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263 Dublin Road Lot 13y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001551 Tax PIN/EH #: 5789-73-3893.1 Billed To: Stacy Lavery Subdivision Info: Shamrock Acres lot #-1B Reference Name: Location/Address: Dublin Road -27008 Proposed Facility: Residence Property Size: see map ATC Number. 2899 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 .1 00 Sewagr1A ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CO NID FOR APERIOD OF FIVE ARS. Environmental Health Specialist's Signa 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. 5100 �2,�tO . r FtQ�T 2 UCS 110 x36•K� er.),4 LV TPTAY-Mm -3 A7-;�sPa�*rdJ[Ovb/�oT �GC [/lSi��I`) Septic System Installed By: /v` lam+' Environmental Health Specialist's Signature • DCHD 05/99 (Revised) a Account #:990001551 Billed To: Stacy Lavery Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5789-73-3893.13 Shamrock Acres Lot # 13 Dublin Road -27006 see map ATC Number: 2699 **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. Residenti al Specification: Building Type�6OSli #People Z #Bedrooms '1 #Baths 3 S� Dishwasher: Garbage Disposal: ❑ Washing Machine: lid Basement w/Plumbing: Er Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size I SO'' -200 Type Water Supplyi3OV TyDesign Wastewater Flow (GPD) 4 00 Site: New C� Repair ❑ System Specifications: Tank Size 1000GAL. Pump Tank GAL. Trench Width&; Rock Depth Linear I�t7cGSI IQSTALL LI. -]`S Other: 2 'moi S TtZa (3J i i OJ 9 J.G. n,Aa rJ. 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 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.**** APP2otc.,—io'm�a. � ��?ST;:� e.e,.� 'L•ie �S 4541 ho ox, cicJs>✓ AtS 5' To Nouse. � � G II DCHD 05/99 (Revised) Specialist's IF 3aotz &ebOE of H00S0 F00^11MT-XV.3 of �� I ' D.I IZ %.Z % U_ m�L e PIMP DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation .. APPLICANT INFORMATION ' PROPERTY INFORMATION Account #::990001551 Tax PIN/EH #: 5789-733893.13 Billed To:,' Sta Lave Subdivision Info: rShamrock Acres Lot # 13 cY �N Reference Name: Location/Address: Dublin Road -27006 Proposed Facility: Residence Propert y Size: 150 x 200 Date Evaluated: D - , Water Supply: On -Site Well Community Public . Evaluation By: "' Auger Boring ... / .' Pit • - Cut : FACTORS 1 2 3 4 .5 6 7,. Landscape position Slope % HORIZON I DEPTH . Texture groupCL Consistence Structure . Q Mineralogy HORIZON H DEPTH Texture groupG . Consistence Structure MineralogyI� HORIZON III DEPTH Texture group Consistence g Structure L Mineralogy; HORIZON IV DEPTH . Texture group Consistence Structure. .. .. Mineralogy SOIL WETNESS .: RESTRICTIVE HORIZON ' SAPROLITE CLASSIFICATION • S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE:01 OTHER(S) PRESENT: REMARKS: LEGEND,; Landscape Position CC =Concave slope -'Convex Linear lope FS - Foot slope N - ; Nose slope R - Ridge . S -,Shoulder T.- Terrace FP - Flood plain . H.- Head slope ,. Textur ' S - Sand' .. LS - Loamy sand SL - Sandy loam . L - Loam SI'- Silt SICL -Silty clay loam SIL -'Silty loam CL - Clay loam SCL - Sandy clay loam SC -'Sandy clay SIC - Silty clay C - Clay CONSISTENCE. Mois i - VFR - Very friable FR - Friable FI = Firm VFI : Very firm EFI Extremely firm Wet y . .., NS -Non stick 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 OR - Granular ABK - Angular blocky i. 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/ft2 DCHD 05/99 (Revised) 200 l -"C) 4909 \ CP to 3688 2nn r 200 IT 15 w ^� 6963 cn i 21 LO o: o i 6754 r 23 i 200 l -"C) 4909 \ CP to 3688 2nn r 200 IT 15 w ^� 6963 cn i 21 LO o: o i 6754 r 23 �`. APPLICATION FOR SITE EVALUATIO1V/16IPII0vF3lENy pEliM171Y & All Davie County Health Department D Enviro848/210 Health ospi Section P.O. Box 848/210 Hospital Street 2 5 Mocksville, Kc 27028 F1 / W (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 BilledContact Person _Ly l_dUP ( y g loo iUel�bsTrc�� jnT-�— Mailing Address _�"'/`� Z.- Vb g4 I Home Phone . � city/state/zIP ._ �cICSy: �Le /tfC ++--z``� � � —Business Phone 2. Name on Permit/ATC /cif /Different than Above lm!y i L� y�.�(ry�erMwAl,( '�{r City/State/Zip {firmiyice AIC '�L40-O6 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC GBoth 4. System to service: 940use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: fl People 2. 1 Bedrooms _j1� g Bathroomso� tel/LIAS wfiahwasher ❑ Garbage Disposal n-Waa hing Machine \/Basemant/Plumbing D Basement/NoPlumb 6. If Business/Industry/other: Specify type # Commodes # Showers IF FOODSERVICE: # Seats ing # People # Sinks # Urinals # Water Coolers Estimated Water Usage (gallons per day) 7. Type of water supply: Q-'60unty/City ❑ Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes; what type? ❑ Community ❑ Yes 540 ***IMPORTANT*** CLIENTS MUSTCOMPLETETIIE REQUIRED PROPERTY INFORMATION REQUES'T'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED bythe client with THIS APPLICATION... Property Dimensions: 15-0 Y .I U o Tax Office PIN: # Property Address: RoadNamepc, 1Al?h J, City/zipAj()p(Nec ,',1.-7-0OZo If in a Subdivision provide information, as follows: Name: 611%N n A -Cy e S Section: Oqo Block: _} Lot. WRITE DIRECTIONS (from Mocissville) to PROT'ER'1'1': 4a AKS+ R61 ao Y�L zea- dN Ada of (prep IC �?�. GSC 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. 1, also, understand that I am responsible jor all charges incurred from INS application. I, hereby, give consent to the Authorized Representative of the Davie County Ifealth Department to enter upon above described property located in Davie County and owned by�8 to conduct all testing procedures as necessary to determine the site suitability. /7 DATE /-05-- eq SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include property lines and dimensions,tructtures, setbacks, and septic locations). 50 1 t •- �j _ Revised DCHD (07/99) Existing and proposed Site Revisit Charge Date(s): Client Notification Date: Account No. Invoice.No. !'l1 - k'Nb