Loading...
128 Pinebrook Drive.\ 14 •I APPLICATIO OR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Boz 848/210 Hospital Street ! Mocksvil �u� 1 6 012 (336)753-6780/ IFax (336)753-1680 Applic W� rte Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of'Application: New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name Addres City/St Email Name Mailing Address Arer� ontact Person; Come Phone _ usiness Phone PROPERTY INFORMATION *Date House/Facility Comers Who votat�j NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Lep-t : `31 7 514 l Owner's Name " C:-:- t_l.�C--1J L fr Lt- f Gbf-C-75 Phone Number 0 . - I n Owner's Address %�-S3 Gl r©SS r,J n -rte City/State/Zip / aMocin- 4' G 7.7 0 / Property Address) 2 �S P��'J�f�re��� !�� - CityRoG -0-0, Lot Size 3 rj. /-n�,rGs Tax PIN# SL}ZZ00,10��?Qr Subdivision Name(if applicable) Section/Lot# V Directions To Site: t Zg Dx If the answer to any of the following questions is "Yes",support'}g documentation must be attached: Are there any existing wastewater systems on the site?.. ✓_Yes No (2, HOME 5/M --1'Z3 B%dDOeC d i Does the site contain jurisdictional wetlands? _Yes V No Are there any easements or right-of-ways on the site? Is the site subject to approval by another public agency? _Yes ,/No Will wastewater other than domestic sewage be generated? _ Yes ZNo IF RESIDENCE FIT J, OI JT THE BOX BELOW # People # Bedrooms I.-, # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No TF NON-RESIDF,NCE FIT I. OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type:� County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Po If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal re resentative signature 17, ate W 1 me,, 6 • Pxnitl/k pf 16!1 Site Revisit Charge Date(s): Client Notification Date_ : EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # 37�4 e PE7t 2 B �� NZ X200 ���� ./� Lo4- GoMAPS - Davie County NC Public Access i W � 0 s� C s x: -1-11r--,N 'NATERSHED STRUCTUF WATER -BODIES lra � �. Nt 4 ADDRESS ***WARNING: This map is prepared for the inventory of real prol deeds, plats, and other public records and data. U: primary information sources should be consulte County and mapping company assume no 1 \2(3 6 1 LBL 4 ��M PRI✓ l o- ZO moo$ 3IS IS NOT A SVEY!*** Wednesday, August 15 2012 ty found within triis jurisdiction, and is compiled from recorded c of this map are hereby notified that the aforementioned public Dr verification of the information contained on this map. The 0tesponsibility for the information contained on this map. 19AAvt�f 0m% D(Z--lsf f4t) M C S LO CA:' ! ©A� 5 �(� e,44 ����o/ T} Et) 'NATERSHED STRUCTUF WATER -BODIES a COUNTY -BOUNDARY 4 ADDRESS CONTOURS DRIVES STREETS k RAILROAD -CENTERLINE f PARCELS �7 201OAerial_Photos C€TY_LIM [TS BERMUDA RUN UCOOLEEMEE DAVIE COUNTY 71 M4OCKSVILLE 4 ��M PRI✓ l o- ZO moo$ 3IS IS NOT A SVEY!*** Wednesday, August 15 2012 ty found within triis jurisdiction, and is compiled from recorded c of this map are hereby notified that the aforementioned public Dr verification of the information contained on this map. The 0tesponsibility for the information contained on this map. 19AAvt�f 0m% D(Z--lsf f4t) M C S LO CA:' ! ©A� 5 �(� e,44 ����o/ T} Et) DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: E50000003301 Subdivision Info: Location/Address: 128 Pinebrook Drjyr)�27028�'. 17.400 Ac Date Evaluated: On -Site Well _ Community Auger Boring Pit ' Public Cut_ FACTORS 1 2 3 4 5 6 7 Landscape position C Slope%O /O 7 v HORIZON I DEPTH 0—/0 (- Texture group Consistence , Structure Mineralogy — r; HORIZON II DEPTH y . Texture group —C Consistence U 'r Structure L V_ Mineralogy' jzo - HORIZON III DEPTH Texture group c?L 5 Consistence V& Structure Mineralogy HORIZON IV DEPTH Texture group. Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE a L CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: i31TWX::,- (,4— GC EVALUATION BY: 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 clay 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 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 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 DCHD 05105 (Revised) Davie County Health Department Phone: 336-753-6780 Fax: 336-753-1680 © 9/© 6/ 2 0 1 2 Sugar Valley Airport 249 Gilbert Road Mocksville, NC 27028 'ARE: Application for improvement permit for: Tax Lot: Tax Block: Property Site: 128 Pinebrook Drive, Mocksvillc, NC 27028 Health Department File No.: 80614 - I Dear Sugar Valley Airport; D U V U ALJ North Carolina Public Health The Davie County Hcalth Department, Environmental Health Division on e s / a 9 / a o 1 a evaluated the above -referenced property at the site designated on the plat/site plan that accompanied your improvement permit application. According to your application the site is to serve a SINGLE FAMILY with a design wastewater flow ofdgallons per day. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 including related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule. 1900 and related rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: ❑Unsuitable soil topography and/or landscape position (Rule .1940) [] Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941) El Unsuitable soil wetness condition (Rule .1942) ❑ Unsuitable soil depth (Rule .1943) ❑ Presence of restrictive horizon (Rule .1944) ❑Insufficient space for septic system and repair area (Rule. 1945) ❑ Unsuitable for meeting required setbacks (Rule .1950) ❑ Other (Rule .1946) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, into surface waters, directly to ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, the Health Department has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and no improvement permit shall be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the soil scientist or environmental health supervisor at the local health department. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for informal review must be made in writing to the local health department. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 431-3000 or from the OAH web site at httpJhvww.ncoah.com/forns.html. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150E-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is 09/06/2012 Meeting the 30 day deadline is critical to your formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to serve a copy of your petition on the Office of General Counsel, N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, N.C. 27699- 2001. Do not serve the petition on your local health department. Sending a copy of your petition to the local health department will not satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, N. C. Department of Health and Human Services. You may call or write the local health department if you need any additional information or assistance. Sincerely, ENVIRONMENTAL HEALTH DIVISION —"WjtQ QM I I k *,RS H Environmental Health pecialist Water and Wastewater Section Encl.: (Enclose copy of site evaluation) (Copy of Rule .1948) 15A NCAC 18A.1948 SITE CLASSIFICATION (d) A site classified as UNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956, or .1957 of this section or a system approved under Rule. 1969 if written documentation, including engineering, hydro -geologic, geologic or soil studies, indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SUITABLE if the local health department determines that the substantiating data indicate that: (1) aground absorption system can be installed so that the effluent will be non-pathogenic, non infectious, non-toxic, and, non -hazardous; (2) the effluent will not contaminate ground water or surface water, and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people, animals, or vectors. The State shall review the substantiating data if requested by the local health department History Note: Authority G.S. 130A -335(e); Eff. July 1,1982; Amended Eff. April 1, 1993; January 1, 1990. NCDENR Division of Environmental Health On -Site Wastewater Section Soil/Site Evaluation For On -Site Wastewater System *Date: 0 9/ 0 6/ 2 0 1 2 *File #: 8 0 6 1 4 PIN *: E50000003301 *Owner Ellen c. Furches Proposed Facility SINGLE FAMILY Proposed Design Flow (.1949) Property Size 37.4 Location of Site 128 Pinebrook Drive Water Supply COMMUNITY Evaluation Method Pit Profiled 1940 Landscape POS Slope °'o Horizon Depth (IN) SOIL MORPHOLOGY .1941 Mineralogy Matrix Mottle Texture Structure Consistence Color Color Other Profile Factors 1 HS 2 % Saprolite: (in) .1 4 0-10 CL 1•Wea sbk fr S5 SP SiL 1-We3 gr .1942 wet. OPS 10.24 C 3-Stng abk vii vs VP .1943 Depth 24-48 SL 1-Wea gr fr ns np .1944 Rest. Horizon 1947 Class U EHS Horizon .1947 Class PS EHS Proole LTAR .—. • Profile LTAR EHS 3 HS 2 % Saprolite:(in) 4 0-24 C 3 -Sing abk vfi VS VP Profile LTAR Copy. Profile .1942 Wet, OPS Co rofile71 24-36 SiL 1-vlea gr fr VS VP .1943 Depth .1944 Rest. Horizon .tL947 Class U ENS LTAR 3 HS 3 % Saprolite:(m) 0-24 C 3-Stng abk vii vs vp .1942 wet. OPS 00PY rofile 24.48 SiL 1-We3 gr fr vs vp .1943 Depth oPS Saprolite:(in) .1944 Rest. Horizon .1944 Rest. 1947 Class U EHS Horizon Proole LTAR .—. • 4 HS 2 % 0-10 CL 1-Wea gr fr VS VP 1942 Wet, OPS f {` Co rofile 10-23 C 3-Stng abk v5 vs VP 1943 Depth oPS Saprolite:(in) .1944 Rest. Horizon .1944 Rest. .1947 Class EHS Horizon Profile LTAR _ .1947 Class U EHS Profile LTAR Copy. Profile Available Space (.1945) OtherFactors(.1946) Site Classification (.1948)N3 Initial LTAR: Repair LTAR: Others Present: Comments: Evaluated By: a4uu))QyJOA % Saprolite:(in) .1942 Wet. OPS f {` Co rofile .1943 Depth .1944 Rest. Horizon .1947 Class EHS Profile LTAR _ Available Space (.1945) OtherFactors(.1946) Site Classification (.1948)N3 Initial LTAR: Repair LTAR: Others Present: Comments: Evaluated By: a4uu))QyJOA NCQENR Divisioh of Environmental Health On -Site Wastewater Section Date: 0 9/ 0 6/ 2 0 12 Soil/Site Evaluation File * 8 0 6 1 4 For On -Site Wastewater System PIN #: E 5 0 0 0 0 0 0 3 3 % GPS Saprolite:(in) `Q EHS Copy—P—,rofil U 1940 Horizon SOIL MORPHOLOGY Profile# Landscape Depth .1941 Other Profile (IN) Mineralogy Matrix Mottle Factors Slope % Texture Structure Consistence Color Color % .1944Rest. Horizon 1947 Class .1942 Wet. Profile LIAR EHS .1943 Depth OPS Saprolite:(in) .1942 Wet. .1944 Rest. % Saprolite:(n) .1943 Depth Horizon W .1944 Rest. Horizon OPS CopyE,�JroTit I. 1947 Class 1947 Class EHS Profile PAR ,_,, .1944 Rest. Horizon 1947 Class Profile copy 60fde LTARProfil— TAR LTA R % GPS Saprolite:(in) `Q EHS Copy—P—,rofil U % Saprolite:Gn) .1942 Wet. .1942 Wet. OPS Copy Profil ❑ .1943 Depth .1943 Depth .1944 Rest. Horizon .1944Rest. Horizon 1947 Class Profile LIAR EHS OPS Saprohte:60 EHS CO rofil .1942 Wet. % Saprolite:(n) .1943 Depth .1944 Rest. Horizon OPS CopyE,�JroTit I. 1947 Class .1943 Depth Profile PAR ,_,, Comments: % Saprolite:Gn) .1942 Wet. OPS Copy Profil ❑ .1943 Depth .1944Rest. Horizon 1947 Class EHS Profile LTAR % Saprolite:(n) .1942 Wet. OPS CopyE,�JroTit .1943 Depth .1944 Rest. Horizon 1947 Class EHS LTARProfil— TAR Comments: 0�159ft rA INEBROOK 221, 128A I �MAIMWIIN 214*" 1 -GILOCRT RD 1 127, 1 113 -148, 7 44 2234 -e 245 2 / "2 24 1236, 1 1201 IA 142, > AvAl 0 mzis rOMARYAVrArZONJ JOE A: TUCKER D.B. 166, Py, 21 (tie > w�1onI {'t x'2966 I Iron I I I I I W QQn Y� I ROBERT BRUCE FURCUES WILL BOOK 2003—.,v-2'42 z REFERENCE: D.B. 63 PG. 39 PAa;wy �� O.s C. �• f r,por f fRT BRUCE FUPCHES BOOK 2003—E-2*12 REFERENCE: t]�7 ).B. f 08 , PG. 369 1 Q � jZg K 0 DRI Tri 1437 V) A 3cod iron � V M 0 W �II rylt` vGctionnike r 3 Of bods ' E --a— JONATR.. D.B. 3 AS OF AS PM M 0 ro", (293,06 totnu N 88'35'14' V JOB I. TUCKER I D.B. 166, Pg. 21 I I I 4 o I I I I I � I JONATHAN L. STARNES D.B. 394 , PG. 217 J ROBERT BRUCE FURCHES RILL BOOK 2003-E-242 REFERENCE: D.B. 63 PG. 39 D.B. 108 , PG. 369 ' J x noo,o u o.. PINEBROOK DRIVE S.R. 1437 ^ �TE KIOf633 LY�rsA 18 Rom .� -oa,e� M. RNEDROOHc DRWE Abt coal � Pep, � 4 CIIBEHf RD ivTE I ti run �� /yr M se nT v aAAle — � $ I -I 3&Af F co O O 4 TRACT 5 ROBERT BRUCE FURCHESOp ^ AREA - 6.015 ACRES + HILL BOOK 2003-E-242 EV C�.I Ii IMCS.RL DES REFERENCES: 4 f7 S.R. IsAREAA R/►'. D.B. 63 PG. 38 } "4 D.B. 63 PG. 40 3 t� D.B. 63 PG. 41 w J � �1r E Ren oAv7 we.0 TRACT 4 0 3[! PA" 0" a a✓ I ^ �TE KIOf633 LY�rsA 18 Rom .� -oa,e� M. RNEDROOHc DRWE Abt coal � Pep, � 4 CIIBEHf RD ivTE I ti run �� /yr TRACT 6 AREA - 8.040 ACRES v AREA INCLUDES S.R. 1437 Ic � To V h� I TRACT 3 SrE Pict o.Yr I b'c' VICINITY MAP 1. a TRACTS TOTAL 2. TOTAL ACWADE — 65.301 ACRES 3. MOVOE LOT SZE — 8.16 ACRES. 4. NO NODS GM YOMAENT WnWM 2000 FT. a. TM PROPERTY IS NOT LOCATED N A FLOW 201E AS DETFALNIFD BY FID I E THS PROPERTY 6 NOT LOCATED N A 'WATERSHED OVERLAY. 7../-1" ACM REUAR" N PARCEL E DANE O"TY WATER SNVL SERVE ALL a EOTS. !. EACH LOT SHALL HMW AN NOMDIYL SEP11C SYSTEI TO ME ARMWED ANO REO TED M THE D W IXILNTY HEALTH DEPARTMENT PLAT MAP: FURCHES FARMS AT PINEBROOK PAGE TWO OF TWO OWNER ------------------ DEVELOPER ELLEN C. PURCIIES 126 PINE BROOK DRIVE MOCKSVtLU, N.C. 27026 (336) 998-2278 FARMINGTON TOWNSHIP DAVIE COUNTY, NORTH CAROLINA DATE: AUGUST 20, 2008 TAX MAP REF.: E-5, P/0 PARCEL 33.01 PIN/ 5841974322 SURVEYED BY: TUTTEROR SURVEYING COMPANY 107 NORTH SAL58URY STREET MOCKSVILE, NC 27028 (336) 751-5616 1' - 150 150 75 0 150 300 450 SCALE IN FEET n� HAAAc: coo«o N.uHE: orswvnrac HuueER: FURSTAT2 JOETUCKI\61 15508-36 SHEET 2 OF 2 � $ I -I wk q cc I- �hw IQ } "4 �ko 3 t� w i � agggyy R w eraa• v w wavr v —� GILBERT ROAD TRACT 6 AREA - 8.040 ACRES v AREA INCLUDES S.R. 1437 Ic � To V h� I TRACT 3 SrE Pict o.Yr I b'c' VICINITY MAP 1. a TRACTS TOTAL 2. TOTAL ACWADE — 65.301 ACRES 3. MOVOE LOT SZE — 8.16 ACRES. 4. NO NODS GM YOMAENT WnWM 2000 FT. a. TM PROPERTY IS NOT LOCATED N A FLOW 201E AS DETFALNIFD BY FID I E THS PROPERTY 6 NOT LOCATED N A 'WATERSHED OVERLAY. 7../-1" ACM REUAR" N PARCEL E DANE O"TY WATER SNVL SERVE ALL a EOTS. !. EACH LOT SHALL HMW AN NOMDIYL SEP11C SYSTEI TO ME ARMWED ANO REO TED M THE D W IXILNTY HEALTH DEPARTMENT PLAT MAP: FURCHES FARMS AT PINEBROOK PAGE TWO OF TWO OWNER ------------------ DEVELOPER ELLEN C. PURCIIES 126 PINE BROOK DRIVE MOCKSVtLU, N.C. 27026 (336) 998-2278 FARMINGTON TOWNSHIP DAVIE COUNTY, NORTH CAROLINA DATE: AUGUST 20, 2008 TAX MAP REF.: E-5, P/0 PARCEL 33.01 PIN/ 5841974322 SURVEYED BY: TUTTEROR SURVEYING COMPANY 107 NORTH SAL58URY STREET MOCKSVILE, NC 27028 (336) 751-5616 1' - 150 150 75 0 150 300 450 SCALE IN FEET n� HAAAc: coo«o N.uHE: orswvnrac HuueER: FURSTAT2 JOETUCKI\61 15508-36 SHEET 2 OF 2 r o 'Permittee' s _ DAVIE COUNTY HEALTH DEPARTMENT ^ S f Name: ,,rt -k.�•'-f i. +� .�'�`J � - °� ' invironmental Health Section PROPERTY INFORMATION �� ���� fQ P.O. Box 848 Directions to ro ert . f e ' '"7'�°'L P P Y Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: " AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO. 2 A Road Name: Zip: 10 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TY P �sSr �# PSL PLE # PEOPLE/SHIFC #SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY` ? DESIGN WASTEWATER FLOW (GPD) NEW NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: `TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH f ROCK DEPTH LINEAR FT. 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT o "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02 (Revised) 1 ! 1 **NOTE'S* This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Bpilding Permits. ' (16 compliance with'Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1111J/1V 111V1VLt111V1\fV11J1 r, n Gll <.Vl\J1 RlJl. 11V1\ t' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS T-� # BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE %f 4 �# P LE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY %'' DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I' SYSTEM SPECIFICATIONS':',.TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH S f' 'ROCK DEPTH ✓ t` LINEAR FT. rVirLICD REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ti J **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. SYSTEM INSTALLED BY: 11 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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. DCHD 07/02 (Revised) f _ PIq -- ��rnvttee% DAVIE COUNTY HEALTH DEPARTMENT T ,.'Name: " Ar, f :' /f' '- environmental Health Section PROPERTY INFORMATION ' P.O. Box 848 ' � per: " chdfis to property: >/ .. Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: ' r" AUTHORIZATION FOR WASTEWATER - - Tax Office PIN:# _ SYSTEM CONSTRUCTION AUTHORIZATION NO:7 A Road Name: Zip: **NOTE'S* This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Bpilding Permits. ' (16 compliance with'Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1111J/1V 111V1VLt111V1\fV11J1 r, n Gll <.Vl\J1 RlJl. 11V1\ t' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS T-� # BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE %f 4 �# P LE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY %'' DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I' SYSTEM SPECIFICATIONS':',.TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH S f' 'ROCK DEPTH ✓ t` LINEAR FT. rVirLICD REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ti J **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. SYSTEM INSTALLED BY: 11 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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. DCHD 07/02 (Revised) f _ _y DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems ,�Jr`��';�5; Permit Number Name.?; �r„r,^ t'% . '. !�•,, 0. > i 2214te /f� / '/� N2 S 17 3 Locations r'i5 u� �)' ” /i, ,::V, 11 t;11' .<<%'� r Subdivision Name Lot No. _ Sec. or Block No. Lot Size ; (`_ House Mobile Home _ Business Speculation No. Bedrooms Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply _ No. Baths J No. in Family YES ❑ NO ❑ Specifications for System: YES ❑ NO YES ❑ NO ❑ *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by T)- --Ls 'S W \N3 Certificate of Completion Date *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT "17 �. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems,:;Y;��Y Permit Number Name rr % ,�"��{?ate % / l _ c _ .� J /V L�� ! lam! `, �f _ - r i ��r^ 'd��`- ,;,'�Y�y /'• '/ ,- Location i — r Subdivision Name Lot No. Sec. or Block No. Lot Size /ril(, House Mobile Home — Business Speculation No. Bedrooms — No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ _ 1 Auto Wash Machine YES ❑ NO ❑ Type Water Supply --- *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. Improvements permit by - ki- *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion --Date I `� *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. 0 WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT p NAME==�'�22�1LT�Q/1 PHONEJiUMBER CU`/- c%" ADDRESS SDIVIION NAME SUBDIVISION LOT# ! ef''� DIRECTIONS TO SITE ' v� DATE SYSTEM INSTALLEDhy NAME SYSTEM INSTALLED UNDER SPECIFY PROBLEMS OCCURRING �� Z �� "'�� DATE REQUESTED INFORMATION TAKEN BY