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253 Dublin Road Lot 12DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900050 Billed To: Wayne James Reference Name: Wayne & Jean James Proposed Facility: Residence Tax PIN/EH #: 5789-73-3688 Subdivision Info: Shamrock Acres Lot#12 Location/Address: 253 Dublin Road -27006 Property Size: 150x200 ATC Number: 2524 **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 #Bedrooms #Baths Dishwasher: d Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply_ Design Wastewater Flow (GPD) _Z�6 2) Site: Newpr�'Repair ❑ System Specifications: Tank Size/10� GAL. Pump Tank GAL. Trench WidthM e Rock Depth" oiLinear Ft..100 Other: Required 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 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** C c�� Health Specialist's Signature: � Date: , to, 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 #: 989900050 Billed To: Wayne James Reference Name: Wayne & Jean James racuny: mesiuence ATC Number: 2524 Tax PIN/EH #: 5789-73-3688 Subdivision Info: Shamrock Acres Lot#12 Location/Address: 253 Dublin Road -27008 A C^-nnn 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: G+ (� 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 I1 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 Pf time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Y Date: U.B. 176 P9. 302. N 06'29'03' E 925.00 z 150.00 150.00 510 150.00 150.00 r } 1 73 00 - z � z g z 00 � 5CD Z �.► • o m C:) o W W N m N cn oo o o (.i � Q (,j co O v o o o o n o ti w 10' unLr.y EASEMENTC z o - 150.00 ---- _ -- 150.00 - ' S 06' 103' k 949.46 ---150.0 --- ---- 150.00 ----' �- C, •x` . 909 / D URLIN ROAD 4.92 c c L 3) (PUBLIC) 1 - - -i 200.00 _ N 06' 29' 03' E-63 4. 92 (60' R/W - 20' PAVED) N 06'29,o3, E o - 170.00 ---- o Z - --- 150.00 r 114.92 6 10' LrnjjTY EASMINT • `.-/ -- • C7 �' 39.09 u w J b C z v o -4 w N O w N • �"' oW o 5 . C:) w F. �a C Q N W N 05'54'46' E f V V '" u$ �r o 199.42. A \' '' C:)� � U s � c '•.p..�9j �J 118.63 -1 125.94 31.3 14.06 122.50 122.50 N 06.29'03' E,:535.00 �y�° o G, o 0. JOo \ liCJ � �` ` •�\\ .puo � ry 0� S 0. hen Ae i 1 U �gCD o J ` DEED NORTH •� 9S o REF: D.B. Tia Pp. 113 .� U �1 C12 `C,`� N �� APPLICATION FOR SITE EVALUATION/IMPROVEMFM PERMR & A s R 1 O 19 D Davie County Health Department EnWivnmental //ealtb Sed 017 P.O. Box 848/210 Hospital street Mockaville, NC 27028 (336) 751-8760 ENVIRONMENTAL IHEALTH ***ZWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION I3 .PRIO^V1IDjjED.—R�e—fer to the INFORMATION BULLETIN for instructions. 1. Bass to be Billed ft`{nl�nn L, Iry/� ONST contact Person Halling Address �. t]. L'2'JX`..'� `, No. Phone City/state/SIP _AQ (� ICJ V / (_� /y '7 �'J4arl sines. Phone 2. Nerve on Permit/ATC it Diffsrmo//t then Abov@—J }A /:iC— /n, Meiling Address PO .PJO `S`-3/ City/state/sip %y%/f(/(_(!1/C Lei AY_ 3. Application For: ❑ Site Evaluation 4. system to Service: P House 5.. If, Residence: 6 People XDishwasher Improvement Permit/ATC ❑ Both 0 Mobile Home ❑ Business 0 Industry ❑ Other tl Bedrooms -9 i Bathrooms 19- n Garbage Disposal Wwashing Machine 6. If Business/Industry/other: specify type ❑ Basement/Plumbing # People XBasement/No Plumbing #Coemodas # Sinks # abusers # Urinals # water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallon per day) 7. Type of water supply: Coua ty/City ❑Well ❑Community B. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ANO If yes, what type? ***IMPORTANT*** CLIENTS MVSTCOMPLEMTHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESVBM17TED by the client with THIS APPLICATION. Property Dimensions: /5 D V- a Da WRITE DIRECTIONS (from MocW11e) to PROPERTY: Tax Office PIN: # 57 f1'9`� � _ � $ �' 80/ V4 7 ed les &-,- CL @ EZ&JJ1aj5 CW, RP a. M� c _ ice �y PrapertyAddrigs Road Name �S �e 3 (if�Cjy� �, /—E7 %n/T6 ISAW17L ac/G City/Zip Cls. *4'Le A&, /d 40 o%✓ o/✓ Ce,�t I If is a Subdivision Provide Information, as follows: /�,2lV2 -ty �`cs� c t� 2 G Name:�] /k!21)e0ce- f C -bj Section: Block: Lot: /"� Date Property Flagged' _7 - / 2 - 0 d 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, understand Mal l 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 D 8 / / - 0 0 SIGN=PLAN Cho THIS AREA MAY BE USED FOR DRAWING YOUR Snclude all of the followiB : Eustis property lines and dimensions, structures, setbacks, and septic locations). g g and proposed Revised DCHD (07/99) Date(s): Site Revisit Charge Date: TY -7 7 Account No. Invoice No 6 F 7 ' y y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �%f2 Soil/Site Evaluation NAME / ADDRESS �^12cC �CJ24o PROPOSED FACIELTY DATE EVALUATED ogJ �S PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well . Community Public 4 / Evaluation By: - Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position G Slope x HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure t 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: LANG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: 1 4 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 VVt�JIJ IGnI IiG ' Moist VFR-Ve-y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky 1 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/ftx