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1726 Angell Rd �� >> DAVIE COUNTY HEALTH DEPARTMENT �'•��- S�=ad Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)75]-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001120 Tax PIN/EH #: 5821-82-4976 Billed To: RiCky McKnight Subdivision Info: Reference Name: Ricky McKnight Location/Address: Angell Rd.-27028 Proposed Facility: Residence Property Size: 208.70 X 419.4 **NOT�*��liib Impro4e�ment/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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 PERNIIT 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 /�'j ,K/� #People .S #Bedrooms� #Baths� Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �I�J� Type Water Supply i,� !�Design Wastewater Flow(GPD)� Site: New� Repair❑ i System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�� Rock Depth/�� Linear Ft:��� Other: Required Site Modifications/Conditions: • IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6°�BELOW FtNISHED GRADE. ****NOTICE: Contact a represen ative fthe Davie County Health Deparhnent for final inspection ofthis system between 830 a.m.to 9:30 a.m. or 1:00 p.m.to 1: 0 m.o the day of installation. Telephone#is(336)751-8760.**** � 1" , , Environmental Health Specialist's Signature: • � '�J� �=�'"L� ' /� � Date: ,��� y�L�� DC�ID OS/99(Revised) �� � ti DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001120 Tax PIN/EH#: 5821-82-4976 Billed To: Ricky McKnight Subdivision Info: Reference Name: Ricky McKnight Location/Address: Angell Rd.-2702$ Proposed Facility: Residence Property Size: 208.7Q X 419.4 ATC Number: 2404 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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: � `�.� �A.�� ' �Date: `S'—`� `G�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicat he s tem scribed on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.C apter 30A ection.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a aran ee th the system will function satisfactorily for any given period of time. � �� I,� � � Septic System Installed By: Environmental Health SpecialisYs Signature: __����� Date: ���` � � DCHD OS/99(Revised) , ,� � ' � `' ' APPUCATION FOEi&�TE EIlAWA910N/oMPR�VEMEM'PERMIT& t-5 � � � " � � Davie County Health Depar[ment Envinvnment�/Hea/tfi 5ec[ion � � 4 2000 P.O. Box B48/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENVIRDOVIE�COUNTy ALTH ***II�ORTANT*** THIS APPL2CATYON CANNOT �E'PROCESSED TJNI,ESS ALI� THE REQUIRED INFORI�ITION IS PROVIDED. Refer to the 3NFORMATION BULLETIN for instruction�. 1. Name to ba Hilled + � � t.- ' � Contact Peraon ` Mailing 7►ddreas �`7� V p r� Q� , _ Home Phone (�vlp �'� � City/State/2IP �( ,,�('�j���/�i N,�� y�� (� Suaineas Ph ne�� _ �-,JG/ �1[ICA. 7��,-10/n�� J�2 t(�_Y' _ __ _ �-- 2. Nama on Permit/ATC :.! Differont than Above Mailinq Addresa , City/State/21p 3. Application For: ❑ Site Evaluation ❑ Improv+ement Permit/ATC � ot'a 4. Syatem to ses,►iaa: � House �Mobile Hom�a ❑ Business Q Industry ❑ O�..her s. if Residence: N People �_ � Bedrooms _� q Bathrooms � F�Diehrasher f-1 Garbage D.'.sposal lK Waehing Mactiine II Hasement/Plumbing fl Hasement/No Plumbing 6. I! Buaineae/Induatry/Othar: Specify type � People � Sinka � Commodea / Shoxera � Urinals # Water Coolcsra IF FOOD£ERVICE: # Seats Estimated Water Usage (gallona per aaY) � .. :y�, r�� wa�ar r,uppiy: ll Coun�y%Ci'�;� �'Well 0 COm�muriity e. Do y�oi�anticipaae ad�ditions or eapansions of the facility this system is intended to serve? ❑Yes �o If y�es,what ty�c;? ***IbtPOI��''ANT***CE.IENTS MUSTCOMPLETiE"i'HE RE�UIRED PROPERTY INFORM!yTlal��►�QUESTED BEL�JW. E�21her a pL.AT or SITE PLAN MUST BF,S''S161I7TED by the client with TH6S,QP?��ICATION.. Property Dimensioaas: o(� ,4 � WRITE DIRECi'IONS(from 11�Eacksville)to PROPERTY: Ta�a Office PI�T.��� 5��I �O o�-��� ' �f>� ` �— Fr�perly Address: Road Naroe �L�P,��.�, � � � (Yl L��S (�� 1 e 1 1 _ Ce:ry/Zip��'.�S�J/�� /�C 1 ,1(_S�t . ,a�1Qa.� If in a Subdivision provide�nfore.ation,as follows: Name: Section: Block: Lot: Date Property Flagged: ,�� l/�� � This is to certify t6at the information provided is correct tQ the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocatioa,if Che site plans or intended use change,or if the information submitted in this application is falsified or c6anged I,also,understanJ tha[1 am responsible jor oll charges incurred jrom lhis app[lcatlon. I,hereby,give consent to the Authorized FtQpresentative of t6e l�avie County Health Department to enter upon abQve described property located in Davie C::;+mty and orvned by �o�� PY1. F'Q v-e.b P P to conduct all testing procedures as necessary to determine t6e site s ita�^a' DATE ��/�"�� SIGNA � THIS AItEA MAY BE USED FOR DRAWING YOUR ST:'E PLAN(Include a.17 of the following: �zisting and proposed property lines and dimensions, structures, setbacks, and��ptic��:.'.�o��). , ► � �i►e Rewi3it Charge ! ' Date(s): Client NoNfication Date: EHS• Account No. ��� Revised DCHD(07/99) Invoice No. 7 �� 482 517 M N N Q f'k (384) 2252 319 290 396 205 (30.84A) 4976 ^ a � o E400000016 � a �10.17A) (9.14A) ^ ^ � � 0768 (12.32A) v o 3767 7713 �9 g (1.53A) � 2502 • '� 83 ' � '' : 2258 �. �, a � � N � �_ "�^�F� � . ....-... .. , - (399) 327) DAVIE COUNTY HEALTH DEPARTMENT .. . . � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001120 Tax PIN/EH#: 5821-82-4976 Billed To: Ricky McKnight Subdivision Info: Reference Name: Ricky McKnight Location/Address: Angell Rd.-27028 Proposed Facility: Residence Property Size: 208.70 X419.4 Date Evaluated: ,�`/-�_ Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring - Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � �. Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �' � �' Texture rou G Consistence Structure /L -� r Mineralo ; HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � � SITE CLASSIFICATION: � EVALUATION BY: / LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 CONSISTENCE 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-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloav 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-gaUday/ft2 DCHD OS/99(Revised) ■������■■■��■■�������■■■����■��■����■■�■���■■�����■■��■�■■��■�■�■■ ■■��■�����■�������■��������������■�����■�■�■����■�■■������������■■ ■����■■■�■���■■�■�\��������■■��■�■�����■■■�����■■�������■���■�■�■ ■■����■�■■�������■�■■���■�■���■■ ■■���■■■■■�■�■■■����■■�■�■�■■■�■ ■�■��■��■�■�■��■�e��■��■�■������■�■■���■�■■��■��■S�■■��������■■■�■ ■■���■���■���■�■�■■����■��■����■■�■■■��■■■��������������■��■�■�■�■ ■��■■���■��■�■���������■��■■���■■�■■����■■�����■��■��■��■■■■�■��■■ 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