The URL can be used to link to this page

193 Dublin Road Lot 7DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mbcksville, NC 27028 (336)751-8760 Account #: 990000736 Tax PIN/EH #: 5789-72-3944 Billed To: Custom Homes of Advance Subdivision Info: Shamrock Acres A Lot # 7 Reference Name: Butch Harter Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: 188x200 ATC Number: 2618 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 ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: . 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 I_LQLQ.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WA taken as a a�antee that the system will function satisfactorily for any given period of time. �� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Ila S✓AL x1p Date: 5 t--� DAVIE COUNTY HEALTH DEPARTMENT /� d Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000736 Tax PIN/EH #: 5789-72-3944 Billed To: Custom Homes of Advance Subdivision Info: Shamrock Acres A Lot # 7 Reference Name: Butch Harter Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: 188x200 **NOTE-*N%is%' prov6ement/Operation Permit DOES NOT authorize the construction of aseptic 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 MENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. i Residential Specification: Building Type # #People #Bedrooms -�/ #Baths o� S Dishwasher -,Er Garbage Disposal: 0'� Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People _ #People/Shift #Seats Industrial Waste: ❑ Lot Size �Y oP Type Water Supply C l/ Design Wastewater Flow (GPD) y9y Site: NewO—Repair ❑ System Specifications: Tank Size 4& GAL. Pump Tank GAL. Trench Width� Rock Depth, Linear Ft.�:w Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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.**** Environmental Health Specialist's Signature: ��!��L�T l J Date:/01�-2j�J DCHD 05/99 (Revised) _,; ECE0�. Davie County Health De r &- kR 2 3 2010 Environmental Health S cd NVIRONMENIALHFAUH j4.8 DAVIE COUNTY P.O. BOX 8 N i ;- is 210 Hospital Street Courier # : 09-40-06 �J Mocksville, NC 27028,° Phone: (336) - 753 - 6780 rm: (336) - 753-1630 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING // (Check One) 'Replacement Remodeling Reconnection Name: lrcak Ce+j" S✓es,� d Phone Number 336. 9(sz. 614'L (lIame}I� Mailing Address: Pn 60 >_ t t S 33 2 SS 7 (Work) le�.�s�.'ll� N� Z76L3 Detailed Directions To Site: e x 1• gK- r o L,+ Property Address: /93 P -Ston 2dLA!✓A..Xe_' Please Fill In The Following Information About.The EXISTING Facility: 1. Name System Installed Under: v?f- A t --A r4G Type Of Facility: Date System Installed (Month/DateNear): .S Al1 Number Of Bedrooms: _Numb[er Of People: Is The Facility Currently Vacant? (D No If Yes, For How Long? A ff 2 77 moi` i s Tl + d Any Known Problems? Yes (:N7oD If Yes,'Explain: Please Fill In The Following Information About The NEW Facility: I Type Of Facility: rel I2nLe Number Of Bedrooms: Number of People Requested By:Date Requested: 3. 2-3. 1 b For Environmental Health Office Use Only Approved Comments: Disapproved Environmental Health Payment: Cash Lec Money Order # / S t+��ou❑c:a_/iwv -w «<_• -�- Paid By: (T pt 1 �_ } Q QA4--� Received By: G_AV �f Account #: ST el 4 Invoice #: 7Z 7'Z Phone: (336) - 753 - 6780 Davie County Health D Environmental Health P.O. Box 848 210 Hospital Street Courier # : 09-4.0-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Pae: (336) 753-1680 Name: Number 3G. Mailing4�2. 61kz(klamsc;j l� Address: X ga r 1 S 334,311 .'255!7 ( Work) levels✓.�1rc�VG. 2'JnL3' Detailed Directions To Site: n Nt MK & rN [1+ % Property Address: /73 P4 bn /z.t AdvAAle- e. Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: d't—AJ✓ et$� - Type Of Facility: s� Date System Installed (Month/Date/Year): S !7 1 Number Of Bedrooms:__�' _Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? A Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: res I A(G Number Of Bedrooms:. Number of People I Requested By:.. "'M / Date Requested: 3. Z3. 1 b (Signature) For Environmental Health Office Use Only Approved ° Disapproved Comments: _A/� G✓s Environmental Health Specialist °��9 Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Order Paid By:�()=r ( Received By: Account #: Invoice #: �2 yZ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Health Section P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANTk** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person Mailing Address _ r,� �] 17(1 Z�'1[7�] Home .Phone ,)3 G �G City/State/ZIP _/ A u VI Le- / ) . 6 �7n Z /06to Business Phone �-7 � 1�,� / L b /L9 / 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑improvement Permit/ATC ❑ Both 4. System to Service: a4ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other i S. 1£- Residence: IF People 1F Bedrooms g Bathrooms Z �Z .fl grenwaaher - �e Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6: If Business/Industry/Other: Specify type M People A Sinks i M Commodes - Y Shoxera 9 urinals B Water Coolers IF FOODSERVICE: # .Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ YesN0 If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name _Du b /1 h .121 City/Zip ff J L'a VI L' H in a Subdivision provide information, as follows: Name: L1 A IM V0 UL V4treLS S=- — q Block: _I_ Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: logff tv (9D 1 ti TI PA&-)QIE-, C, eek 17—d Date Property Flagged: 10—Z-5-`2-000 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 f am responsible for all charges incurred from this application. 1, 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 J U SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, str , , septic locations). 70 L�50V 4Revised DCHD ( Ile -1„ Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. Y° Invoice No. v rt DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS - e d� 'CJ?.PQ PROPERTY SIZE ?�S� PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group Consistence . Structure / Mineralogy HORIZON II DEPTH Texture group Consistence Structure lC 7 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Ily S LONG-TERM ACCEPTANCE RATE i '- SITE CLASSIFICATION: A�_ EVALUATED BY: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-901 Landscave Position OTHER(S) PRESENT: r 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 _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-Fim1 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(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