135 Dublin Road Lot 3DAVIE COUNTY HEALTH DEPARTMENT d�
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002706 Tax PIN/EH #: 5789-62-8518
Billed To: Jeff Hayes Subdivision Info: Shamrock Acres Lot # 03
Reference Name: Location/Address: Dublin Road -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4048
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 Tr tment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA MON S ALID FOR A PERIOD F FIVE YEARS.
Environmental Health Specialist's Signature: Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system
has been installed in compliance with Article 11 of G.S. Chapter 139AV
Disposal Systems," but shall in NO WAY be taken as a gpar
given period of time.
so
Tia -+IL —L4
Septic System Installed By:
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
� A.1 t.
Improvement/Operation Permit .
I "Sewage Treatment and
I function satisfactorily for any
%%a,
0
Account #: 990002706
Billed To: Jeff Hayes
Reference Name:
Proposed Facility Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT .
Tax PIN/EH #: 5789-62-8518
Subdivision Info: Shamrock Acres Lot # 03
Location/Address: Dublin Road -27006
PropertyS.ize: see map
ATC Number: 4048
**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 ��IG #People #Bedrooms #Baths 7 -
Dishwasher: Or' Garbage Disposal: ❑ Washing Machine: ❑�— Basement w/Plumbing: ❑ Basement/No Plumbing: C>'
Commercial Specification: 13pecification: Facility Type #People_ #People/Shift #Seats Industrial Waste:
Lot Size 09 �-'�S Type Water Supply C2t-1JI'tzDesign Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size IMOGAL.�PumpQ�Tank GAL. Trench Width Rock Depth 17 Linear Ft.'360
Other:ST(L1,�tJ
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 x: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.****
SID,g
.71
�t
Environmental Health Special
DCHD 05/99 (Revised)
AYR. 12, 2005 2:32PM CBT TRIAD+ 99B 4492 NO. 4605 P. 1
p ECS_
PLICATION FOR SITE L-VALUATION/iMPROY81W PEWIT S• ATC
�R 1 2 20 Davie County,ljealth Department 3
Enyironmerlta/HeaI�JiSection �� � �
P.O. Dox 848/210 Hospital Street- J
ENRMMINTAUNTY HEWN riockaville, =27020
DAViEcO
(336)751-0760
***iMP01t?.SNI*** THIS APPLICATION CANNOT PIs• PROCESSED 7r31LL•'SS BLL TIM 8.-PUIRED
INF•ORt4ATI0N 15 PROVZDED. Refer to the INFOR12ATI011 BVLLETIN for ins true tiona.
1. Neme to be'.Dilled - Contact Person
Meiling Address b / �✓ ��� SaeJf�L , Noma Plwaa• ,
City/Statenit. GUN L/ ii 7-074015, Duainoaa Phone SZ? ,�s�x _
2. Hama on Pormit/ATC if Different than Above ___,,,_• „•,, ,,
Mailing Address City/State/Zip - _•,"•„•„____,_,_
J. Application For: D Site Evaluation AZ Tmprovement el t/ ❑ Doth
A. system to service:A-zouse ❑ MolSile Home ❑ Buninebs 11 Industry D other
b ;
5. Type aystam requea ted: I—areonvontional ❑ ceavdatianal modified Q i.nnbval;ivo'
6. if Residence: it People 0 Eodrooms _• F Bathroelur -_
ishvaaher (]Garbage Dlapoaal NashiDg Machine QDacement/Plumbing Gacement/No Plumbing
7. If' Duainaas/Induotry /other= verify type 6 People F Sinl=
0 commodes It showers 0 urinals 1! 14aeer Coolaru
IF FOODSZXVTCEe ti Seats Estimated Water Usage (gallons per day)
a. Type of water aupply�county/Ciey ❑ well ❑ community
a. m you oatieipate additions or C\p 11153ojt5 a(li1C faClllly lllls Sy5(C1A IS Inll`t1dCQ to SCI•Vl•': ❑ Yes ❑ No
I•f ycs, what type?
'**1AW0RTAN7***CLIENTS AIOSTCOAI=,TL•THC ALQ(jIIt1DPItOpEIrj-yIPO111Y inONItliQlllsS'1'L)
3ELOW. Ehler a PLAT or SITE PLAN Att/STBC• SVBAf1=.D by the chant 1vi(h THIS APPLICA'170N.
1>roperly llimcnstou: I'AkLs/ X2l% WRITEDIREC11ONS (from 11•locl:s0lic) to PRoMit'I'v:
Tax Orr] ccPIN: # 57E96 7 op.; -18 ,
TropertyAddress: IQoadNianc /
Citymp Zzf� ae Ale,
as follows:
C ,�n
cclion: �L DIQF40 _� Lot: Date home corners llagged: '���� oS
This is to certify that the Information provided Is correct to the best ofinyl(nOwledge• I unders4•ind !hat any pernnjt(s)
issued ltercaficr arc snbfcct to suspenslon or ('evocation, lithe srtoplans orintended use d(angq ar if Ute iuforntaliDtt
sublviitted lit this application is f:dsincd or cliauPed I. also.
----•--r,•••--••�•••.,..�.ave,b•+awuacu(muic,auutortTcaitcpresciitalivcdfihclluvieCuuitiyIlealthDcp:u'tn:tul ,
to enter upon above described property located In Davie County and otivnod by
(a conduct all testing pt•o u%res as accessary to determine ilia site suitability.
DATLt _/ %i %L SICNATU=,
TW AREA MAY IiE USED r, OR DRAWING YOUR SITE PLAN udc all of ilia fulloiyiu L t3 d d
property lines and dimensions, structures, setbacks, gild septic locations). b' � ub .un pt opus(
Sign given J”
R>•JlreA tll:LT11 rprrm
Site Revisit Charge
Datc(s):
ClleutNatillctttion Date:
];IIS• ' .. ,
AeeouutSto. 76
DIA 1 a '—/7 7!
01
DAVIE COUNTY HEALTH DEPARTMENT 3
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS-�lnO�.+�KOC� /iCt/i0o
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE �fl/G7
LOCATION OF SITE ree.'
Water Supply: - On -Site Well Community Public
Evaluation By: Auger Boring Pit L/ Cut
FACTORS
1 2 3 4
Landscape position
1,
Slope Z
bZ
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
r
Texture group
Consistence
Structure
h X
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: -
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: lh /
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-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
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(suilable), 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 rale - gal/day/ft2