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208 Victory Ln � � OPERATION PERMIT o� i�� se �v , _ y ,. Oavie County Heaith Department 'CDP File PJumber 114275- � • � -: `-'�?�`+.� {.���,t ..���j 210 Hospital Street G2ooeooa�s ,� �-,. '� "�'�� " '��` P.O. Box 848 County ID Plumber: �SY.� � /bi "���-r� Mocksville NC 27028 Evaluated For. NEW Phone: 336-753-6780 Fax: 336-753-1680 Township: A�p�;canr Ronald G. Jones Property oL��ner. Matt and Tracy Seats A�dress: 142 Cedar Hill Lane Address: 2742 US Hwy 158 ��Y� Advance ��Y� Mocksviile State,Zip: NC 27006 State:2ip: NC 27028 Phone::: (336) 998-7206 phone�_ (336)817-4696 Pro ert Location � Site information AddressiRoac7 ::: SubdNision: Phase: Lot: 208 Victory Lane Mocksville NC 27028 Directions str��cture: SINGLE FAMILY 64 West past Lake Myers, turn right on Callahan Rd. go till you see Church on right property at back left ::of Bedrooms: 4 edge of chUrch. » of People: 1 'W�ter Supply: NE:ti�::�ELL �,.,.�,,�,�..�.�,,��,,..�,.,..,�,�, ..�,,.,�..m.�..�.,u.�.,...�.�.,��.,..�»�,�..,,.�.a,,.M....n..��_..- "IP 155ued by: 2244-Daytivalt,Andre•.y 'System Classif�catbniDescnption: 7YPE Il A.CQVV SYS7ERt(SI�tGLE-FAh1l;.Y OR�i8D GPD OR IESS) `GA issued by: 22aa-oaywalt,Andre•,v Saprolite System? (JYes t��PJo Desigrt Flot��: 4 $ 0 . Gf2.1vITY-S�RIAt Pun�a Requ:red� Distrbution Type: �}Yes �;}tlo So�l A�plication Rate: � 2 "Rre-Treatrnent: Drain field �d drificatron Field SU ft� 'SySt2m TypE: �yF�LTRATOR OUICK.STANDr1RD �do. Dr�in Ltnes , shcrmandunn InstaLer. Total Trench Length: 6 0 0 n� Certification �: Trench Spacing: _ 9 ��Inches O.C. �?Feet O.C. 'EHS: 22aa•O,y4:i�t.Andrev! Trench Width: ` 3 6 ('?�nches ('�Feet p�t�. 0 7 / 2 6 � 2 0 1 3 Aggregate Depth: mches �rlinimum Trench Depth: Inches � t.�inimum Soi1 Cover Approval Status Incties r;taximum Trench Depth: Inches � Approved O DiSapprOved , t:laximum SoiE Cover: Inches , CDP F�Ie Number 114275 - 1 County ID Number: c2000000�s . ' Septic Tank ' , t:i�nufacturer snoat Lat. ,�;� � STB: Long: , Gailons: 1G00 Instal►er: Date: 0 4 / 2 0 � 2 0 1 3 CerU6cat�on :: 'EH S: 22•::a-Oay,.va't.Andrerr 'Ftlter Brand: ST t.9arker: O Yes ❑ No Date: 0 7 / 2 6 / 2 0 1 3 Reinforced Tank: ❑ Y�S ❑ NO Approval Status 1 Piece Tank: ❑ YeS 0 No � Approved O Disapproved Pump Tank �;tanufacturer. Instailer. PT: Certification �: Gallons: 'EHS: Daie: / � Date: � � RiserSeated ❑ Yes ❑ No Riser Hei�ht: O Yes ❑ No (�.1in.G in.) Approvai Status Reiniocced Tank: ❑ Yes ❑ No Q Approved❑ Disapproved 1 Piece Tank: ❑ Y2S ❑ NO Supply Line Pipe Size: inch diarneter Instatler: Pi�e Length: feet Certification K: 'Schedute: "EHS: Pressure Rated ❑ Yes ❑ NO Date: C � Approved fittings ❑ Yes ❑ No Apptova!Status ❑ Approved ❑ Disapproved Pu Re uire ent Pump Ty�pe: Installer. Dosing Volume: — �a� Certification �: Dra�: Do:�yn: Inches 'EHS: 'Chain: Date: � � Valves Accessible � Yes ❑ NO Flotv Adjustment Valve ❑ Yes . ❑ No Chech-valve ❑ Yes ❑ No Approval Status Pvc unions ❑ Yes � No D Approved � Disapproved Vent Hole Q Yes ❑ N o � Anti-siphon Hole � Yes ❑ NO � CDP Ftite Number �14275 - 1 County ID Number: cz�aa000�a , Electric E ui ment P�1FF.1A4X Eiox or Eguivalent p Yes ❑ No Instalier: E3ox 12 inches Abovc Grade ❑ Yes ❑ NO Certification�: Box Adj.To Pump Tank ❑ Y8S ❑ NO Conduit Sealed Q Yes ❑ NO 'EHS: Pumpt�tanuallyOperable p Yes ❑ NO / / 'Activation F:tethod: Date: Alarm Audible 0 Yes ❑ No Approval Status � Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 22�i•i-Da�n:at;,Mdre�r "Operation Perm�t completed by: �liithonzed State Agent: Date of Issue: 0 7 � 2 6 � 2 0 1 3 This system has been installed in compl:ance tivrth applicable �JC General Statutes: Articfe 11,Chapter 130A, Rules for Sewage Treatment and Disposal, 15A FJCAC 18A .1900 et. Seq., and all condiUons of the Improvement Penn�t and Construction iluthor¢ation. This property is seNc� by a nPE n,� sewage septic system. Rule .1961 requires that a Type TYPE°A _____ sept�c system meet the folloti��ing cnteria: t.tinimurn System Revie��a E3yThe l.ocal Nealth Department: N?A____________ t.9anagement Entity: o�r^��NER____ F.9iniri�uni System Inspection;l,laintenance FrequencyE3yCertitied Operator. N?!� Reporting Frequency E3y Certificd Operator. N�A_!_______ Rule .1�6t requires i1�at a Type IV arid V sep4�c sy�stems designed tor a home�business o�vner must maintain a valid contract �ti dh a public management entity:radh a certif�ed operator or a pnvate cerUfied aperator tor the life of the septic sy�sterty. Rule .1n61 requires thatType VI septic systems designed fora home�business o��rner must maintain a vatid contract with a publfc mana�ement entity i�rith a ceRified operator for the life of the septic sy�stem. Rule. 1�61 (2)(e)requ►res a contract shall be executed bets}�een the system oti:�ner anci a m�nagement entrty prior to the issuance of an Operation Permit for a system required to be maintained bya pub6c or private management entity, unless the systern atvner and certrf�ed operator are the same_ The contract shaU require specific reyuiremenls for it�aintenance and operafion, respoE�sibiiilies nf the ovrner ac�d systems operator,prov�sions that the contract shall be u� effect tor as long as the system is in use, and other requirements for the cont�nued proper performance oi the system. tt shall also be a condition of the Operation Pem�it that subsequent o��rners ot the systems execute such� contract. L>Hand Drawing Olmport Drawing **Site PIan/Drawing attached.** Tota1 Tfine.(HH:t.tlti) ACtiVRy COdC: S�1�J 2Q•!-UP issueti NEti"J Typc II Quick 4 � 1 Heurs � � ►.t inutes �- J �, ' . ; ° � DAVIE COUNTY ENVIRONMENTAL HEALTH `, , P.O.Box 848/2l0 Hospital Smet ' • Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 � OPERATi01�1 PERMTT Acc�►�nt #: 989900079 '��x FIf�:EH#: G200000078 �iile�To: Ronald Jones Sufadivi�ior� lnfa: Refer�rtce Rt��te: LocaiioniAdc�r�ss: Victory Lane-27028 Pro�c�sed Fa�:i€ity: Residential Pco��r#y&iz�: 12 Acres ATC (rlu�tb�r: 6030 . **NOTE**The issuance of thisOperation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Syst ms," but shall in NO WAY�be taken as a guarantee that the system will function satisfactorily for auy given perio of time. � � System Type:�S.T.Manufacturer_`?�� Tank Date -20 Tank Size 1 da0 , Pump Tank Size l Bedrooms: t� System Installed By: ,��i^Y1n��.��y1 Installer# Date: 2 20!3 GPS Coordinat � � O� � �J� � ��` c�� � � ,,� � �� , . . � f , �;%� � �1� � � �� � ' �� , ���` � , � �,� � . � Environmental Health Specialist Date: ��� <<�a��- DCHD 11/06(Revised) . , � CONSTRiJCTION For ottice use on�v � � . A�UTHORIZATION 'CDP File Number 114275- � ', ��='="»'� Davie County Health Department County ID Number: G200000078 � � ' t���'�� 210 Hospitai Street Evaluated For: NEW `•�,�y,;,.� P.O. Box 848 Tovrnship: Mocksvitle NC 27028 PERt.1IT VALID UNTIL: Phone: 336-753-6780 Fax:336-753•1680 0 1 � 0 1 � 0 0 0 6 Applicant: Ronald G.Jones Property Owner: Matt and Tracy Seats Address: 142 Cedar Hill Lane Address: 2742 US Hwy 158 Cdy: Advance Crty: Mocksville State2ip: NC 27006 State2ip: NC 27028 Phone#: (336)998-7206 Phone n: (336)817-4696 Propertv Location 8 Site Information AddresslRoad #: Subdivisan: Phase: Lot: Vctory Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY �West past Lake Myers, turn right on Callahan Rd. go till you see Church on right property at back left edge of #of Bedrooms: 4 churCh. #of People: 1 'Water Supply: NEwwE�� Svstem Specifications t�linimum 7rench Depth: a 4 Site Classification: PS Inches Minimum Soil Cover. Saprolite System? QYes QNo Inches Design Flotiv: 4 $ Q Maximum Trench Depth: 3 6 Inches Soil Application Rate: tvtaximum Soil Cover: Inches e . a *System Classification/Description: *Distribution Type: Gw�v�7Y-SERu� TYPE II A COIVV SYSTEM(SINGLE-FAh7fLY OR 480 GPD OR IESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 259oREDUC7lON 1-f�iece: QYes QNo Pump Required: QYes QNo QP�tay Be Required Ndrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: QYes QNo TotalTrenchLength: 6 � g ft. GPFd—vs-- ft. TDH Trench Spacing: _ 9 Qlnches O.C. Dosin Volume: _ Gallons QFeet O.C. 9 Trench Width: 3 6 Inches _ (�Feet Grease Trap: Gallons Aggregate Depth: � � - inches Pre-Treatment: �NSF �TS-1 OTS-II Septic Tank Installer G rade Level Required: Q I �II �I)I O IV Page 1 of 3 . CDP File Number 114275 - 1 County ID Number. G2U0000078 ' ' � ❑ Open Pump System Sheet � Repair System RQquired:OYeS O No ONo, but has Availabie Space epair Svstem Trench Spacing: Inches O. . "Site Classification: PS — 9 • Feet O.C. Trench Width: Q Inches Design Flo�v: 4 $ � _ 3 6 Q Feet Aggregate Oepth: Soil Application Rate: � , a inches � Minimum Trench Depth: a q Inches *System Classification/Description: TYPE II A CO�1V SYSTEM(SlNGLE-FAh�ILY OR 480 GPO OR LESS) hlinimum Soil Cover. Inches t�laximum Trench Depth: 3 6 'Proposed System: 25%REOUCTION Inches hMaximum Soil Cover: Nrtrification Field Inches Sq. it. No. Drain Lines 'DistnbutionType: PUh�PTOGRAvi'rv TotalTrench Length: 6 � � � Pump Required: QYes �No �FAay Be Required Pre-Treatment: ONSF OTS-I OTS-II "Site Modifications No grading or construction activity is allo�ved in areas designated for system and �epair without approval oi Health Department. 'Permit Cond(tio�s The issuance ofthis permit bythe Health Department in no tivayguarantees the issuance of other petmits.The permit holder is responsible for checking tivith appropriate gaverning bodies in meeting their requirements. fiis Authorfzatfon tor Wastewater Systen Constructlon shall be valld for a person equal to the period of validity of the Improvemertt Pertnit not to exceed five years,and mry be Issued at the saonetime the Improvement Permit Iswed�NCGS 130A-336(b)�.If tt�e installatlon has not been completed during the perlod of vatidity of the Constructlon Permtt,the IMormatlon sudnitted In tne app�icatlon tor a permft or Constr�ution Autt�riution is fourxi to have been incorrecL i�lsifled or ct�anged.or the site is al2ered,lhe pertnl2 or C�structlon Autho�ization shall become inwlld,and mry be susperxied�revoked(.1937(g)).The person awning or corttrolling the system shatl be respor►sible tor assuring compliance with the laws,n�es,and pertnft conditfons regarding system locatlon,Installation,operation,maintenaru�monitoring,reporting and repafr (1938(b)). ApplicanULegal Reps. Signature Required? OYes �NO ApplicanVLegal Reps. Signature� Date: � � *ISsued By_ 2244-Daywalt.Andrew Date of Issue: � a / 1 a / a 0 1 3 Authorized State Agent: Prtalfunction Log OYes pHand Drawing plmport Drawing TotalTime:(HH:1,�►,�� **Site Plan/Drawing attached.** Page 2 of 3 1 Haurs. � I.1lnutes , � CONSTRUCTION AUTHORI2ATION �, • , . Davie County Health Department CDP File Number: 114275 - 1 , . 210 Hospital Street G2Uo00o078 � a.o.Box sa8 County File Number: h4ocksvilie ntc 2�o2s Date: Q � I 1 a / a o i 3 � Qinch Dra�viog Drawing Type: Construction Authorization Scale: � . . OBiock = .ft. QN/A _ _ _ _ __ __. _ __ __ ___. _ _ __ _ _ __ _ _ ___ _ _ _ , i � __ _ __ _ _. _ , _ _ . _ _ _. _ ' : . �a� �/ ,� � ; _ ��� . . _ , _ _ _ _ _ : _ _ _ � _ _ . � _ -�----- ��a : _ _ ��-��c��-��� . _; � �sz.� ': __ _ :_ ���` _ _ _. _ , _ � . _ _ . _ _ _, _ ( ; : ' _ �o�__ f c,c.(�,�,� `�` , ' _ �- -� i� �, � , ; _;i�o' _ _ _ . � :C�� : '_ _ _ ; , ___ . ' _ _ __ _ � __ . _ _ ____ _ _. . __ _ . ___ __ . _.._ _ . _ __ _ _ __ ___ _ Paae 3 of 3 � ' . . ' �� Davie County Environmental Health � P.O.Box 848/210 Hospital Street � ' . Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 989900079 Tax PIN/EH #: G200000078 Billed To: Ronald Jones Subdivision Info: Address: 142 Cedar Hill Lane Location/Address: Victory Lane-27028 City: Advance Property Size: 12 Acres Reference Name: Proposed Facilit�r: Residential **NOTE* This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. �P � � . J_)___:_.�Z�'-:_.._.,...__. Permit Type: J�New ❑Repair ❑Expansion Permit Valid for: �5 Years ❑No Expiration , Residential Specifieations: #Bedrooms L #Bathrooms�#People � Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type � #People #Seats Square Footage(or Dimensions of Facility) , Design Flow(GPD):��� Type of Water Supply: ❑County/City �Well ❑Community Well � Site Modifications/Permit Conditions: S stem T e LTAR Initial Z Re air `e � � 'Z • Site Plan • vJ � � � a \�� � , � `� , �;i�`°��� � � ,�° ) Q�,n`���,.` / � �Environmental�Health Specialist \ / • Date ab� F i.p.11-06 / , ' � . � � . ` � ` ' DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation � � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900079 Tax PIN/EH#: G200000078 Billed To: Ronald Jones Subdivision Info: Reference Name: Location/Address: Victory Lane-27028 Proposed Facility: Residential ' Property Size: 12 Acres Date Evaluated: _J I��3 'I Water Supply: On-Site Well k Community Public Evaluation By: Auger Boring 'l. Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition I' �S Slope% `"� �fl �°/n HORIZON I DEPTH -Z� - �� :y(� Texture grou Consistence h I l� I�L � Structure � 1�� r'il� v L� 1 i�L Mineralo n 'xL' ?. I` HORIZON II DEPTH Z- �I- b Texture rou � ; � 5E Consistence r Structure ,�,-t,� ,�w�o Mineralo 1;1 ; HORIZON III DEPTH ' Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICfIVE HORIZON SAPROLITE ' CLASSIFICATION �S �5 � LONG-TERM ACCEPTANCE RATE .1 ,'1 �-S / SITE CLASSIFICATION: � EVALUATION BY: f'(/I.CI�i� �, �/iJd.J.� LONG-TERM ACCEPTANCE RATE: � Z OTHER(S)PRESENT: REMARKS: ��Lt✓Yl P ("a�j�tn►�.<_'(� ��Y' ��f��',�r' LEGEND i.andscape 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 CON I T .N . 1�15� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm �Y�.t � NS -Non sticky SS -Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S�tustlirg SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic • Mineralo�v ��-� I���� 1:1,2:1,Mixed � lYQieS Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from jand 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/OS(Redi, ■��■■���■��������■■���■■����■���■■■�■�■�■■■■����■■�■■��■■■������■■ ■�■■�■��■�■��■�■��■��■�■■■■�■����■■��■�■■■■■���■■■�������������■■ ■■■���■�■■■�����■■��■■�■■�■�■��■ ■■������■■���■■■■�■��■■�■���■��■ ■■■■��■■■■■����■�■■■�■■■■■���■�������■�����■■■����■��■�■■���■■■�■■ ■�■■��■�■■�������■■■�■����■��■����■��������■■■■���■■■���■�■���■��■ ■��■�■��■�■�■����■■■��■■��■��■��■��■����■■■��■■���■�■��■���■■�■��■ 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■�■■■■■���■�■�■�■■������■■■■����■��■���������■�■��■��■��■��������■ ■��■��■■�������■■�■■�■■■���■�■������■�����������■■�■■■�■■�������■ ■■■��■����■�■■�������■�■■■■■���■ ■■���������■■■���■��■�■��■■����■ ■■�■■■��■■������■■■��■����■��■■�■■������■��■■■����■■��������■��■�■ ■���■■��■■�■�■�■■■�■■■����■��■���■t■�■��■��■■�■�������■��■■�■�■��■ � � ,# ' .� . 1 , . �:..���.�_ - (.��i'�����J/�--TI�IC qv�� � - V ' ' �.___— -- - .- _-:_ � ^�� ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT P�E�T & ATC� Davie County Environmental Health �Q��' � P.O.Bog 848/210 Hospital Street /� �,�,c-C, "�� � , '�.�" Mocksville,NC 27028 � ` � �' � �, : .� D�C ,�, '` 20�� (336)753-6780/Fax(336)753-1680 e� ; C��/ ��lf 6�$r �P.'�► �ication Fo ' ' "" a uation/Improvement Permit � Authorization To Construct(ATC) ❑ ` -_.. of ion: �New System ❑Repair to Existin�System L7Expansion/Modification of Existin�Svstem or Fa ilitv ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI�REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instructions. �yp� ���i"J APPT,TC'ANT 1NFnRMATTnN d� C'Or��1�-I �i�����1Nsa��� �jc�Q—�rj'3 7 Name �-�+�J-�L �/ • , Contact Person �dY�' �CJ• 0 Address Home Phone ,336 ^�9'g"'�I� (v City/State/ZII' � ,G 70D( Business Phone .33G-QO�/ -//43 Email Name on PermidATC if D fferent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE:_ A survey plat or site plan must accompany this application. Included: ite Plan �Plat(to scale) (Permit is vahd for 6 months wi site plan,no expiration with complete plat.) Ow,'ner's Name' ' %���-- o� Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# -cZ -000-00-O� Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is�"Yes",supporting documen�.ation must be attached: Are there any existing wastewater systems on the site7 Yes t�i�o Does the site contain jurisdictional wetlands? Yes �_/ Are there any easements or right-of-ways on the site? Yes �.t�g/ Is the site subject to approval by another public agency? Yes Y�� Will wastewater other than domestic sewage be generated7 Yes �1Qo TF RF,S�nF,NCE FTT,T,ni TT THF,ROX RF,T.(�W #People #Bedrooms #Bathrooms__`�___ Garden Tub/Whirlpool es ❑No Basement: ❑Yes o Basement Plumbing: ❑Yes C�3�o IF�nN-RF,STDF,NCF.,FiI I,nIJT THF,AnX�3F.L,(�W Type of FacilityBusiness Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats - Type system requested: ❑Conventionai ❑Accepted ❑Innovative ❑Alternative OOther Water Supply Type: 0 County/City Water @�New Well ❑Existing Well ❑ Community V�e�l Do you anticipate addit'ions or expansions of the facility this system is intended to serve? ❑ Yes [3'No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my laiowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entr.y to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or st ing the house/facility location,proposed well location and the location of any other amenities. Property owner's or owne ' lega��resentative signature Site Revisit Charge Date(s): �c�- o�'�—�Z Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# ��`I�U�L�?t Revised 11/06 � � Invoice# ���� �� 114�Z7 � i , • ,�-(V OJ� � , � � . i � ; 509 � � ,- . I ; __ __ _ � _ __ - . 1� 1��,fs� � -r �7 �'}-aado.� ��� � - Q5� L:7 ---- _ __ _ _ , i �� � , I � ' 1 i i t,��, � '� � I � � , _ _-- - ^,� �I �� � - - � :; j '� �_-:(:� I � � i I � � �� � j � � � , � , _.._-- -, 32q � _---- _ --- � � � -- _ _— '�astle �<< �' i ,,_.;_ � �.. -„_ � ; I � �� O���F � �i� � All data is provided as is without warranty or guarantee of any kind either expressed or Impiied including but not limited to the implied �;` ��.y �: ti � `\\'1 ���}; warranties of inerchanWbility or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of �h N� � Davie,North Carolina,its agents,consultants,contractors or employees from any and ail claims or causes of action due to or arising out of ♦ q i ` [he use or inability to use the GIS data provided by this website. P rI I�led.DeC 27� 2� I 2 �i - -C� � ������ • . . , , . � Mar C a •�,09:32a Information Services 3367531680 p.2 . , , I , - • � • � ' ' � • � :.,._,v4 y�v.:r,...�:������C l7�`��1.'T�IA£�':�T�vk�NT,....�...;�,��::�.�"`a��7 ' �✓ Em�ronmenta]Nealth Section P.0:Box 848/210 Hospital Street � C Courier 09-40-06 .• �`�" � hfocks�iile,NC 27a2S J �� e��' �,�='v''-�-��.�36,}Y51-8.�}760 �-^��-�� r�_u�-rl�'' !..'"��� � r �a"''c,��r2^' ' S "P���yv �'� '-r—'7�ti."^LF..a'����'�Y,��7.�1 C�-L,�4,�t�,,.y�,��.�,�,�,,.�r✓„�{ �..�i ty-.-t+� �. ,�.`rif-5.-1 3'�C+`� -�' 6, '�'��s�, r}���( � . ,y ?` ..33_,,,�. �atf�CT, . ,�.�1/// , `F cr�"�n.�''fy'^ -s,�,'a�c'F� ���s,��L�.'�' y,,, � �--�{r��..,�,'� � �"E.t :..�..--��� `% ,�_"==e:-"..��,.;:.......... -�'- --�ti - - � February 14,2005 Matt&Tncy Shects 27�.2 US H'igarti•ay 153 . �Iocksville,l�TC 27028 _ Re_ Site EvaIuation.� off CalahzlnRoad Tax Offic�PIN: ���09-58-6653 Dear Cli�t(s): As requested,a representatice from this office visited the aforementioned site on, � February 9,2005_ Bas�d upon the information provided on the flpplicarion for Site �vafuation and a.�ter an evaluation v.�as completed on thc site,the site was found to be pro�7siona2ly suitab?e for the instalIation of�a oversized iaodified on-site sewa�e system. Be�ore anlmprove»:enz PermiU'.4uchorizaliorz to Corzrrrucr caa be issned Fhe appzopriate applicationmustbe filled out andthehouse/mobile home location staked off. If you have any questions,please feel free to contact this offce. Sincerely, ���.t���'�. Rob�t B.Hall,7r_,RS. /�{ Environmen'�al He21th Specialist ��(/ . RBH/dlf . � ,,{� Enclo�e(s) . � `1 V \ _n�\ ��r � � . C �A�f�` � �� �����5 � � � ' � � , . , . . . -, • ► ' II I ' � �'�`I I ' � ' y�� � ..• , _ �_ ._ _v�ccory ln— ------�—_-- I � � �------� I i � _ ' �._____"_"_______..._ ._.1 � � � , I I I I I' � I I ( i � � I � )11.1 I � i I � ) � i ; , , � , � _.__ .__.._.� I __. _.. ,? r � . . .,-- .� �, , - _.._ I .. ` i . ,c,.i��, ; _ _ i �' � � � � i �_-- -- � i --� .. i � � ! , ! i ; � � - — i � �� I � r— _ ,_ __ _ — _..__ _ __—C.3s1 n � ' I -���; Ca��1e L� i ; r ----�r ; i, i , ' I .---- ;,� ' . � —�--- . � , . , --.._.__ i � I j ' . , _�-� � � . i _.- . I -__'. / ' . ., 'I 'i. _' __ -. - •j^ i � _ ,: .,. � � �il -f � i I r' '�� _.__ _. �"'_ i ( I . -_-__�_. -_ . . _ .___.__... _. �I I '____'_ . '�I I �� � f' � i I", 'i ' i �'-- � ' + .�, =�!l a II _ I �. I ,. . �a� � . . � r_� ;' �., : � � j � .,_ ; ,, , ,:` � —— -- ' � � -- , , - -- -- -------- s i - `�� , _ � , �i , ,.... i I -� _ , -------- ---� � , i �, i i �� o���F ; �` � All data is provided as is without warranty or guarentee of any kind either expressed or implied including but not limited to the implied ' '�:;�:� � �l `�����,`�"^�f; warranties of inerchantability or fitness for a particular use.All users of Davie County's GIS website shall hotd harmless the County of �U ti� � �� D a v i e,N o rt h C a r o l i n a,i t s a g e n t s,c o n s u l W n t s,c o n t r a c t o r s o r e mp l oy e e s fro m any an d a l l c laims or causes o f ac tion due to or arising ou t o f 4 � ` t h e u s e o r i n a b i l i ry t o u s e t h e G I S d a t a p ro v i d e d b y t h i s w e b s i t e. � , � PrI C�ted.DeC 1�� 2��2 I � ��p �a 1 ( '-fa�5 , . , , � , • � , � , � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003483 Tax PIN/EH#: 5709-58-6653 Billed To: Matt&Tracy Seats Subdivision Info: Reference Name: Location/Address: off callahan road-27028 Proposed Facility Residence Property Size: 12 acres ATC Number: 3994 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION / **NOTE** This Authorization for Wastewater System Construction MiJST 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date:��/� ��.5� v�--T.-�-J- CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation 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 a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: � y�7S DCHD OS/99(Revised) ! ' , ' � ' n � r . . , . • • . . , � _���:...,.�...������Cf�UI����T�i���-Fi?��Tl���`.�.�t....�.����%�: Environmental Health Section �� P. O. Box 848/210 Hospital Street � Courier 09-40-06 . Mocksville, NC 27028 � �� . �' tt (336)751 8760 � �� , ", , � �, � � ; � � , .�� , ����.; r �� �;, ,w � ,a <� a � - �� : f�r �� a �, <,, � � �� 6= ' �.:._,..�.;:,.�....��.,.��.. �. .,�N�...�...,u..��.�..�.�,� , �.�.� February 14, 2005 Matt&Tracy Sheets 2742 US Highway 158 Mocksville,NC 27028 Re: Site Evaluation/ off Calahaln Road Tax Office PIN: #5709-58-6653 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, February 9,2005. Based upon the information provided on the Application for Site Evalz�ation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an oversized modified on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, � � �4�����p�i. Robert B. Hall, Jr.,R.S. Environmental Health Specialist RBH/dlf Enclosure(s) ��� � � i�a�s ' .� • , ' , , , . DAVIE COUNTY HEALT'H DEPARTMENT ����.���("�C.2�, . � . . • Environmental Health Section e`����5 • ' � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 .. - .�- " (33G)751-87C►0 . IMPROVEMENT/OPERATION PERMIT Account #: 990003483 Tax PIN/EH#: 5709-58-6653 Billed To: Matt&Tracy Seats Subdivision Info: Reference Name: Location/Address: off callahan road-27028 Proposed Facility Residence Property Size: 12 acres ATC Number: 3994 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 V #Baths � Dishwasher� Garbage Disposal: ❑ Washing Machir�� 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❑ �i System Specifications: Tank Size�(/�GAL. Pump Tank/Odf1 GAL. Trench WidthL� Rock Depth��Linear Ft.�� Other: Required Site Modifications/Conditions: 11�1PROVEI�'[ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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.**** � �— `jt'Q�t,t'����� U1/�A/'GY l'OCj' t � � j�T � ' 1�� C���/.�/��-l-�ti ��p�D� �p��� ���r� v�rtl r�- �e�r h � °� � Environmental Health Specialist's Signature: S�`''�e�j� Date:__�G� C�� (����� . DCHD OS/99(Revised) � ' �' � � 1 � �� . 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' DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section r Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003483 Tax PIN/EH#: 5709-58-6653 Billed To: Matt&Tracy Seats Subdivision Info: � Reference Name: Location/Address: off callahan road-27028 Proposed Facility: Residence Property Size: 12 acres Date Evaluated: � /��dS r Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition // Slo e% �Z � �- HORIZON I DEPTH '' �� Texture rou � '� Consistence Structure Mineralo HORIZON II DEPTH .� l'" 3 � v Texture rou �- � Consistence Structure < i Mineralo �1 c 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 � � SITE CLASSIFICATION: ,� EVALUATION BY: /7-9'�� LONG-TERM AC PTANCE RATE:� L— OTHER(S)PRESENT: REMARKS: / � ✓ ` n� . . ��(� -� � � Landscape Position �9lft��e. �S ��� � 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-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed �� Notes I�,l 2 Horizon depth-In inches ^DP� �� 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 OS/99(Revised) ■����������■����e��■�■��������■��■�����■�������■■������������■��■■ ■���■�������■�������������������������t■����������■���■�������■��■ ■������o���■���■����■■■�■■���■���■�■��■���■������■��������������■ ■�����■�������������■����������■ ■■��■�■■�������■■����■�������■�■ ■����������������������������������������������������������������■ ■������������■������■������������■��■������■������������■������■�■ ■���������■����■����■■�■■��■���■��■■■��������■�������■����������■■ ■����������■■���■����■■���■■���■������■■�����■��■■�������������■�■ ■������■���■■������■■���■■��������■■��■�■■�■����■■■��■��■��������■ ■■������■���■�����e����■�■���■�����■�����■�������������■���■��■�■■ �������������a��������������������������������������������������■ ■■�■�■������■�����■�■��■�■���■�■ ■■■�■�■������■■■����■�■��������■ ■������������■�■�����■■��������■�■■■���■�■����■�����■�■�������a�■■ 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'���� r �� d�-��� �' � /✓ ��EB —�_2����1�' U FOR SITE EVALUA710N/IhiPROVEM1IFIVT PCRhi1T&ATC �D� ,/� g � � Davie County Health Department ` 1�� ; �E � c� �yv�RON�?+�Nj��NEA�-�N Environmenta/Hea/th Section f P. . Box 848/210 Hospital Street � Mocksville, NC 27028 DPV1E COUN1`( (336)751-8760 ***IMPORTANl*** THIS APPLICATION C1lNNOT BE PROCESSED UNLESS A�L TIiE REQUIRED INFORMATION 15 PROVIDED. Refer to the INFORMATION IIULLETIN for instructions. 1. Namo to bc Billed ./VI���f 3 /r,.iL� �C'C�S Contact Poraon ��� �L'�7> � Mailing Addreas J.,J7�I,-,� us ��i ��,4 Home Phone 33��""' t�jU '� �C��7 City/State/ZIP _/t'l/.[_��VillO. �E c���.�,sj IIusinesa Phona _��7� y� �7� 2. Name on Permit/ATC ii Different than Above__ �t(y�` . )e�cY.A Mailing Addresa ,�7y,�- �S f'W i � S � City/Stat /Zip �'�����r%�/P � �-'(��-�( 3. Application For: �] Site Evalua�ion �mpro��nd� Permit/ATC � I3o�h 4. system to service: I�HouBa ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type syatem requested:�Conventional ❑ convantional modifiad ❑ innovative 6. If Residence: � People �r # Bedrooms . -� � Bathroomu °.� �Diahwanher ❑Garbago Disposal �Washinc� Dfachine �Hasement/Plumbing ❑Basement/No Plumbing 7. If Duainesa/Industry /Othar: verify typa # Paopla # Sinks # Commodos # Showors # Urinals Ik Water Coolars IF FOODSERVICE: # Seata Eatimated Water Usage (gallona par day) 8. Typo of water supply:� County/City �Well ❑ Community 9. no You anticipate additions or cxpausions of tl�c facility tl�is system is intcndcd to scrvc? O 1'cs l�`No If ycs,�vl�at typc? , ***I/IIPORTAN7�"**CLI�NTS AfUST COMPLETE TIIG RLQUIRL•D PROPGRTY INrORN1ATlON RGQU�STGD - [3ELO�Y. �itl�cr a PLAT orSITE PLAN MUST IlI3SUBAlI7T�D by ttic clicut witl�TIIIS APPLICATION. Property Dimet�sions: �,� �'.U1S tiVI2ITG DIRCCCIONS(from Mocicsvillc)to PROPG2Tl': Tax OfGcc PIIY: # .S'�O 9— .S� ' (o `�3 �G���C ��)� ��+� �t� �'�.�T LC.k�, Property AdJress: Road Namc d r�CQ/�a� ,��V�r j C�ti��i�_�. l U vn /�� ���� j ✓ CIty�7.11) �h C.C4��Ct�ZGc:+"'1 /�-�-I c�, ��Y�����' c`ICat'rl'� If in a Subdivision proviJc information,as follotivs: �l c���' � �i t�' St'e c'� ���✓�7� u;,� Or �,i��� � � , Namc: ��<<"� 1� �W y; % .�- r E- /� S�Z���S' C�::�� l3c,.c:l� ��� ��-f� f�� f� ��i�-�- � C �r'c-,�� GiCC��SS V�>ct� sS Sectioii: Block: Lot: __Z���y� Date liomc cdri�ers llagged: �w�� �.J1�= L �� �7,� S f�%'t L P�'?� Tl�is is to ccrtify tliat thc inforli�ation providcd is corrcct to tl�c bc of n�y Iaiotivlcdgc. I undcrstaiid tliat any permit(s) issucd l�crcaftcr are subject to suspcnsion or revocatioi�,if tlic sitc �lans or intendccl use ctiangc,or if tlic ii�formation subn�ittcd in tliis application is falsircd or cl�angcd. I,aJso,«i crstnnrllhat I aur respousiLlc for al!clrnrgcs i�icrurc�l frvm 11ris applicnlio�r. T,hereby,give consent to tl�e Autl�orize presentative of the Davie County IIealth Department to enter upoii above described property located in Davi Coui►ty and o����ied by � tu conduct all tcsting proccdiires as ncccsslry to dctcrmit�c tlic sitc suitabili y. DATL � �L� �}� SIGNATUI� �J', i r - •�' ., TIiIS AItEA MAY BE US�D FOR DRAWING YOUIt SITE PLAN( iicludc all of tlic folIotivii�g: Existing and proposcd property lit�es and dimensions, structures, setbacks, and septic locations). Sitc Revisit Cliargc Datc(s): p�l��2�5 Clicnt Notification Datc: ' �° a� . �FIS: Sign givcn � / Account No. �� V � Reviscd DCI3D(OS/03 Iiivoicc No. � 6 3� �