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123 Dublin Road Lot 2DAVIE COUNTY HELTH DEPARTMENT Environmental' Health Section P. O. Boa 848/210 Hospital Street MockrAlle, NC 27028 ce 16 / L/ 3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900050 Tax PIN/EH #: 5789-62-6571 Billed To: Wayne James Subdivision Info: Shamrock Acres Lot # 2 Reference Name: Location/Address: Dublin Road -27008 Proposed Facility: Residence Property Size: see map ATC Number: 2748 **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: , cation: Building Type ##People #Bedrooms 3 #Baths Dishwasher picGarbage Disposal: 13 Washing Machinele Basement w/Plumbing: Basement/No Plumbing: 13 Commercial Specification: FacilityType #People _ #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply ( d Design Wastewater Flow (GPD) Site: New.Z?'O'Repair System Specifications: Tank Size APb GAL. Pump Tank GAL. Trench Width W Rock Depth Linear Ft -W Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF "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 1on the day of installation. Telephone # is (336)751-8760.**** /i Account#: 989900050 Billed To: Wayne James Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5789-62-6571 Subdivision Info: Shamrock Acres Lot # 2 Location/Address: Dublin Road -27006 Proposed Facility: Residence I Property Size: see map ATC Number: 2746 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: -7 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 asl a guarantee that the system will function satisfactorily for any given period of time. LItjxl-_ S V;zc) t�j e- Q/��',t. kr 2 F 1 Septic System Installed By: 17!�) Environmental Health Specialist's Signature DCHD 05/99 (Revised) T�L)I,w Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section C -t Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY Water Supply: Evaluation By:. On -Site Well Auger Boring DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Pelnee,C Community Public 1,--� Pit V Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure e S /C 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: LDNG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-901 TED BY: hoz' // 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-.Vc.ry friable FR -Friable FI -Finn 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 fr le 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 EAS ,y MUNE S ti ' � k "G ,r ��',�• �`��,�r,�"'%��H "rte LOT p� i FL" •"".;;iM ;ter( Jr LOT $q M .^ 1-4 DT # ,�' APPLICATION FOR SiTE EVALUATION/IMPROVEMENT PERMIT & AFDAIVIF Davie County Health Department EnvlronmentalHea/thSection 92W(P.O. Boa 848/210 Bospital Street Mockaville, NC 27028NTALH(336)751-0760 ni:. �LiH -� IHMPI ORTANT*** THIS APPLICATION CANNOT BE, s` O zSED INFORMATION IS PROVIDED Refer to the INFORMATION BULLETIN UNLESS four innsstructions 1. Name to be Billed Lt),4WrJ� ,j"q.m .S. Contact Person nn Halling Address r•O• PJO X- �3 i - none Phone �,5/—'2146) city/Brat./axp Mor.Ksy,'uE or- o27oa61 Business phone -P. Name on permit/ATC if Different -than Abow (,U4VAIM• . Meiling Address _iI) /.�j0>L 1L31 3. Application For: l! <Site Evaluation e. System to eervlca: B House ❑ Mobile Home S. If Residence: —499?.,ccsNC a'702e Permit/ATC ❑ Both Business ❑ Industry ❑ Other e reopLe ! BedrOOma A � /xashi 02+ pI DSehxsslwr f.7 Garbage Disposal11 Bathrooms* / n4 MachineC1 6aeamant/Plumbing xBaeement/No plumbing 6. If eusinoss/Industry/Other: Specify type ! People ! Sinks ! Commodes ! Showers ! Urinals !Nater coolers ' IF FOODSERVICE:. # Seats Estimated Water Usage (gallons per day) 7. Type of Mater supply: County/City ❑wall ❑ Community e. Do YOU anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW., Either a PLAT or S1TE PLAN MUST BESUBMITTED by the client with THIS APPI.IrATInN Property Dimensions: Tax Office PIN: #�/r/�q/o2 C$%� Property Address: Road Name 1U ibj; n Rc( City/ZIP UlA wy o✓ A10 If in a Subdivision provide information, as follows: �7oo fo Name: SFIftRoC6 4(es Section: Block:. Let. .1-1 (WRITE DIRECTIONS (from Mod"lle) to PROPERTY:, bel E -fa 20�1 Af 6 Peoplesk-L P - LA. rl' h*pn Pecpjes ev-ed , \— CSMMYDCK. rt( /i'P w �m' en def -f-) 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 to 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 suitability. DATE 99—Q� SIGNATURE `}Dn nJ2M �B THIS AREA MAY USED FOR DRAWING YOUR SITE PI AN (Include all of the following: Existing and proposed property Tines and dlmeusions, structures, setbacks, and septic locations). Revised DCHD (07/99) 0 Site Revisit Charge Client Notification Date: EHS• � . � Account Na Invoice No. 1' 6