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288 Armsworthy Rd � - DAVIE COUNTY HEALTH DEPARTMENT ��//�`Z�� . ` Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000816 Tax PIN/EH#: 5861-66-6110.02 Billed To: �olet Arms�nrorthy Subdivision Info: Reference Name: Wayne Frye Location/Address: Armsworthy Road-27006 Proposed Facility: Residence Property Size: 1.5 Acres ATC Number: 2231 **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 {7� #People #Bedrooms � #Baths�_ Dishwasher: U Garbage Disposal: ❑ Washing Machine: �" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �i s J� C Type Water Supply-�� Design Wastewater Flow(GPD) `S 6� Site: New�Repair❑ �� R System Specifications: Tank Size�DD�GAL. Pump Tank GAL. Trench Width �lo Rock Depth /� Linear Ft. .:�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFF'LUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m . p.m.on the day of installation. Telephone#is(336)751-8760.**** �� ��SL I`� � 3 � ,�� �� / �J � /' Environmental Health Specialist's Signature: � . �- � Date: �J`'�o2 y�� DCHD OS/99(Revised) ,� . ��`er-�,��� . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990000816 Tax PIN/EH#: 5861-66-6110.02 Billed To: volet Armsworthy Subdivision Info: Reference Name: Wayne Frye Location/Address: Armsw�orthy Road-27006 Proposed Facility: Residence Property Size: 1.5 Acres ATC Number: 2231 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: •�Date: /�—/��7� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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: Environmental Health Specialist's Signature: Date: �"��-Q� � DCHD OS/99(Revised) A �' � 1 t - � � � '� � APPLICATION FOR SITE EYAI�lAT10N/IMPROVEMfM PERMR ����� l5 � Davle County Health Oepartment Q �� � Env�itonme�tta!Hea/tfi Sec�fon �� p.o. Box 8�8/210 �otpital BtrNt OC� l � �999 pj�' . Moak�vill�, NC 27028 � �� (336)751-8760 ��VlROUh���T�1L HEALTH bp.'•JIE COU_NTY �+►+►IHPQRI'Al4T+►** TA28 71I+pI.ICl1TICN � � PROC�BBSD UNLa88 `�l'� ItaQUIRaD IN�'01t�ATi02i i8 �AOVIDF�D. R�lor to th� tNa'ORM1lT=ON StII.I+�TiN !or instruatioaa. �. uan. e�o�.—s��1.a � �/ns1l�� coac.ot �.r•oa 1 � �� ��� �... � L 1� .a.. �. �/ — F� 3� � ' cihr�■t�a�::a 14�U�l�C� �(.fG o� �� su.s�... �. Z. xw on �sait/�TC 1! pitt�r�at tban �bo�� 1lailiaq �dds��• City/Ytat.�/iip a. 1►ppiiaatioa tor: ,�.8i.�t-�s�ua�tioa 0 Improvsm�t p�ssit/1LTC �Both �. eY.c.. co �.�w� 1�8ons� 0 MAbil� Homs � Busin�sa 0 iadu�tsy � Oth�r a. i! R��idu�o�s i p�opi� f B�drooma _ � Bsthrooms �_ 0 oi.h,r..b�r o oarb.�o. ai.po..l o �a.ninQ wobsa. o s.,.arat/pl,absaq n s.,.�.nt/�to alu�bsaQ �. st su.1s►.../I��S•esY/och.s� sp.nsl�r lyp. � p.o�rl. f �swax. � Coa�od�� i Ybo�nr� ! Oriaal• f Nsbr Cool�ss =t �'00�8=RVIQ: � S�ata =stimi�d Nat�r Oaaq� tvu�• � a•Y� T. Typ� o! xat�r suppiys 0 Connty/City �lf�ll 0 Commuaity a. Do yon andcipate addiHow or e��adon�oi t6e fncility t6V ryatem b intended to�erveT 0 Yea �No Itya,w6�t type? *"*JMPORTANT''**CWENf3 MUTT C10MPLETETHE REQUIRED PROPERTY INFORMATION REQUESfED Elt6er�PL.AT or SITE PLAN MUST BBSUBMI7TED by the cUent �vlth TNI3 APPWCATION. l i� , � r�1/:j- F AC/G. � Prope men�ionu_'J/ � �l��.A� S✓DL'S: � � R+RITE D1�tECRONB(from Mak:vtlle)to PROPERTX: Ta:081ce PINt #����' �D��� �2/nSll�D�hU �14�1 '1 Prop�rty Address: Rad Name �1.(7U r !t�%�G DJ�'� �lul� ^ �n �Y�i � CitylZip�U��uc�. ��2�oob Yaca•-r� � DL{S��i I[in�Sabdivbion provtde Informsdoa,ou foUaMs , N�mes �T t� �G ' SecHons Blockt � Lots D�te Property Fis�eds �G"�/-Y'� T6te b to certi!'y t6at t6e InfbrmsHon pravlded b con�ect to t6e best oi my knuwledga I ander:tand t6�t�ny permit(�) lasaed 6eceafter�re�object to�aspen�ton or revoaiHon,it the dte pltnt or Intended ua�c6an�e,or if the Iotorm�Hon �abmitted io t6b appllcallon V falettial or c6anQed. J,aLso,anderatand tJiot I am ruponslble jor all cl�arges lncumd frorn t1ils applJcadon. I,6enby,�ive cowent to the Ant6orized Rspnuubtive ot the Davie Coadty Health Department to enter npon�bove dactibed property laated in Dsvie Coanty and a�vned bp to condact aq tattn�procedara u neeeaary to detecmine t6e dte�attabWty. DATE �D— Ir=GI � SIGNATURE , •O� . THl3 AREA MAY BE USED FOR DRAWING YOUR S1TL PLAN(ln¢lu sli of t6e follo�vinQ: E�sHn�snd propaed property Uaes sqd dimewioni, ttractwa, utba¢ki, �ud aptic loc�Hon�). • 8ih Revbtt Ch�r�e / Date(�): ` 1 Client NoHBcaH�n Dste: 'N ,�(�� EA3: M1`� 7l, Accoant Na �/tv Revtaed DCHD(07/99) Invoice Na ��`�� � •• , , � . ^� , + . ;� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section S ��� Soil/Site EvaluaHon APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000816 Tax PIN/EH#: 5861-66-6110 Bilied To: Violet Armsworthy Subdivision Info: Reference Name: Ricky G.Armsworthy, POA Location/Address: Armsworthy Road-27006 Prpposed Facility: Residence Property Size: �!lAcres Date Evaluated: /�`/�l'� /�.5'�c. 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 p'' 3p ' Texture rou Consistence � � Swcture ( / Mineralo ; ,' HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Q LONG-TERM ACCEPTANCE RATE < < SITE CLASSIFICATION: ��� EVALUATION BY: i 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-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 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) ■������■■■■����������■■■�■■��■�■���■■�■�����■�■���■■����■��■■�■��■ ■�■��■��■■■�■�������■�■■■����■��■�■�■�■���■��■����■������■��■��■�■ ■�������■�■�■��■���■■�■■■■�����■�■■■�■■■�■��■��■�■�■■�■■���■��■■ ■■�����■■�■�������■���■■�■���■■■ ■■■�■■■■■����■��■��■■�■�����■��■ ■������■■■■■��0�■A■■��■■����■■�■■���■�■■��■�■�■■av■�\■■■■�■�■�■��■ 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