T1�1 ORTA *** THZS ABPLICATION CANNOT BS PROCEt�SED IINLfiSS ALL TAE REQIIIHLA � � � ORIUITION S PROVZD�L. RePer to the TNFORMATZ�:N BIILLETTN Eor iaeCructiona. �(�RO�N CO��J�v1�N cDilled� (� J���G ContacGYeraon �fGYIQ,e! J/IDY�G lx� C� 33[ �/Ca3 -y�D.? Tiailing Addrese�� , itoma Pl�ona v' cser/"+tate/2IP Un.,� �r� � 0 Huelnass Phona,33�-y/3- 039/or�33lo-?�3'e�o�3� - 2. Namo oa Permlt/ASC SL Diiierant Chan nbova � Ttailinq Addrao _ Ci�y/Eta[e/Zip 7. Applicatioa For: 0 SiLe Evaluation O Im�:�rovement PermiC/ATC �d Doth � 4. 9y�C«o eo ser..ica. �(]iouae: C7 Mobile Somo ❑ Duaineas ❑ InduaCry ❑ Other �� 5. Type uyutem requoatad: �Cu�vmtlonal ❑ oonv.ntimal nwdiii�d Q innovalive L'JacCepted 1 6. If iteyidence: 0 Peop7.e ��_ i Dedro�ms ��� Y Authrooais ��„_ a7pinhwaeher aarbage Dln.�onal OfWashSag 7Qachino � c1r'Baaement/plumbing � ❑uasemene/No P1wMing �. If Guaine�a/Industry/othar� aerliy type , y People { Sinka �_. _.�_ I Commodau t Shovara i Urliale ! Wstor Coolars IF POODSERVICE: 1� Seat[t Eatimated ilatar Uaage (gallons par aay) e. ay�o �t wac.r �upply� ❑ Ca�:nty/City t�W�ll ❑ Community s. Dp you an[Scipate aaastsona or czpansions of tl�c faci]ity tl�is apslcm is intcnded to scrvc?❑1'cs �No Ifycs,u•hat t)Tc? "*"I�iIPOR7'�lNTw'•CLIC•Cf1'SAlUSTCOAfPLETETHE REQUI;�L•DPROPER7'YIiVFORh1ATlONREQUEST['sD UEI,01V. Eithcr a PLAT orF ITG�PLAN hIUST B6SUUA!l7TL•D b�•thc tlicnt vrltL TIIIS APPLICA'CION. Property llimcnstons: \VRI fC DiRCCfIONS(from Moticsvillc)lu PILOPCILTI':: n•uorr,��i'IN: B ss�3 9y7ay �'��,�-�',�,OI /Vor��. )-o Property Address: Road Namc �1�� L�i r✓�✓ (���Q r�. �n a eDrn,a(. ��rytip� �c;v,�i� e '�?Q�'�.���at a.,aC Dr�ve- wa✓ If in a Subdivision providc informatimi,as fopows: ,�.�� �C Dh �i E I�f�- Namc• �l�91 G.6�r�y C� /�oC. � SccUon: B)od[:_ Lat: DaG: homc corncrs IIag;ed: �'��'"a� 'I'tiis is lo eerlify tlmf lUc(nfonnadon provided is corrcct to tlic besi of:ny knorvledge. I understanJ tliat any permil(s) issueJ hcrcrttcr are su6jcct to suspcnsion or revocation,if the site plar.:ar inten�ed use d�ange,or iC lhe informalian submittccl in tt�is applicatiou is[alsi:i¢d or cliangecL I,also,urrderstwec lhat I ani respansible jar a1!c6arges i�fcrrrredfrom d+is applicatiun. I,hereby,give conscnt to tLe AutGorized Representati:e of tlte Davte Couuty T�Icallli Dcparlmcut la enter upou abovc c(escrIbed prap;rty loc�led in Davie County and e vned by LGG S�O'r�. lo conduct xll tesling procedures as necessary ro Jeternilne tl�e site suit ibilil�. DATG �S�a�n D� _ SIGNATURE,�,,�,�ld �J�7.P TFIIS AT2�A ASAY B�USL�D TOIt DRAWING YOUR Si'CE PLAN(I:�cludc ail o[tl�c follo�rIng: Lxisting aud proposcd property Iincs�nd dimensions, structures, setbacks, and septic loc�ti�:ns). Silc Acvisit Cliargc . Datc(s): Clicnt NoliGcation D�tc: �ITS: Signgivcn � • AccounlNo.VO,� � Itevised DC1Ill(05/03 I�n�oice No.--�y� . (�E �J W i-,� � '�. � I � �• .:,� � '°s c,� -, :- � ��„f� � a 3 ty � ✓ 3 K i t` L � i �� � � �r� - I , ` � � � �'1'"4� � �6�94724 �� , A�p-�x doroc I �� (3.93A) i <` 0882 y��" �occl�on �,a o �.S �„F.p���i � ��y 2�iT �4 v � � n fo (3.23A � Z66E ; - n . m z .osaR �i�$,� 4 �f � 0575 ^ � � � ¢ � ...��x.: ,�.�.� � �` � __, ., � r � _„_ �p � _ ... .._ ,,,3'16..._.. °��..w^ ` r+r . ' � - DAVIE COUNTY HEALTH DEPARTMENT = � �'~ • Environmental Health Section . � . . Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003853 Tax PIN/EH#: 5803-39-4724 Billed To: Michael Shore Subdivision Info: Reference Name: Michael Location/Address: 2691 Liberty Ch Rd-27055 Proposed Facility: Residence Property Size: Date Evaluated: � �G� v �r Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 , 2 3 4 5 6 7 Landsca e sition C ' Slo % HORIZON I DEPTH � �-/� �`•• c0� Texture rou $L y 5�,� c . sc-t.- , Consistence S SC' SSS Structure � ' S3 ic .�� Mineralo HORIZON II DEPTH J 2- t7 "1r �� Texture rou G G Consistence �S Structure S`•'3) � - Mineralo 5� X�� �.'1C HORIZON III DEPTH - ', .... - r3C, - �Z. Texture rou '° Ct. =+ -1-5... Consistence ' r S � S �Q �- � Structure '� 5 Mineralo .� s S7cP HORIZON IV DEPTH ' (y- Z k i' Texture rou 4�- �C S.� LPu CfS ; Consistence r$ Sy' n1SN � St�vcture s�k ��k Mineralo SOIL WETNESS ti-3�-- RESTRICTNE HORIZON SAPROLITE CLASSIFICATION � LONG-TERMACCEPTANCERATE � '? D.Z ��3 SITE CLASSIFICATION: Y� EVALUATION BY: �'F ��-u1�E1'4 h^r LONG-TERM ACCEPTANCE RATE: �•Z�O�27� . OTHER(S)PRESENT: (<!'r _ ��s: �� � C r�� �Ins s�., Qc;�� n�,x� ►a f�z �:u�►,��-rL�a�e�-s;p/�3 .ssw•��x..��..,�-30 LEGEND Landscane Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-F1ood plain H-Head slope T�xtucg , _ 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 .ONSI�T .N . 1Y�iSt . VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3�'e.t � . NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ,�171�ti3I� SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK=Subangular blocky PL-Platy PR-Prismatic , Mineralo�v 1:1,2:1,Mixed ' ; lYoies � 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]and 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/OS(Revised) .�t�i6.!���_ ■■�■���■��■■�■■■■■�����■�■■������i�■■■o��ri��►��■�u■o����■■■�■�■���■ ■■o■���■�����,■�■����■■��■�■�■■�� ■■�o■��so�■��■��■■�■��■���■�■■��■ ■�■■��■�■■e■ri■������i■■��■�■��■���i�■��■�i■a����■s�■�■�■�■��■■■■���■ ■��■��■����e�i�■�■�■u■0■�■���v■�■�c:::c•�i��■■�■►�������■����■■���■�■ 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