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191 Shutt Rd" DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003549 Tax PIN/EH #: 5789-58-4508 Billed To: Pam Gavin Subdivision Info: /I Reference Name: Location/Address: Shutt Road -27006 Proposed Facility Residence Property Size: 39 acres ATC Number: 4030 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION /Pe:�11— **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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: / Date: _? 120%s **NOTE** The issuance of this has been installed in c Disposal Systems," be given period of time. CERTIFICATE OF COMPLETION ate of Completion shall indicate the system described on Improvement/Operation Permit .nce with Article 11 of G.S. Chapter30A, Section .1900 "Sewage Treatment and in NO WAY be taken as auar�ntee hat the system will function satisfactorily for any Z Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 16121', 01r Date: V � % 0-5 y DAVIE COUNTY HEALTH DEPARTMENT • r Environmental Health Section / S r" P. O. Boz 848/210 Hospital Street yr\� Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003549 Tax PIN/EH #: 5789-58-4508 Billed To: Pam Gavin Subdivision Info: Reference Name: Location/Address: Shutt Road -27006 Proposed Facility Residence Property Size: 39 acres ATC Number: 4030 **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 Y #Bedrooms #Baths 12 Dishwasher: Z Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size C Type Water Supply 1 e// Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size/ jjDQ GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width 646 Rock Depth_ Linear Ft.,X06 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPIO D EFFLUENT FILTER. FINISHED GRADE. ****NOTICE: Contact a representative fr e avie County Health Dep, system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. n day of installation. Telepl s' Environmental Health Specialist's DCHD 05/99 (Revised) prop IL'' �- > ;ER(S) IF 6 " BELOW .nt for final inspection of this # is (336)751-8760.**** 0 toe 11 Date: �j S APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER61 Davie County Health Department Environmental Reaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 FmM 2 8 2005 E1+'�IIRON IMTALHEAR DAME COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TIIE REQUIRED INFORMATION IS PROVIDED. Refer to the INFOR16ATION BULLETIN for instructions. 1. llama to be Billed n Contact Person Mailing Address�(C /y� J �� Home Phone City/State/ZIPl�Cdf �L71C�� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 11 Site Evaluation 11Improvement Permit/ATC 0 -90th 4. system to Service: 011oouuse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: El Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms ? it Bathrooms L1Dishwasher ❑Garbage Disposal Mashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Businoss/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals IF FOODSERVICE: ll Seats 8. Typo of water supply: ❑ County/City # Water Coolers Estimated Water Usage (gallons per day) _ [Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 14-K-0 If yes, wllat type? ***IAIP0RT.4N7'*** CLIENTS AIUST COAIPLETE TILE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BESUBAIITTBD by the client with THIS APPLICATION. Property Dimensions: 3q& - Tax Office PIN: it Property Address: Road Name �7 �l Y77 f(lr City/Zip If in a Subdivision provide information, as follows: Namc: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: e7z 6 Date home corners nagged: 34,4-6 S This is to certify that the information provided is correct to the best of my knowledge. I understand that any per►nit(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 frons this application. I, hereby, give consent to the Authorized Representative of the Dav' County I-Icalth Department to enter upon above described property locate(I in Davie County and owned by to conduct all testing procedures as necessary to dctcrmine.the site suitability. DATE;��/z �Ct. �- SIGNATURE TIlIS 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). Sign given Revised DCIID (05/03 Site Revisit Charge Date(s): Client Notification Date: EIIS: Account No. 3� T Invoice No. V -7 a � 95Z4 Yt L Z9 \ v 9£s C,�4 6Z5G a�`, >•� YtBb Ytt � r 1 4 I (tl �swu Cu A E 2,d CA .. •.�6z 89ZS u. tl00f e 88 °� OO 6649 (bSE"b1 \ L956 tV66 £) V v \ 6bZ 06LE Yfife se LL94 A rots e> teszi p iinH £660�� vog < 6026 't L@n� ti tl Zs . o.0 Y i0? _ ZZL4 tl ls'E 5086 Yt0's 96 V%y .gym a \.a,�.,..k ,_�'a. - 9E86 � OZ4£ Vsb'b to g YEo It N Eno, e 4 5898 YZ9'b f�lW} —. V Cl) M VMC E Z. ' V e 1�•' h Otbt YZO'6" A oc Po 9!L V Poi V09 9GZ I � t • Wz sq _ Ox 2099 6695 '" 8 s, Lzsecc �[9� N 99 co� s srt 4 �� S6LS N Rte' _ (YEE'Z) v O ^ C ui O (7 p6 8[Z Z --i r 6080 6465 t o;t � L i M 966f .. r tl6Z't l) (LZ6 y< A � 6e09 APPLICANT INFORMATION Account 990003549 Billed To: Pam Gavin Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5789-58-4508 Subdivision Info: Location/Address: Shutt Road -27006 Property Size: 39 acres Date Evaluated:JI ' Water Supply: On -Site Well _ Community Evaluation By: Auger Boring — Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % Al V HORIZON I DEPTH Texture grou2 LC Consistence _C111 - Structure Mineralogy HORIZON II DEPTH Texture grou2 Consistence Structure i 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: N EVALUATION BY: OTHER(S) PRESENT: 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 oist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm .W NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic r ct re '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 DCI ID 05/99 (Revised) ■��i��■ ■��it��■ �� ■��ir��■ ■��v��■ ■ ■�� ■��i��_� ��■ ■��i��t��■ ■ ■ ■ .........��.................................................. �.0 ■��i��a��■ �� i��■ ■�� ■��■��■ ■■ �■ .........��......................�..................._..�... . .........��...................... � ................... .. ... .. .........��.................................................. � ._ .........��................................................... . .........��...............................................■... ■ .........��.■....■■...........�............................. ■�. ......�...�................... ......................�..... .. ■ ■��i��a��u�� C■ ■■■■■■■■■.�■■■■■■■■■■■■s■■■■■■■■■�■■■■■■■■■■■■■■■■■■�.■■■■■■ ■ � ■ ■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■�,■■■■■■3 ■ ■■ ■■■■■■■■■■►■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■��■■■■■■ ■ ■■■ ..........�..........................................��.....�.� _.. ..........�..........................................��..... .. ■��o��e��■ ��■ ■��■��i�� ■ ■��■ ■■ ■ ■��■ ■��■ ■��■ ■ ■ ■ ■��i��■ ■■ ■ ■ ■��t��■ ■ ��■ ■ ■��e��■ ■� ■ ■ ...�................................................��.....�.��.. . ....................................................��..... . .... ....................................................��.......... .. ■■�■��■��I■■■■■■■■�■��■��■■■■ ■■�■■��■■��■ ■��i��■ r ■ ..........r......................��,..................�....... .G E. ..........�......................��....o.............�.......�a=E � ....... .�.�..........................................��....... �. o��e��i��i��n��i��■ ■ ■��►.i��i��c�r��i�� ■� ��i�iu��i��:��r��, n■ C ■ �r;s�n:a��i��s��u "=i■ -� ��■ u��■ ■�e��■ �■■■■■■�a��i ■��:� ■��11�� ■��il��t��11��e��e�►�11��II��:iL7��►\��fl�tr" � �� ■G!rr�//Ic��iS��/II��Iliii��fAr� � ■ r��ie��r��r��i��a��s��r��■ ■ ■■ ��r��i��i�� ...��►.r...�i..............��..............��•..G��.......... .g ■�r ■��C��r■ ■ ■■ ....�i.....�i..............��:.::: ...:..�a......�........�C ��... ■��■ ■��i��t��r►:��..�s:��t�� ■■ ■ ■��i��ti��r��.��■ �i� ■�� ■��i��■ ■��■ .....�C..................................►�................' �..... ....� ...�.................................�................ ... ■■■■�■■�■�■■�■��■�■■■�■■■��■��►��■ ■r� � ■��■ ■/��\1��/��■ ■■ ...■...��.■.........■..........�......................�C. � � ........ �.........��.......... .........►....�........■ ■. ■��■ ■■ ■�� s�e��au�� ■ ■■ ■��i�•.��r��n,��r�� ■ ■■ ■��.��.��t��■ ■��i��■ ■ ■ ■��i��■�� i ■��■ ■��►�� ■��►��i ■■ ■ ■��►��i��■ ■�� ■ ■��■.-�� i��■ ....�.......•.��...............�.........�..►.......�...��C� ■��i/��r%��■ ■��l��■ ■�\��I��■ ■ ...........�.....■...................................��..... � ■��i�� a��►�� ■��■ ■ ■��o��►•�� ■■ ■ ■��■ ■��v��r��n►��,�� ■■ ■ �� ■��t��t��s��i��a��i:i��■ �� ■��■ ■��t��e��■ ■■ ■�■ ...........o...................�......................��. g... ...........►............................................ . � ... ...........�............................................... .. ...........�................................................ �: ...........�......................................... . .. �....................................................�.�. a .s ................................. ................. .. . :::::::::::::::::::::::::::::::�.::::::::::::::::::::�� .............................. .................... ....a ..............................�CC....................�..... �.