316 Sheffield Farms Trail Lot 10Account #: 990001870
Billed To: Charles Phelps
Reference Name:
Proposed Facility: Residence
ATC Number: 2944
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 4891.81-7813
Subdivision Info: S W&W Fccw+ taito
Location/Address: Sheffield Farms Trail -28834
Property Size: 7.4 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 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTE WATE O STRUCTION IS V4LLID FOR A PERIOD OF FIIVV�E 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.
Ep x 'x
1 Ofl ' _
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iWt- 11QTe> 8.2.10
Septic System Installed By:
Health Specialist's Signature:
DCHD 05/99 (Revised)
Account #: 990001870
Billed To: Charles Phelps
Reference Name:
Proposed Facility: Residence
ATC Number: 2944
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028 A -30
(336)751-8760
IMPROVEMENT/OPERATION PERMIT'
Tax PIN/EH #: 4 91-81-7813 1 Z% to
Subdivision Info: SWef fc�.s
Location/Address: Sheffield Farms Trail -28834
Property Size: 7.4 acres
**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 ArL5V:� #People_ #Bedrooms S #Baths
Dishwasher:zn�Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size k190 Type Water Supply Ale' l/ Design Wastewater Flow (GPD) Sdd Site: NewraRepair ❑
System Specifications: Tank Siz%Q� GAL. Pump Tank GAL. Trench Width Rock Depth 16L Linear Ft.&M
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 u 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.****
Health Specialist's Signature: Date: — 1/
DCHD 05/99 (Revised)
PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
- 6 Davie County Health Department
Ei7Vi OHMental Health Section
ENVIRONMENTALHEALTH P.O. Box 848/210 Hospital Street
OAVIECOUN?Y Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BEPROCESSEDUNLESS'ALL THE REQUIRED.'
INFORMATION IS PROVIDED. Ref
lerto the INFORMATION BULLETIN for instructions.
1. Name to be Billed he, (IV B . �G1eIPS Contact Person C4r(e5 & P►,,z
Mailing Address FCLM S ) /
rtI. Home Phone 9 2402-
q-' CDS ,
City/State/ZIP 0dagen.( NL ZS6364 Business Phone IZ-'l-IOGO�I
2. Name on Permit/ATC if Different than Above s&N�i /'<v� SJ e-^- OPAe
Mailing Address LuIMJf City/State/Zip SQ.6viJ-
3. Application For: ��5ite Evaluation I�71mprovement Permit/ATC 1�T Both_
4. System to Service: &i House ❑ Mobile Home ❑ .Business '❑ Industry ❑ Other
5. If Residence: .# People 2' # Bedrooms # Bathrooms Ji 2—
IJ Dishwasher
IJDishwasher ❑ Garbage Disposal WWashing Machine ❑ Basement/Plumbing 1-1 Basement/No Plumbing
6. I£ Business/Industry/Other: Specify type # People - - # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water �Ussa/age (gallons per day)
7. Type of water supply: ❑ County/City VWell D Community -
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes M No
If yes, what type?
***IMPORTANT***. CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI?TED by the client with THIS APPLICATION.
Properly Dimensions:. I (�(,i,Q.g WRITE DIRECTIONS (fromlIMocksvillel) to PROPEIL'IT:� __
Tax Office PIN: # LAI I l g j -s ID q w am 40 cGrl4" i y lQ iia RdCJJ
311, rr
Property Address: Road Name SkJT I old Tar w,5T`r''� 'ilt Y rl (Z ted I 6v\ cJ kR17 i9 �GiYYYIS �f �.
City/zip � VmOY�U & dr;y�telWn is 10tA cl6a Ltay
If in a Subdivision provide information, as follows: Oil l h1L R. t
Name:
Section: Block: Lot:, / Date Property Flagged:
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 ant responsible for all charges incurred front
this application. I, hereby, give consent to the Authorized Representative of the D vie Count ,yy Health Department
to enter upon above described property located in Davie County and owned by �tiac(eS F3 % JPSSc CG, -P kQ (pS
to conduct all//testing procedures as necessary to determine the site suitability. J
DATE �� 1p- O I SIGNATURE tp� a- 9.i
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).
;Revised DCHD (07199)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No.
i
�2
s
g Acres
x
Parcel 12.12
Tax Map F-1
v u D.B. 186 — 477
o ti+ Charles G. Phelps
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FACTORS 1 2: 3 4 5 6 7
Landscape position Z
Slope %
HORIZON I DEPTH
Texture group
Consistence .
Structure
Mineralogy
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON BI 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: - EVALUATION BY: Q✓
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 = LoamSI - Silt
BICC - 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 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 - gal/day/ft2
DCM(oi-so)
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