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125 Bunker Way Lot 20DAVIE COUNTY HEALTH DEPARTMENT e Environmental Health Section i� d P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001458 Tax PIN/EH #: 5746-48-2346.20 Billed To: John Phillips Subdivision Info: Twin Cedars Lot # 20 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map **NOT * i�iIss proveement/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 #Bedrooms #Baths Z Dishwasher: 12" Garbage Disposal: 133*� Washing Machine: 62" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size A71Jt�ype Water Supply�Design Wastewater Flow (GPD)c l Site: New Repair ❑ �I System Specifications: Tank Size/1l `M GAL. Pump Tank GAL. Trench Width Rock Depth I Z Linear Ft. �-L� Other:��T=�-~- t ��STAt,L U�(G`S / 1�.%• iVl��-%• Required Site Modifications/Conditions: f -[J= `t'14-- t- a2=' L( , &!=4E L�' B—F'� r" IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this s st een3A. to0m. or 00 pyo 1:3 p.m. on the ay ofinstallation. Telephone # is (336)751-8760.**** cl'o. C. 1 � f-% %A" � oo 45 Fever T L46 Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: /S DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001458 Tax PIN/EH #: 5746-48-2346.20 Billed To: John Phillips Subdivision Info: Twin Cedars Lot # 20 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2642 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 Trea t and Disposal Systems). THIS AUTHORIZATION FOR WASTE W NS SID A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : 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. [IV .02,247 Septic System Installed By: ►`� �O Environmental Health Specialist's Signature: ate: 0 / DCHD 05/99 (Revised) ` APPLICATION FOR SITE EVALUATION IMPROVEMENT PERMIT & ATC D Now Davie County Health Department NoV Environmental Health Section 9 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENT (336) 751-8760 DAVIE COUNTyEpLTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFO TION BULLETIN for instructions. 'A ' 1. Name to be Billed Y` Y(. f Contact Person Mailing Address or Home Phone 7 / City/State/ZIP / r i, siness Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation 4. System to Service: House ❑ Mobile Home S. If Residence: # People 13 C;ity/State/Zip ,Lmprovement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other # Bedrooms -- # Bathrooms XDishwasher Garbage Disposal )X Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: / VI/ 1'14 !�: Section: Block: Lot: %0 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date Property Flagged: //o%% 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 County 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 suitabi ' _ ^ I DATE T' — — O SIGNATURE %� 9/�/ -jJC�// l THIS AREA MAY BE USED FOR DRAWING YOIT_SITL rLLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and�Wicfiocations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. Invoice No., APPU('A110N FOR SITE EVAWAMON/IMPROVEMENT PERMIT & ATC Davie County Health Department Envimmenfa/Health SmWon P.O. Box 848/210 Hospital Street FM Mocksville, NC 27028 (336)751-8760 U W N NOV 1710 * * * na:,o=ANT* * * THIS APPLICATION CANNOT BE PROCESSED UWZS3 TH&.REQUIRED. _ A,� INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN fo in _nir F�El1LTHLTH 1. Nems to be Billed / t *- ` �� C YC �ui! contact Person loll feeU U Nailing Address Home Phone City/state/ZIP[!�U 41 �� -'2 70aSl� Business Phone 47 Z- 5b l v 2. flame on Permit/ASC it Different than Above Nailing Address City/state/Zip 3. Application For: .�p�Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: /\House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People Z - 7 dr # Beooms 3 # Bathrooms ff Dishwasher 0 Garbage Disposal lashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Conmodes # showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. T"m of water supply: County/City ❑ Well ❑ Comm maty e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ❑ No If yes, what type. ***IMPORTANT'** CLIENTS AIUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3 o�DOo • �• Tax Office PIN: # 2-3 4 6 L o� a O Property Address: Road Name 10a, 4 a,, City/zip 1114OC"S.sllac /V/C- WRITE DIRECTIONS (from Mocknille) to PROPERTY: 6Ul 5 l)fS�/jtc�J l�'c• /o 4'44-/ Ad" If in a Subdivision provide information, as follows: 'gg1Q Name: L✓//✓ 6eZ)14-(L 5 W U Section: Block: Lot: ji• r &tie Property Flagged: 15' i J Y'Ab& 1703N 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 ani responsiblefor all charges incurred frons this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by O 21 C. to cond:Z6 sting procedures as necessary to determine the site sultabilitt. DATE?���� /�W SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN cl all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. Invoice No. d o ,Ie�`9I. C A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME TC C2 C_ PROPOSEDFACILITY ^H6I© L SUBDIVISION ^ i to (a;DQ 2s Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit q_jy SECTION IOT,� 10 DATE EVALUATED 12 t� �1 PROPERTY SIZE I_S i� 11. - X ZZ D ,cl ROAD NAME l.Jatr-'jI,S�� Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Gly Slope % HORIZON I DEPTH Texture grou -1 Consistence V '7 Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 01L Mineralogy a HORIZON III DEPTH Texture group Consistence Structure l i Mineralogy c HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION V LONG-TERM ACCEPTANCE RATE 0 • r-( SITE CLASSIFICATION: EVALUATION BY: AFI_ '&�C A P l ' /� LONG-TERM ACCEPTANCE RATE: �' OTHER(S) PRESENT: l i0 j J -r D0aA.J REMARKS: A Vo 10 U0 A,2&4 WiU— DaoWLe Otr1 ;> to Cow_ DCHD (01-90) 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 Mineralogy 1:1, 2:1, Mixed Noes 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