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150 Irishman Place Lot 25DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000736 Tax PIN/EH #: 5789-83-2494.24 Billed To: 6btehIlaHei�'D.GLI"v#zry bLC-LJA► Subdivision Info: Shamrock AcresH970/A Lot Reference Name: Btdeh 1 Isker Qlvn iwu sf Location/Address: Irishman Place -27006 Proposed Facility: Residence ATC Number: 2153 Property Size: See Map 150 J.Ri h nAd !Plage- 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 WASTEWATER CONSTT�RUCCTIION IS VALID FOR A PERIOD OFF FIVE YEARS. Environmental Health Specialist's Signature: cI - fiY ? "Date: 2102 /4e 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. Septic System Installed By: cJ Environmental Health Specialist's Signature:. ( Date: 2 ✓ DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 156:[E1, X[RAee Account #: 990000736 Tax PIN/EH #: 5789-83-2494.26r Billed To: BtdehII94eFsZ•Gt&L-X 00r b"'ld" Subdivision Info: Shamrock Acres H9701A Lot #&4ww4-2-C Reference Name: Matter JTl i-nY e rows Location/Address: Irishman Place -27006 Proposed Facility: Residence Property Size: See Map ATC Number: 2153 **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 I1 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_ Dishwasher: Garbage Disposal: ❑ Commercial Specification: Facility Type #People S� #Bedrooms \,? #Baths _ Washing Machine: 21 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Cy'0f Site: New Repair ❑ l'L i System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width,�f� Rock Depth Linear Ft d Other: Reauired Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 K 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 1:00P.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: � Date: �2� DCHD 05/99 (Revised) APPLICATION FOR SITE EVAWA110N/IMPROVEMENT pERMI1 & ATC Davie County Health Department Eavlronmenta/Healtli SeW017 P.O. Sox 848/210 Hospital Street Mooksville, HC 27028 (336)781-8760 ***ZHPORTA2M*** THIS APPLICATION CAWlfOT BE PMMSEW UNLESS ALL "M REQUIRED INFORMATION IS PROVIDED, 'Refer to the ZMMFMIITICH BUWATIH for instructions. I- Mass to be Billed Ge JLC U CK(FtOS i1CftC151tiLOa?S contact. Peejz�ftlL� :son Sm , s -7 Mailing Asides.s n0/ c-LmoR-G RD, Mase phone city/state/zlp .. r OC.I<S �I i \lG NG X702B Business Phone 2. Name On Persit/AIC 1f Different than above - Mailing Address City/state/sip 3• Application For: V Site Evaluation VImprovement Permit/ATC ❑ Both e• system to service: WHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other a. E£/ Residence: 6 Dishwasher I People # Bedrooms 3 0 garbage Disposal gashing Machine 1r Easement/Plumbing 6. If Eusiness/Industry/other: specify type a Commodes a showers i urinals i Bathrooms 2y 0 Basement/wo Plumbing • People t sinks t: water Coolers IP FOODSERVICE.- ff Seats Estimated Mater Usage (gallons per day) 7. Type of water supply: @County/City ❑ Well ❑ community B. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes II NO If yes, what type! ***IMPDRTANT*** CUENTSAfUSTCOAIPLETEWE NEQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 00'X 379'K /V Tax Office PIN: H Property Address: Road Name SRl5ffw*J PjArg City/Zip_ AJIVA J6c jUC 27006 If in a Subdivision provide information, as follows: Name: S4AxM tout- !tic L,, -s Section: Block: Lot: Z5 WRITE DIRECTIONS (from Macknille) to PROPERTY: -'o 0C Rol Sotil't,. 'tom iPepp (zs CK R. -k 0 1-44 f.17R "cc- ) LeFr- 661 {�eopieS GIG -t0 Sh*MPocic L, --Fr o4 Duct^rJ P-1. kkc7wr o4 Zeislh.-,n,J PlftcE /LMT 2,5 on/ &,94:rCmfuuz ' 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• 1, also, snderatand that I am "VonAble for all charges incurred jrom ..this application. 1, hereby give consent to the Authoriz4,d Representative of the Davie County ITealtb Department to enter upon above described property located lit Davie County and owned by _ �a RN Tin/% P_A.at s to conduct all testing procedures as necessary to determine the site suits li DATE S- -3O -0' 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 locatlons). • � �� [ � AIDvotccount Na. _��71 v� 3�C Revised DCHD (07!98) n ��`7� ee No. ,7l B APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC U D Davie County Health Department Envlronmenfof Health Section E -AUG 2 3 1999 P.O. Box 848/230 Hospital street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336) 751-8760 DAME MINTY IwwwIMpCRTANTstt THIS APPLICATION CANNOT BE pRO=5MW UNLESS ALL TSS RSQUIRSD IHIORMATIOH I8 nOVIDSD. Refer to the INI'ORMATIOH BUM&TIN for instructions. I- flu* to be Billed Railing address Cite/state/SIP a. Kase on Pereit/AM it Different than AboweA14 Nailing Address S/.l M CV Contaot *arson am* *bona GI Yd ` Io l u l Suainese Phone 3� 9 - 3 Z S� 3. Application Fort D Site !valuation B�rovement permit/ATC D Both 6. Systen to s.s.ioe3 la'Bonse D Mobile Home O Business 0 Industry 0 Other 5. If 14sidance: 6 people0.L a Bedrooms _ 6 Bathrooms Zr Z 0.,lUshwasher 'O'earbsee Disposal O(Waab a meobine 0 Beseaent/exuabine KBaseynt/ao Plimbine 6. Xt Business/xndustry/Others Spenify type # People a Sinks Coaodee I a showare a Urinals # lhbs Coolers IF FOODBzRVICz: # seats Sstimated Water Usage taallene per day) 7. Type of water supply: County/City 0 Well 0 Community e. Do you anticipate additions or expansions of the facWty this system to Intended to serve? 0 Yes 00 if yes, ghat type? e"e1MP0RTAN7"e1 CLIENTS bfUBTCOMPLEPETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESIIBMITIED by the efient with TIAs APPLICATION. Property Dimensions: ''h0_7Z 5 4.jra Tax Office PIN: N ILTq - L Property Addreaat RoadNime J 8 Z� qac CItyalp. V <.Q WRITE DIRECTIONS (from Mockevllle) to PROPERTY: A� If in a Sobdivhlon provide information, as follows: Name: 4n. 0,04 v, 001, e,re s Section: 9q7D Blockt_ Lot: A qfS SIL QQ7JR Date Property Ragged: Tbb b to certify that the Information provided h arrest to the beat of my knowledge, I understand that any permit() Issued hereafter are subject to Inspenalun or rt 11 if the site plans or Intended we change, or If the Information submitted ID this application h falsified or chasged. 1, also, undnamnd #Yat 1 am responstale for all charges incurredJ6om this applIcadom 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described properly located In Davie County and owned by to conduct all testing procedures as necessary to determine the site seitab. DATE 9 `Z � — IqurSIGNATURE THIS AREA MAY BE USED FOR DRAVMG YOUR SITE PLAN (Include all of the following: Existing and proposed property Hues and dimensions, structures, setbacks, and septic locations). D DCHD (07/99) N �Dp 1 Site Revbit Charge Ghent Notifladon Date: EAS: Account No. Jj(�_ Invoice No. 1r SS 41 19 •i zv ---LMia----------------- L( M., 8 EX 17 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation. NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE/Ae LOCATION OF SITE Water Supply: On -Site Well Community - Public LI--, Evaluation By: Auger Boring Pit Gam- Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH d Texture groupG Consistence Structure h Jl 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: _a LONG-TERM ACCEPTANCE RATE:_ REMARKS: DCHD (01-901 EVALUATED BY: OTHER(S) PRESENT: LEGEND Landscape Position 1. - R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope CC -Concave slope CV -Convex slopeT-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 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 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 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