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267 Sheffield Farms Trail Lot 3DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900618 Billed To: Piedmont Housing Reference Name: Teresa Newton Proposed Facility: Residence ATC Number: 2079 Tax PIN/EH #: 4871-81-8453.03 Subdivision Info: Sheffield Farms Lot # 3 Location/Address: Sheffield Farms Tr. -28634 Property Size: 5.5 Acres 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 i l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE R NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �V / e� Date: 6 '-_-?Q— 7Z 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. _ /No7 on s�TE. . F ` Wd/t Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 7— / 97 DAVIE COUNTY HEALTH DEPARTMENT Environmental, Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900618 Tax PIN/EH #: 4871.81-8453.03 Billed To: Piedmont Housing Subdivision Info: Shetfleld Farms Lot # 3 Reference Name: Teresa NeMon1rm0LM4Cbe1/c11)a^,u- Location/Address: Shetfield Farms Tr. -28634 Proposed Facility: Residence Property Size: 5.5 Acres ATC Number: 2079 **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 — aM #People 49 #Bedrooms _C3 #Baths Dishwasher: fit( Garbage Disposal: ❑ Washing Machine:y Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ J Commercial Specification: Facility Type #People _ #People/Shift �#/Seats Industrial Waste: ❑ Lot Size�5�Type Water Supply WL Design Wastewater Flow (GPD) c 7(00 Site: NewX Repair ❑ System Specifications: Tank Size A00 GAL. Pump Tank _GAL. Trench Width, 70 Rock Depth L Linear Ft360 Other: Required Site Modifications/Conditions: I i IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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)751-8760.**** n+q 90&/ &kR Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 0 I F71 3 APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environments/Hea/fh Sea(ion P.O. Box 848/210. Hospital Street . KJUNIg Mockaville, NC 27028 (336) 751-8760 ENVIROONMENTAL HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed ,�`(�C1S'IYCI Meiling ]Address 'tA .'i , al (�� City/state/ZIP �CU�z , 1 V ,t Name on Permit/ATC if Different then Abova T I1Mk Mailing Address p��VC�ec'AiC�.hCa. City/1 Application For: X Site Evaluation �I Improvement Permit/ATC 4. system to Service: ❑ House Mobile Home 0 Business �1❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms Contact Person Some Phone Dishwasher O Garbage Disposal washing Machine If Business/Industry/Other: Specify type # Commodes # showers 0 Basement/Plumbing # People ❑ Both ❑ Bassmant/No Plumbing # sinks # urinals # water Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) Type of water supply: ❑ County/City Xwell ❑ Community �p Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑ Yes No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions k�� S WRITE DIRECTIONS (from Mocksviile) to PROPERTY: Tax O1BCe PIN: # i zs t1l — 4s l - 59 U53 .03 a Any L -kc) S)i!C eld Q1, Property Address: Road Name � 5bbySeIA FGCCRS�R 7a-� k(kg e� ah city/zip Nc3rm=c , Nk 63q farm 7C , I # If in a Subdivisionprovideinformation, as follows: nr 1i�11Pto J�1 I l Name: 7 PQtm:5 Section: Block: Lot: Date Property Flagged: st/iLk/Q Q 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 ConubdHealth Department to enter upon above described property located in Davie County and owned by 1)O AS en\ -1 [4I _ to conduct all testing procedures as necessary to determine the site suitability. -- DATE(I5)'`ig SIGNATURE t 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 Date(s)- Client Notification Date: EHS: Revised DCHD (07/99) Account No. Invoice No.� w y vc,9 / a r I / � � • � � �.... �i 1 od" o. n oll v Ali 46, rl 10,V lz ? n 10. V g?Js \ %;ry 4 . ` SO n d��Do � � �C:i;�s grip •. � h878'�Qti :/ 'ti /'� . ` °oyr�On/ 7-0 a y^« C • \ /� yei2y,N �. �• `` 04? CIE 2205 W ~r '7 � °'a v x°. CY r5 / ;1 z� 4 y�w I },n 1e•xe'ss w 142.60' Vv y �e C 7 `��!�, `�• �y/ l� 10'30'35"W \\ 104.0;' Q t c. ta•lYoo'w 75.91' °o• s �• ��. 667' B g•t— n 30.1e•40'w 47-W �s2S��8S ?s / J04, /s, sg•ts 114.,1t•30.� e4.e3• 7 -\00'14 2e k 13•15'31V 7708, �1 0'%0-3"- 107.21' T 0'1y 1402.20roaw 50.35' 676• 1C�• H °1.4,•x5' cs w s,�• . , N °y 71 ea V 8 ob ,4755 . N v \� 6.0 Ac. 7.t.1,0 l 8 oo-b �2 u I • x . j9 00'°r w 5 0 A c . x.," f�1 hA ► ' S� Gr �, ^i p 134 5 .9•50'•'N S V a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation . APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900618 Tax PIN/EH #: 4871-81-8453.03 Billed To: Piedmont Housing Subdivision Info: Shetfield Farms Lot # 3 Reference Name: Teresa Newton Location/Address: Shetfield Farms Tr. -28634 Proposed Facility: Residence Property Size: 5.5 Acres Date Evaluated: Water Supply: On -Site Well / Community Public Evaluation By: Auger Boring_ Pit Cut HORIZON I DEPTHi 0RwM. IM,_ ,Consistence �t�'Jr�l�Jr�ISJ•����' Consistence HORIZON III DEPTH Consistence SOL WETNESS • • • • i�G�JtIFT�:�i�C->�•1���� _ , , �uJ•�tl�tW>•�e�� SITE CLASSIFICATION:_ LONG-TERM ACCEPTANCE RATE: 0 1 REMARKS: EVALUATION BY: OTHER(S) PRESENT: a.anascape M mon V 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 Tex ur 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 Moist CONI TEN E 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 OR - 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 - gaVday/ft2 DCHD (Revised 05/99)