The URL can be used to link to this page

320 Cornwallis Drive Lot 10 Davie County Health Department q�6f� Environmental Health Section r ' P.O. Box 848 210 Hospital Street Q Courier# : 09-40-06 1 r►i i U Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: �J � -0 -��-1*3 Phone Number 63 .3 f —TZo (Home) Mailing Address: 2--:-1 G (Work) Email Address: Detailed Directions To Site: .,�� A. -� .R. <--- Property Address: 3 Lrz> Cc Jam. Please Fill In The Following Information About The EXISTING Facility: La Name System Installed Under: �odgzj Pade�k Type Of Facility: Date System Installed(Month/Date/Year): /R b q La J Number Of Bedrooms: Number Of People: 2 Is The Facility Currently Vacant? Ye No If Yes,For How Long? Any Known Problems? Yes &DO If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: R A t -4- Number Of Bedrooms: Number of People -Pool Size: Garage Size: 3=r Z Other: Requested By: Date Requested: Signature) For Environmental Health Office Use Only A presved Disapproved Comments: Ot Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in noway intended,nor should betaken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: L l -- pO Davie County Health Department P8 t� Environmental Health Section P.O. Box 848 1 , � 210 Hospital Street RECEDED, Q �1 4 3 Courier# : 09-40-0 7�T113 02 ocksville, NC 27028 Phone:(336)-753-6780 �6`��a Fax:(336)-751-8786 ON- TE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: %�� c ►r7 Phone Number \ (Home) Mailing Address: �'7z'�Ccs-r�c,�y��c s�2.tJ� C�� L- L -�Z�� (Work) . �"-"Oc.u,S di CL rte-,s�- 't-Z�.�- Email�'�krC..'T�r.»J Mrli�S Com•„C3Y.w�.�� C.c�•�-�. Detailed Directions To Site: R• cz c ` �s��+��- K cis fir' Property Address: -3 Z.o .L.Z� �vr�-�-c «s R. k --��eKse)G - �yC_ '2-•?oz� Please Fill In The Following Information About The EXISTING Facility: 44-W-10 Name System Installed Under: !Ro;�4 9A4�u4 Type Of Facility: £ Date System Installed(Month/Date/Year): 9Zs- Number Of Bedrooms: Number Of People: 2- Is The Facility Currently Vacant? Yes 0If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: pini �5n�ogoo � � Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Z- Requested By: Date Requested: 7,��3 ignature) For Environmental Health Office Use Only pprove Disapproved Comments:—tpp oO l �� /� GwV DEW J)�P&% Stee; � P Environmental Health Specialist Date: 7//S/tee/3 *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cas Chec Money Order # I-lao Amount:$ ICSS Date: Paid By: �� v�'�' Received By. 'p Account#: L ZZ2.3Z. Invoice#: C-op .�-�'-�` �•/P�1.1,..1 S _._.��..�,_._..� } DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (330751-8760 Account #: 990003685 Tax PIN/EH#: 5841-06-5066 Billed To: Rodney Bailey Subdivision Info: Pudding Ridge Lot# 10 Reference Name: Location/Address: Cornwallis Drive-27006 Proposed Facility Residence Prol2erty Size: 1.210 acres ATC Number: 4155 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 CONS RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: C,, �� 11C Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section s P.O.Boz 848/210 Hospital Street Gt y( �v ' Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003685 Tax PIN/EH#: 5841-06-5066 Billed To: Rodney Bailey Subdivision Info: Pudding Ridge Lot# 10 Reference Name: Location/Address: Cornwallis Drive-27006 Proposed Facility Residence Property Size: 1.210 acres ATC Number: 4155 **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 k #People #Bedrooms _ #Baths _ Dishwasher. Garbage Disposal Washing Machine: 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) J'19,0 Site: New e" Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth/ac Linear F44rgff ,'DO Other: = i:�C. llbd sr&m may also be t Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYO FLUENT FILTER. RISER(S) IF 6 "BELOW FINISHED GRADE. ****NOTICE: Co a repres County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 0 1:30 p.m.on the day f installation. Telephone#is(336)751-8760.**** � COc'.1 G✓Gt��/� —� Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) :ENVIROViENTAL 2 52005 AP I ION FOR SITE EVALUATION/IMPROVE&IENT PERMIT&ATC Davie County Health Department Environmental Health Section NEALTH P.O. Box 848/210 Hospital Street ECOUlJTY Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions`. 1. Name to be Billed y�2\/ C 1� �� Contact Person Mailing Address /�C�L� S �` N�/ (J-i�r✓i L-PI, Home Phone C City/State/ZIP 2wyLi Business Phone 7 U 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation 0-T-5--p-rovement Permit/ATC ❑ Both 4. System to Service: a,-1-0use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: a Conventional ❑ conventional modified ❑ innovative paccepted 6. If Residence: ��# People �,� # Bedrooms _i # Bathrooms 2 . 2rDishwasher �JGarbage Disposal WIa ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Others verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: #1��Seats Estimated Water Usage (gallons per day) S. Type of water supply: L�County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes a No If yes,what type? ***1AfP0RTAN2'***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED IIELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client witl:THIS APPLICATION. Property Dimensions: / WRITE DIRECTIONS(from Mocksville)to PROPERTY:` Ta�xO IN: it 59 Lt I Property Address: Road Name City/Zip If in a Subdivision provide information,as follows: Name: �u�� 9 : 1r,L3- Section: Block: Lot: Date home corners flagged: ZJ S 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 Davie Comity 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_ �'' Sr^t�5 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 Datc(s): D,t Client Notification Date: EIIS: Sign give Account No. Revised DC D(051 3 Invoice No. '. DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation �y9► /� NAME LJ s e e DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t Texture group Consistence r r- Structure /l 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: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: '� OTHER(S) PRESENT: REMARKS: P� ��`�� e'f �� 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 SILL-Silty :lay 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 3C-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 \ s C-2 EXISTING -r IROAW CAP , PROPOSED MOUSE \ EY.ISTIM s � ( 'r IRON\W CAP �6% \ r; Lori 10 / \\ 1.210 ACRES ( DMD ��o