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149 Dublin Road Lot 4DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section c ! . '• : P. O. Box 848/210 Hospital Street n Mocksville, NC 27028 (336)751-8760 r 1�,pb 0 IMPROVEMENT/OPERATION PERMIT Account #: 990002706 Tax PIN/EH #: 5789-62-9656 Billed To: Jeff Hayes Subdivision Info: Sahmrock Acres Lot # 4 Reference Name: Jeff Hayes Location/Address: Dublin Road -27006 Proposed Facility: Property Size: 3/4 acre **NOSTE * Thm 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 t lt✓ #People #Bedrooms c3 #Baths —/ Dishwasher: Garbage Disposal: ❑ Washing Machine: Q� Basement w/Plumbing: ❑ Basement/No Plumbing: L� Commercial Specification: Facility Type #People _ #People/Shift #Seats Industrial Waste: ❑ Lot Size D.7 AC"�-'S Type Water Supply (2vtww Design Wastewater Flow (GPD) 3 "00 Site: New 21" Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank ]COO GAL. Trench Width Rock DepthAL Linear Ft.."3-�/ As stated In 15A NCAC also Other: I Di`NVIIF)OT-I z bo*:s ,/�,�accepted Systems may also be used Required Site Modifications/Conditions: {r.�TAL,- 9..i e�9p,)9, y-�=4 Id Drr P&P L,-3& VJP t5'Ew tKaw 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.**** ,� r•A,bj�TQ."Jc-K LATH 2�� in.IP1.117 9WE I i� � � I MuJ.15� N I / Environmental Heal $pe alist's Signature: D &-20 A e. ttb tip p i DCHD 05/99 (Revised) An`.147 1 tq ... r•�4 . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002706 Billed To: Jeff Hayes Reference Name: Jeff Hayes ATC Number: 4307 Tax PIN/EH #: 5789-62-9656 Subdivision Info: Sahmrock Acres Lot # 4 Location/Address: Dublin Road -27006 As stated In 15A NCAC 1BA.1969(5) accepted Systems may also be used AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 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 Se age Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW S V F R A PERIOD OF FIVE YEARS. dal Health Specialist's Signature Date: F— D 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 1 I 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. PIC � xa Septic System Installed By:W Environmental Health Specialist's Signature: �� Date: DCHD 05/99 (Revised) �" pp PPLICATION FOR SITE EVALUATION/IMPIIOVEMENT PERMIT & ATC G` Q U D Davie County Health Department Environmental Health Section ,006 P.O. Box 848/210 Hospital Street I � 8 Moo ksville, NC27028 (336)751-8760 „ f ((ytNT*** APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED ON IS PROV D. Ref onthe INFORMATION BULLETIN for instructions.. 1. Name to be Billed / "Contact Person Mailing Addteas - Homo Phone City/State/ZIP Business Phone.�� Jy . 2. Name on 'Permit/ATC if Different than Above Mailing Address City/state/Zip' 3.. Application For:. ❑ site Evaluation C lImprovement Permit/ATC' ❑ Both 4. System to Service: House ❑ Mobile Home. ❑ Business ❑ Industry ❑ Other _.5. Type system requested: 21/Conventional El con ventional modified ❑ innovativepaCCepted / 6. If Residence: it People it Bedrooms 3 it Bathrooms Z— dishwasher ❑Garbage Disposal ashing Machine ❑Basement/Plumbing *agement/Ho Plumbing 7. If Business/Industry /other: verify type_ k People i4 Sinks q Commodes 9 showers .S Urinals It Water Coolers IF FOODSERVICE: It Seats -Estimated Water Usage (gallons per day) S. Type of water supply: {2f/County/City' ❑ Well ❑ Community 9. Do you anticipate addictions or expansions of the facility this system is intended to serve?.. ❑ Yes . ❑ No If yes, what type? ***1,11POR7/1N7"** CLIENTSDIUSTCOMPLETETI'IE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: ' I G �� - WRITE DIRECTIONS (front Mocitsv)IIc) to PROPERTY* Tax Office I'IN: # 7i / 6 - (/ Property Address: Road Name Ak-- City/Zip /1CVy�t'Yo C� �7zr� If in a Subdivision provide in/formation, as follows: Name: GN/ r' / d CL /L f� Section: Block: �7 Lot: Date home corners flagged: �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 responsiblefor all charges incurred front this applicafion. I, hereby, give consent to the Authorized Representative of the Davie County health Departnmut 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. DATESIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Inced . 1 of the foil ng: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Sign given Revised DCIID (05/03 I fV1 Datc(s): Client Notification Date: EIIS: Account No._ Invoice No. w`t r DAVIE COUNTY HEALTH DEPARTMEN', Environmental Health Section Soil/Site Evaluation NAME" I /l DATE EVALUATED ADDRESS S�(al.,,—eoele !�e/2Do PROPERTY SIZE nA�/� / PROPOSED FACIH,TY LOCATION OF SITE D % (r4L1 �N I Water Supply: On -Site Well Community Public (/ Evaluation By: AvgerBoring Pit Cut I FACTORS 1 2 3 4 Landscape position 77 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Ale +- Y Texture groupC Consistence Structure C 1 Mineralogy •/ HORIZON III DEPTH Texture group I Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy I SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE c SITE CLASSIFICATION: lls LONG-TERM ACCEPTANCE RATE. REMARKS: Landscaue Position EVALUATED BY: OTHER(S) PRESENT: R -Ridge S -Shoulder L -Linear slope - FS -Foot slope N -Ni CC -Concave slope CV -Convex slope T -Terrace FP -Flood pl Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty •,,lay loam, .SIL -Silty loam CL -Clay loam SCL-Sa: SC -Sandy clay SIC -Silty clay C -Clay Moist VFR-Vey friable Wet NS -Non sticky NP -Non plastic CONSISTENCE FR -Friable FI -Firm VFI-Very firm slope H -Head slope clay loam SS -Slightly sticky S -Sticky VS -Very Sticky 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 firm 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 with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 (01-901 soil colors