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244 Dublin Road Lot 1711 T Z J Account #: Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 990000738 Tax PIN/EH #: 5789-73-8548.17 Custom Homes of Advance Subdivision Info: Shamrock Acres Lot # 17 Butch Harterr Location/Address: Dublin Road -27008 Residence Property Size: 170x 200 `kis Ii ipr&iaent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater +stem. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this epartment prior to the construction/installation of a system or the issuance of a building permit (in compliance with rticle 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS ERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR VASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. I �'' Residential Specification: Building Type T��L` #People #Bedrooms 3 #Baths 2'S Dishwasher. Garbage Disposal: Q'� Washing Machine: MBasement w/Plumbing: ❑ Basement/No Plumbing: ❑ Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ i Lot Size Type Water Supply DesignWastewater Flow (GPDDD Site: New 09( Repair❑ System Specifications: Tank Sizel000 GAL. Pump Tank GAL. Trench Width &; ' Rock Depth 12.E � Linear Ft.� Other: Required Site Modifications/Conditions: Nu, 0,� Got.lwe-, VZ,,;P S &PP VIENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this een 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.**** I��cz. i i i , toy Plop, a—i DCHD 05/99 Health Specialist's Signature: 1 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 890000736 Tax PIN/EH #: 5789-73-6548.17 Billed To: Custom Homes of Advance Subdivision Info: Shamrock Acres Lot # 17 Reference) Name: Butch Harterr Location/Address: Dublin Road -27006 rivNwcu rdumy. rceswem:a ATC Number. 2487 �W)ArSP1 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE**l 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 Treatme t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER NS TIO S V FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate: CERTIFICATE OF COMPLETION 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, Health Specialist's Signature: DCHD 05/99 (Revised) ELI r - . '7, APPLICATION FOR SITE EVALUATION/IMPROVEMFM PERMIT & ATC A;DAVI'COUNTY 62000Davie County Health Department ILEnvironmental Health Section P.O: Box 848/210 Hospital StreetTAL HEAL Mockaville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION Is PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 11 =M lab s� aelya litContaot Person 1�U�/Ll 1 elyk\ Mailing Address _��L) 1 k z_/ ° Some Phone 33% 7 L16 —00/) City/state/ZIP 14AuA t . Business Phone t> lb 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation R-I�provement Permit/ATC a. system I to service:ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ❑ Both S. IfResidence: # People # Bedrooms ' # Bathrooms W<1hwaahe. arbage Disposal a achine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Burin les/Industry/Other: specify type # People # Sinks # Commodes IF FOODSERVICE # Showers # S # urinals # water Coolars r u eats //'Estimated Water Usage (gallons per day) 7. Type of water supply: oL�YC linty/City ❑ Well ❑ Community / e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �as� If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI77ED by the client with THIS APPLICATION. Property Di ensions: Cb I' ZOD Tax Office FIN: #_ ��, Property Address: Road Name, )'h Vd City/Zip AAQAIILC Z70D� If In a Subdivision provide information, as follows: Name: VRITE DIRECTIONS (from Mocksville) to PROPERTY: Lto r bi ra5& T ('brn er RI 61) f Zud I e IP JD6 Ott Section: Block: Let: Date Property Flagged: 7 '1KaD This is to certify that the information ro d 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 lncuned from this appllca"o' , 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 suits ifity. DATE �— IQ Z DO; SIGNATURE 77 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines land dimensions, structures, setbacks, and septic locations). W Revised DCHD (07/99) 1 Sae Revisit Charge Client Notification Date: EHS• Account No..'ZL Invoice No. f DAVIE COUNTY HEALTH DEPARTMENTJ7 Environmental Health Section Soil/Site Evaluation NAME ADDRESS ��2/tCJ2%o PROPOSED FACIILTY I . Water Supply: On -Site Well Evaluation By: Auger Boring DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Community Pit Public c.-� FACTORS 1 2 3 4 Landscape position ,L & Slope b I HORIZON I DEPTH Texture group Consistence Structure I Mineralogyl HORIZON III DEPTH b' D Texture groupC Consistence Structure I Mineralogyl ! ' HORIZON III DEPTH Texture group Consistence Structure I Mineralogyi HORIZON IV DEPTH Texture group Consistence Structure I Mineraloptyl SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE I. CLASSIFICATION LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-901 EVALUATED BY: /YU& OTHER(S) PRESENT: 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 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 Mineraloey 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/ftz L S,Vbn A17 4k4- .+0°�2 . \ �.(;� 4•,N t��j ods` P .`� ,{�'iri 9 �• n,q 7 A r ) 10 /�� cy SHAMROCK ACRES s ow�si�orvstont*6 Jrra- MW FA MUM tp. je�- PLACE 2C� PAVED A&AW 0294mle- ii) i✓ PEOPLES 01EW4r ROW AD`C: y c cG Ff/ J �c�l r O Cb f 910 ! 940-50" SHADY DAM COLOVY ACR7M CAROLINA roo o ne foo wo ` 1 �� °� c A ac" r9off 'r�CL y ar usEffm alftH 6610 v A W MMLE. NC 27026 q4 i o e ( 7041 492-16/6 !p