Loading...
1391 Yadkin Valley Rd , DAVIE COUNTY HEALTH DEPARTMENT ���i 9� � � � _ + Environmental Health Section � g . P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 � (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 99000069d Tax PIN/EH#: 5863-34-9588 Billed To: Thelma Wiiliams Subdivision Info: Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 2 Acres ATC Number: 2133 **NOTE** lfiis Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 PERNIIT LS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ��¢�jn�' #People� #Bedrooms� #Baths Z Dishwasher: �" Garbage Disposal: ❑ Washing Machine: n Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �'�''`�� Type Water Suppl�� Design Wastewater Flow(GPD)��� Site: New�Repair❑ �i i� � System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth�.� Linear Ft.�?lG✓ Other: Required Site Modifications/Conditions: iMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G "BELOW F'INISHED 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(336)751-87G0.**** Environmental Health Specialist's Signature: Date: ' — DCHD OS/99(Revised) ' . , ' - � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section ' P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000694 Tax PIN/EH#: 5863-34-9588 Billed To: Thelma Williams Subdivision Info: Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 2 Acres ATC Number: 2133 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number shouid be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � Date: �� CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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. F� ����� Q � � Septic System Installed By: �--lti Environmental Health Specialist's Signature: 5(�• � � Date: ���i�?//�� DCHD OS/99(Revised) , . APPUCATION FOR SRE EVALUATION/IMPROVEMENT PERMff&ATC � � � � � � � � � �+ � ,_ „ � Davie County Health Department Envirvnmenta/Hea/th Se�c[ion �e�,�� p.o. $oX 848/210 Hospital 3tzeet � 2 6 Iggg Mocksville, NC 27028 �. • � � (336)751-8760 Et1VIRON�.I�ENTA�NEALTH ***II�ORTANT*** THI$ APPLICATION CANNOT B�E PROCLrSSED UNLE33 ALL THE D � IZTH'OR1�1Ti0N I3 PROVIDED. Refer to the INFORt�ATION BULLETIN for instructioas. 1. Nam� to b� Bill�d /rf�L�J/� LJ • �if//��/YIS Contact ?�rsoa �����r-1.�����/?sfs Mailinq 11ddr�s• .�% � �� 8� phoa� �3�r- ,��d ��� .. City/Stat�/SIP /T�� �TO ll����i,-. -. ����!) 8win�u Phosu 2. 1�Iam� oa p�rmit/l1TC i! Difl�ruit than Abow��LJJ f� cJ� G!/!//%/�ms Maiiiaq I►ddr�es .D•�DX�� City/Stat�/Lip P�.�// ��DG(//� 1/!o 'Ci' �/(/�� 3, a►ppiication ror: I�31te Enaluation �improvemeat Permit/ATC �j Both a. sy.r..m to s.�i�.: ❑ Housa �Mobile Homa ❑ Buaiaesa ❑ =ndustry ❑ Other s. If Reaidence: # Peopie ,� � Bedrooms ,�_ # Bathrooms �_ �Dishxash�r O Garbaq� Di�posal �1PashinQ Machin� ❑ Bas�t/plumbinQ O Sa��nt/No plumbiaq 6. I! Husinoss/Industsy/Oth�r: Sp�aify typ� � p�opl� i Sis�ks � Commod�s # Show�r� i Urinals i 1Pat�r Cool�rs IF P'OOD3ERVICE: # SerltB Estimated Water US�igA (qaliona p�r day) 7. Type of Kater supply: ;L�( Cotu�ty/City O �Pell O Co�ity e. Do you anticipate additions or eapansions of the facilIty this system is intended to serve? ❑Yes �No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INF�3RMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MIIST BE SUBMITTED by the cHent with TH1S APPLICATION. � i � /� Property Dimensions: o��g��X 3(�a o�'GG�7C''�e�W RITE DIREGTIONS(from Mocksville)to PROPERTY: �p Taz Otiice PIN: # � O�3—��f��� �� `��E�'r� gt�//� / � ��E/j�, /'34/ / � Property Address: Road Na�e / � ��a �i i1�<�o �'F1�y� ��✓ F�io�. ��f�C'�-y 1S t� li � City/Zip � �OT o�r�.�F� _:�,s� �s v�u �,�ss�d�.��[��-'n-�•- If in a Subdivision provlde information,as follows: Of��iP l�F�/1►a n/c� ,C l✓� o� �Lc.�-ni�4 L�)p L/�2 � o �R� �'�- i3 yi y�l�F���,w��E y ��1. Name: � ' �d,��d'�_'S',p�.t� 1Gf�,,,.,:tis.� �t/. Sectlon: Block: Lot: Date Property Flagged: � �(o�-�/� SzrYv���,�� 7 z Z� 99 This is to certify that the information provided is correct to the best t►f my kn ledge. I understand that any permit(s) issued 6ereafter ure subject to suspenslon or revocaHon,if t6e aite plans or intended ase change,or if t6e information sabmltted i�t6is applicaHon is falslfied��r changed. I,also,understand that I am responslble for all charges Incuned jrom thts applrcadon. I,hereby,giv�s consent to th�Aathorized RepresentaHve of the Davie Connty Health Department to enter upon abcNe described p�roperty located'►�Davie Coaaty and awned by to condnct all tecting procednres as necessary to determIne the site snitabWty. DA.TE /- � (D —,�/ SIGNATURE � I '�"HIS A�.EA:�IAY BE�JSED FOR DRAWING YOUR SITE PI.�,N(Include all of the following: E�sting and proposed proper:y Ilnes and djmensions, structures, setbacks, nnd sepNc locations). Site Revlsit Chsrge o���d� Dat�cg�: �� �tie'� � Client h�uttficanon Date: � SX7�� � � ,� 1� EHS• � i•�� � I� / �� r � q Account Na � /�9�wA�/s. � � � �_3 Reviised ID�;:'{D+�n7/99) ��(G�`� U����Y �/, Lnvoice No. • . . � � PK Noil Set _ dd�e t W• R� e 399 �u �e►"ry �2, P°g m �, Deed Book J � � � I� N o .� �. I � Z � Road Valley Na�� Yadktin # �452 Na�� Pset ,-+ Found .R� .9� , 8 ao S go40,0���E 24 ��63. I 7 N re-l. RR S �ke � Set ' � � NIP � co i �* � � �: , � � ; :. o i, F � w 2.000 Acres , .§ o � ; a � o a � � a � 0 Z � � a; I co � co �d o� 0 O � � 0 N1P � 0 7go4o�o4 W 248•9�� i �� .— S P � � ---- -- -- - - _ —__ L - ' , ,' �., °° � DAVIE COUNTY HEALTH DEPARTMENT � r Environmental Health Section , � ' Soil/Site Evaluation APPLYCANT INFORMATION PROPERTY INFORMATION Account #: 99000U694 Tax PIN/EH#: 5863-34-9588 Billed To: Thelma Williams Subdivision Info: Reference Name: Thelma J.Williams Location/Address: 1391 Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: ���(�� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring a� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �� 'i Texture rou Consistence ( Structure � / Mineralo 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: ` LONG-TERM ACCEPTANCE RATE: �� 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 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 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 DC�ID OS/99(Revised) ■���■������■■��■��■�■�■�■�■■■�■��■■��■■■■■���■��■■�■■�■■ 0■■��■■■ ■■��■�■■�■■■■�■■��■�■���■■���■■��■■��■��■■■��■■■■�■■�■■������■�■■■ ■�������■■■���■■����■■��■��■�■������■�■��■■����■�■��������■ ■��■■ ■���■���■������■������■■■��■�■�■ ■�■■■■��■��■��■��■■■■����������■ ■�������■��■�■eoe����■■■e��������■■�■■�����������@es■����������■�■ ■����■���■�■����■��■�■��■�■■��■��■■���■■��■�■���■���■�������■■�■�■ ■�■��■■■��■���■�■�����■�■���■■�■■■�■■�■■�■■�■■��■�■■ov■s�����■�■�■ ■���■�e■■■s�a■■��■�■■�■■���■■�■�����■■■■�■■��■■����e�����■�■■��■■■ ■�■����■�■■■■��■�■��o■�■�■��■■■��■■■■�■■■■■�o■��■■■■�■■■■■■■■■�■�■ ■■��■■■■■■��■■■�����■����■■■e�■■�ee�s�■■■■■■����■�����■■�e�■■■��■■ ■���■����■�■■��■��■�■■��■���■�■��■���■■�■■��■■■■�■��■■��■��■�■�■■ ■��■���■���■��■■����■■�■�■■■��■■ ■■■���■■�■■���■�■■�■■■■�����■�■■ ■■■��■����■��■�������■�■��■■��■��■■■��■■�■■■����■�■���■■■■���■��■■ ■��■�■■■■■���■��■��■���■■�■��■�■��■�■�■■■■■■�■��■�■■���■����■■��■■ ■■■�■■■■��■��■■�■■�■�■��■��■�■�■■����■�■■�■■�■■�■�����■�■����■■■■■ ■■�■■■■■��■�■�■■�■�■�■■��■■■�■��■�■■�■�■■�■■�■��■�■��w■������■■■�■ ■�■�■�■■�■��■■■■��■�■■■■■�■■���■■�■■�■■■■�■■�■■�■�■■��■�����■��■�■ ■������■■�■■■■■■■���■■■■■��■�■■■■�■■�■�■■��■�■e����������■��■■�■■■ ■■�■��■����■■■��■���■■■■■■�■�����■��■�■��■��■�■■�■■����■���■■�■■■ ■�■■■■�■■��■�■��■�■�■■■■�■��■�■■ ■■�■�■■�■��■�■■�■■�■■�■■���■�■■■ ■��■�■����������■�■�■��■�■■�■�■■■��■■��■■�■■�■��■�■■��■������■■■�■ ■�■������■����■■■�■■■�■■■■■���■■■���■■�■��■■�■��■�■■��■�■�■�■���■■ ■�■■���■�■■�■�■■■■■■�■�■■■��■�■■■■�■■��■■�■■�■�■■�■��■■�■�������■■ ■�■�����■■■■■�■■■�■�■■�■�■■�■���■■��■■�■■■■■�■�■■�■■���■■�■■�■�■■■ ■�■■�■■���■■■�■■�■�■■■�■■�■����■■■�■��■�■�■■���■■��■�■■�■�a■■■■■■■■ ■�■��■■■��■■■■■■�■�■■■■�■�■■��■■�■�■����■���������■■�������■�■■■��■ ■�■�■�■�■��■�■�■�■�■■■■�■��■���■�■��■■�■■�����■��■������■�a��■�■��■ ■��■��■����■�■�■■�■�■�■�■■�■�■�■ ■�■�■�■■�■■■■�■■�■��■■������■��■�■ ■■�■����■■�■�■��■�■�■■���■�■���■�■■�■�■��■�■����■■�■e���■�����■■■��■ ■■■■■���■■���■■�■�■�■�■�■■�■�■�■■�■�■■■■�■�■����■�������■��a�■■■■�■■ ■���■��■■■���■■���■�■�■■�■�■■��■■�■���■■■��■■■■����■i��t�■■�����■■■�■■ ■■■�■���■■■���■�■�■������■�■■■�■��■���■■���■■�■�����c�■■■��a�■���■�■ ■�■■■■�■��■�■�■■■■■■�■�■�■■�■■■�■■�■���■�■■�■�■���■■a�■■■■�i■�■��■�■ ■�■��■■■■■■■���■���■■■�e■���■■■����■■�����■■■■�■■�■■u������■�■■��■■ ■�■��■��■■■�■����■�■�■�■■�■�■■■���■■���■�■■�■�■■�■■��������■■■�■■■ ■���■■■��t■■■■�■�■�■�■�■■�■�■■■■ ■■■�■�■�■■�■�■■���r����■■�■■�■■■■ ■��■■������■�■�■���■����■�■o�■��■■��■�■�■��■���■■�■■i�.�■■�■■�■■■■■■■ ■■�■■�■■��■■■■���■�■���■■■■■��■�a■�■■�■�■■■����■■�■■i.����■■�■�■��■■ ■■�■��■■■�■■■��e�■�■�■�■■�■■■�■�r:���■■■�■■■■�■���■■■i,����■■�■■���■■ ■��■��■■■�■■���■■����■■�■����■■��■��■■■�■■�■■�■�■■�■r�■����i����■��■ ■��■��■■■������■���■■■■�■��■■■�■���������■�■■■■��■�����■■■��i�■■■■��■ ■�■�■�■■■��■���■�■■�■�■■■■�■�■�■�■■���■■�■��■■■■�■■��,�■����i�■■■■��■ �iiiiii�iiiiii�iiiiiii�iiiiiii '�iiiiiii�iiiiii�iiiiiii�ii iiiii� ■�■■■■■■■■■■■�■■�■■�■�■��■�■■■�■■�■■�■■■�■■�■■■■�■■���■■■■■�a■���■■■ ■�■■����■�■■���■�■�■��■�■■�■�■��■�■■���■��■����■��■������■■�a■■■�■■■ ■�■■�■■■■■■■�■■■�■�■■�■■■■�■■���■■■■�■���■■��■�■��■■���■■■�.i■��■��a ■���■■■■■������■���■■■s�■■■■■���■■�■■��■■�■■�■����■■■�����„�■�■■�■ ■��■■■�■■■���■�■e��■■■■�■■������■■�■■�■�■�■■■�■�■■�■�■�■����■��■�■■ ■�■■�������■■■�■��■■■■■��■������■■�■■■��■■�■■■■�■■�■�■■■■■��■�����■ ■�■■■■��■■�■�■�■�■■�■■■■�■��■�■���■■�■�■■�■��■���■�■�■■■■�a■���■■■ ■�■��■■��■■���■���■�■■�■�■■�■■■• ■■■�■�■■�■■■■■■■■■��������■�����■ ■■����■���■���■�■�■����■■�■�0■■E!i■�■■�■�■■�■■�■������P,�■■���J���■■�■ ■■■�■■■��■����■�■�ve■�■■��■■��■�u■��■■■��■��■�■■�■���r�■■����■■■���■ ■■■��■■�■■■��■Ne�■�■��■�■■�■■�■�■■�■■■��■■�■■■■�■■��r�■■■■��■■■■■�■ ■■■�������■�■■����■■■■■�����■��■�■■�■■■■�■�■�■■■■�■■�����■����■■■■■■ ■■■��■■���■t��■�■��■�■�■■�■■�■�■�■■���■■�■■��■��■�■■�n�■���,7��■���■ ■■■�■�■■■�■���■�■��■����■�■■■■�■■�■���■■■■■��■��■�■■■���■����i�■■■■■■ �■■■■■■■■�����■�■������■■�■■■■■������■■��■■■■■�■�■■■�i�■��ri���■■■■ ■■�■■�■■�����■■�■■������■�■■■■■■ ■■���■■■■��■��■■■■■11■■��11�■■■■�■ ■■�■■�■■■�■�■■■�■■���■��■�■■■■�■■�■����■�■■�■■�■■���■11����1'1■■■�■�■ ■�■■■�■■��■��■■■■��■�■■■■��■\■�■�■■■�■�■��■��■��■�■■■1/■■��fl�■■■■�■ ■����������■■■■■■■������■��■■■■■■�■■■■■■■��■■■�����■�I�����C���■■��■ ■��■■■■■■■■�■���■■�■�■■■■■�■�■���������■■�■�■■■�■��■■I�■■��f��■■■��■ ■■�����■��■■■■■■■■��������■■■■■■■■�■�■■■■�■�■����■��■I�■■��I�!�����■ ■■�■■��■■■■�■��■�■�■�■�����■�v�■■�■■■■■■■��■��■�■����I�■■���������■ ■■�■■■■�■C����Gisi�`I�i■����1���1��^"_��C��i�C�����Gii1�����������������■ ■����������■■■■■�■■■■���■■■�■■■■�■��■■■■■■■■■�■■�■■�■■�■■■■■��■�■■ ■�■■■�■■�■�■■■�■�■��■■���■��■�1�■�■■/,A��%P_ta■■■■■■��■■��■�■■■■■�■■■■ ■■■■�■�■����■■■■■�■■■�����■�■��/I�IU�L►lt���■�����■����■����■�������■ ■�■��■��■�■��■■�■�■■■��■������r���l■���■��■■■�■�■��■�����■■■�■���■■ ■■�■����■�■■■���■■■�■�■■����■�■��■��■■■��■�����■■�■�����■■■�■�■�■■ ■■���■■���■�■�������■■■■■■����■�■■■■■��■■■■■■�����������������■��■ ■�����■���■�■�■�■�■�■��■�■■�■�■■�■■■■■■�■■■■■■■■�■■��■��■■■■■�■■■■ ■��■■��■��■�■�■�■�■■■��■■■■��■■��■■■■■■■■■■��■■■��������■■■■■■■■■ ■■�■■■�■■■■■■■�■■■■■■■■■�������■ ■�■�■��■��■■■■���■�■�■■■�■■���■■ �t�����n��■�■���■����■■■■■■■�■■■■��■�■■■■■����■������������■■■�■■ ■■�■�■■■��■�����■■■■�������������■■�������■�■�■■■�■■■■�■■■■�■�■�■■ ■■�■��■■■■■■■■■■■��■■�����■���■�■■■■■�■��■�����■��■�����■■■■■�■■■■ ■■��■���■■■■■■■■■��■■■■■■■■■�■■■■■■■��■■■■■■■■�■��■■■■■■■■■�■■■�■■ ■����■■���■��■■����■��■■■■■■■■����s���■■■�■��■■■■■�■�■��■■��■■��■■ ■���■■■■�■■�■■■���■■�■������■��■■■���■■■��■■■■■■�■■�����■�■■�■■■■■ ■■��■�■■�■■■■■■■�■■■�����������■�■■■■■■■■■■■�����■�������■■■■■■�■ ■■���■■��■��■��■■■■■���■��■■■■�■ ■��■��■�■■■■■�■■■■■■■■���■■■■��■ ■��■�■�������■������■������■�■����■�■■����■��■■�■■■■■■■■■■■��■���■