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161 Dublin Road Lot 5Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT fcL rl--,-7--° -2J 510 890001248 ITax PIN/EH #: 5789-72-1704 Mike Hester Building Co. Subdivision Info: Shamrock Acres Lot # 5 Location/Address: Dublin Road -27008 Residence Property Size: see map ATC Number. 2574 **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 #People t -i #Bedrooms , j #Baths '2 - Dishwasher: Dishwasher: G Garbage Disposal: ❑ Washing Machine: M Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type �t #People #People/Shift #Seats IndustEl trriaal Waste: Lot Size £�� I$�c� Type Water Supply l:-Fit?4IqDesign Wastewater Flow (GPD) 3UO Site: New Repair ❑ System Specifications: Tank SizelOCOGAL. Pump Tank GAL. Trench Widtb3& " Rock Depth 12" Linear Ft. 5�x>I Other: 2'DIS'1`e4$07io-) BDK&S Required Site Modifications/Conditions: IfhTALLOt� C&,)-r0OfZr140ci5'oFC Fi!hM V' -'-E:( Imp DFF PRoP.1-WC 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.**** T-EM10, WG. 6- ootmpJ l �l c►Ga�C t)T \O L LoT (e 7 s \) goo, F2o,jr tDp � �KSp� t I 35 rnvironMtalealth Specialist'sSignature: Date&l,l t,) IC,Q� lal DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account M 990001248 Tax PIN/EH #: 5789-72-1704 Billed To: Mike Hester Building Co. Subdivision Info: Shamrock Acres Lot # 5 Reference Name: Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2574 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 WAS TEW C I N I GALID FORA PERIOD OF FIVE ARS. Environmental Health Specialist's Signa e: 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 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. (ZPAt2 A,96& 10 Q -V -'T Ofr EX 1STo(�ST�t°✓` 2-S?o PSD J tx(DA s4--Srar�, Nws�, 9i_�r-mar EM& Septic System Installed By: Environmental Health Specialist's DCHD 05/99 (Revised) U N6.i c-7t.,ft.or, Ar i 4v:? c'rn APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnWronmenta/f/ea/tBSec on P.O. Box 848/210 Hospital Street. Mockaville, NC 27028 (336)751-8760 U N2 0W D 50 182000 ENVIRONMENTAL AIO7Y�� ***ZMPORTANT►** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed )(( 1, I7 C� Contact Person /1-, /r /� e /j e S l & Nailing Address t/ SA Home Phone (k City/state/sIP -ei-7 (P en ( Business Phone 2, Name on Permit/ATC if Different than Above Nailing address City/state/sip 3. Application For: 0 Site Evaluation L -r rovement Permit/ATC ❑ Both *. System to service: [U H6use ❑ Mobile Rome ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms X_ # Bathrooms iahwasher ❑ Garbage Disposal thing machine ❑ Basement/Plumbic g ❑ Basement/No Plumbing 6. If Business/Industry/other: Specify type # People oP # Sinks # Commodes # Showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water Supply: U-County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes p pin! If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: SSP M WP Tax Office PIN: # Sf19 73 ( -) O y Property Address: RosdName_1)C466/R/ (?0/,A(?0/,City1ZIp � - "vire If in a Subdivision provide information, as follows: Name: 11 V- is k kr fz fr5�( e'L 5 Section Block Lot: 9 --- WRITE DIRECTIONS (from Mocksville) to PROPERTY: q E--n-S - r �cS /Ir C i r `!Po�f(es Ci��G 61 t N Date Property Flagged: 5? -1q -'0q 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 responsible for all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County palth epartmen 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 / ' ( R- Cly SIGNA / 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 locations). EHS: Site Revisit Charge Notification Date: Account No. Revised DCHD (07/99) Invoice No. _LZ (P / 1 la a rr w 4j Ale 0�1 Qap ` ;• -�+ ctr� 'L �1 oo oop p t, • ^a. f ooll 5A woo 10 • so,�, Zti 6 �,,'� • , `5cs N• o � �a �\ ti3Naoo \ 101 11Non e�• iJ �� ONi/�',�dr� ?- ru �� is K O" O t "Bob i � i!►'� � M► . � / 1Z•L� Al . N � �O e' M3S*a 30 / / .1•9 m . y;•tig tC•B�: / P M Its tort S Q2lOk� H3Ntio:) Due Yl� 'lowj4oy DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE X2/53 LOCATION OF SITE Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit ✓ Public - Cut' FACTORS 1 2 3 1 4 Landscape position Slope % HORIZON I DEPTH Texture grou Consistence Structure Mineralogy HORIZON II DEPTH t' J Texture groupC Consistence Structure /e 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: �� EVALUATED Fly: �� LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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 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 .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 Saprolile - 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/fl2 DCHD(01-901