106 Irishman Place Lot 31DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
,{ P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900204
Billed To: J. D. Crews Homebuilder
Reference Name:
Proposed Facility: Residence
Tax PIN/EH M 5789-73-5182
Subdivision Info: Shamrock Acres Lot#31
Location/Address: Dublin Road -27008
Property Size: see map
**NOTE** ThisbK-provee3mlent/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 I� #People #Bedrooms'_ #Baths 2 -
Dishwasher: 0 Garbage Disposal: 21' Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type n #People_ #People/Shitt #Seats Industrial Waste: ❑
Lot Size Type Water Supply ( tJ Design Wastewater Flow (GPD) 3G Site: New do"" Repair ❑
System Specifications: Tank Size &L GAL. Pump Tank GAL. Trench Width 1. Rock Depth Linear Ft.,2,40
Other:
Required Site Modifications/Conditions:
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.****
Environmental Health Specialist's Signature: 5! VAN Date: �� L'e)
DCHD 05/99 (Revised)
a DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900204 Tax PIN/EH #: 5789-73-5182
Billed To: J. D. Crews Homebuilder Subdivision Info: Shamrock Acres Lot # 31
Reference Name: Location/Address: Dublin Road -27008
r-iupuseu raaury: mesmenee
ATC Number: 2631
5¢e: see
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 .19000SSewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA'�t�r�.� UCTION ISVA VID OR 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 I 1 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.
1�0,)S6
, 10
Go.
Septic System Installed By:
Environmental Health Specialist's Signature : Date:
DCHD 05/99 (Revised)
APPLiCAIION FOR SIZE EVAWAIION/IMPROVE6IENT PFRIM & A.
Davie County Health Department
Anv/ronmenblllleaftsection D
P.O. Bos: 848/210 Hospital street
Moaksville, HC 27028
(336)751-8760
L
fffitlPOItTAWV** THIS APPLICATION CAIUM 8H PROCESSED U=SS ALL THE RE I
INFt�RTAT70N IS PROKIM)..'Refer to,tho I rOMIATION BULLETIN for instructions.
OCT 2 7 2000 it
i.
_sass to be Billed —
0 �EL■9$ l inn a
QC contact person pewS
Mailing Address -
qo( =LTAOR4 Ro RSA '
Rome none q%Z-7&te
city/state/ZIP
M QCKSVTl(c ( VC, Z7V&r7
Business phone _ GWK%4
a.
Mame en psmli/ATC if Different than Above
-
Mailing Address
..
City/state/zip ..
3.
.application for:
U Site Evaluation
s Improvement
Permit/ATC ❑ Both
c.
system to service:
VHcuse ❑ Mobile Home
0 Business ❑ Industry' ❑ Other
s.
If Residence:tf
People 4
Bedrooms 3 # Bathrooms Z
-/
041shwasher g Aatbage Disposal t7 Mashing Maddoe
13 Barmen!/plvsbinq 0 Basement/Mo plumbing
S. if Easiness/IaCustry/other: specify type # people / sifts
f Commodes f showers 4 Urinals—
frfates coolers
IF POODSF.AVICE: / Seats —/ Ea
7. Type of water supply: N County/city
Est
crater Usaye (gallons per day)
❑ well
s . Do you anticipate additions or expansions of the facility this system is intended to serve!
If yes, what type'
❑ community
❑ Yes IINo
•••/MPVRTANT"'*•CLIzmUUSTC6arPLE7ETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions. 12S X 240 Y 12S'X ayol
'fax Office PIN: #
Property Address: Road Name D USI.i h/ R'o A -p
City/Zip Advo gcL
If in a Subdivision provide information, as follows:
Name: --5011M ROCK 4C -RES
Section: Block: let: 31
WRITE DIRECTIONS (from MsekrAlle) to PROPERTY:
I I/o 'mst1 exT &- Hwy CFO Soc//rf/
.LEi� on/ b(181, eJ Rd- 110-D .SHmn0ade
/oT 3 r o/✓ /-SFT
Date Property Flanged: / 0- Z 7-0'2)
This Is to certify that the information provided is correct to the best of my knowledge.. I understand that any permil(s)
Issued hereafter are subject to suspension or revocation, if the site plans or Intended aw cbauge, or if the Information
submitted in this application Is falsified or changed 1, also, asderatand dui l am mWnsible jor all charges incurredfrom
e +Uevr/lom f, hereby, e-e's��tto ttietAatborirwl Representative of the Davic.Cannty Eiraltle De'Psatment__ ....
to eater upon above described property located is Davie County and owned by,,
to conduct all testing procedures as necessary to determine the site sotabl
DATE -a7•-02r 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 loeationsl.
Revised DCHD (07m)
i r 79 /
Account No. ' `ZI l�
nvolce NoLo.. A � �7 0
` DAVIE COUNTY HEALTH DEPARTMENT
y Environmental Health Section
Cn;l/Cites Rvahtatinn
NAME ��pp /�
ADDRESS �r C^ "��l— / tC��
PROPOSED FACIILTY
DATE EVALUATED 76111 ��
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit F/ Cut
FACTORS
1 2 3 4
Landscape position
Slope
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
exp. ON
Texture groupG
Consistence
Structure
/G
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
c
SITE CLASSIFICATION: G� "
1
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: A4&
OTHER(S) PRESENT:
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 •.lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR- V,. -.-y 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
Ilorizon 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