165 Irishman Place Lot 23DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
' Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990001248
Billed To: Mike Hester Building Co.
Reference Name: Mike Hester
Proposed Facility: Residence
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Tax PIN/EH #: 5789-73-9880.23
Subdivision Info: Shamrock Acres Lot#23
Location/Address: Irishman Place -27006
Property Size: 1.179 Acre
ATC Number: 2467
**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 l I 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 n #People #Bedrooms 3 #Baths .2, S
Dishwasher: 2!( Garbage Disposal: ❑ Washing Machine: 000' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 1, / 7fAC, Type Water SupplyDesign Wastewater Flow (GPD)<-!�O_ Site: New 0 Repair ❑
System Specifications: Tank Size GAL. Pump Tank _ GAL. Trench Width � Rock Depth &� Linear FE�,V&
oil
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/88:30 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.****
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Environmental Health Specialist's Signature: "I`c" Date: 1� c7 b�
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
Billed To: Mike Hester Building Co.
Reference Name: Mike Hester
Proposed Facility: Residence
ATC Number: 2467
Tax PIN/EH M 5789-73-9880.23
Subdivision Info: Shamrock Acres Lot # 23
Location/Address: Irishman Place -27006
Property Size: 1.179 Acre
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?rTRU TION IS VALID FOR A PERIOD OF FI�V/E YEARS.
Environmental Health Specialist's Signature: Date: t� O
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Compl 'on shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with elf 11 f G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WA t as a guarantee that the system will function satisfactorily for any
given period of time. k
iwoei% a
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date: 7 —1
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERmIT & ATC
Davie County Health Department
EnvitonmentaiHeaitb Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
JUN 2 212 000
„ ENVIRONMENTAL HEALTH
DAVIE COUNTY 4
***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 JI i 1]( /��'��i? �/1`0 {p(feraot Pa...
Mailing Address aL'3 h 4 dy aveQ cel. Boma Phone
city/state/zipj/ (/1'1'�(� i1/LC -JI- i/4 i0 Baaineea Phots / / d 5- -76
2. Name on Permit/ATC if Differant than Above
Mailing Address City/state/zip
3. Application For: ❑ Site Evaluation fa.Z*r-ovement Permit/ATC ❑ Both
i
4. System to service: ase ❑ Mobile Home 0 Business ❑ Industry ❑Other
i
s. If Residence: #People _ y_10 E Bedrooms _ i Bathrooms a. C
CYDiahrasher ❑ Garbnge Disposal Machine 0 Baeemeat/Plumbing ❑ Basament/No Plumbing
6. If Business/Industry/other: specify type
# People # Dinka
# Commodes i Shovers # urinals
# Water Coolers
i
IF FOODSERVICE: # Seats Estimated Water Usage (gallon. par day)
7. Type of Nater supply: OYCounty/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is Intended to serve? ❑ Yes
If yes, what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTYINFORMATIONREQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION
Property Dimensions: - 1, 1 -% 5 (k ,
Tax Office PIN: #�'� --) I3
Property Address: Road Name TV $ I> /%1 i' �•
City/zip 61t'et1 < ^fr At '
If in a Subdivision provide information, as follows:
Name: S/1 G ou t?C-C 4 & re f, r
Section• Block: Lot: 1 -3
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Lit5T rta ti c IFS /
5cd q /." %% r Gt-,
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 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 to 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).
Site Revisit Charge
Client Notification Date:
EHS:
Revised DCHD (07/99)
Account No. /Mg,/
Invoice No. �4�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �7
ADDRESS � �bc R CAPQ
PROPOSED FACIILTY
DATE EVALUATED %_1;2 F --V r
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit e/ Cut
FACTORS
1 2 3 4
Landscape position
G
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
eio ' Or
Texture group
Consistence
i r
Structure
Mineralogy/
HORIZON III DEPTH
Texturerou
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: /Z
LDNG-TERM ASr UTANCE RATE:
REMARKS:_
DCHD(01-901
Landscape Position
EVALUATED BY: /6Y /
' OTHER(S) PRESENT:
LEGEND
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
T
_ exture
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-FinnVFI-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/ft2