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522 Baltimore Rd - DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section /� 2 ' j P.O.Boz 848/210 Hospital Street %` ��/� � . • �' , . Mocksville,NC 27028 (336)751-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 989900610 Tax PIN/EH#: 5861-73-9399 Biiled To: Paul Boger Subdivision Info: Reference Name: Paula Goheen Location/Address: �Baltimore Road-27006 Proposed Facility: Residence Property Size: 125 x 400 ATC Nurrlber: 3155 **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 •Z Dishwasher: � Garbage Disposal: 0 Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing:� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ i��) � �,.,�J Lot Size �� "''(�'� Type Water Supply �"'�7 Design Wastewater Flow(GPD)�� Site: New� Repair N r► , 1 System Specifications: Tank Size�O� GAL. Pump Tank GAL. Trench Width� Rock Depth �2 Linear Ft.� Other: � �1S ��TTIO��T4L1. i.�1,�JVS ��O.�'—, M,lc1. Required Site Modifications/Conditions: __ 4�TQU- 0'J ��f�� 0� (�t%, KL;`��P�p'�U'� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G��BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis s}�stem..between 8:3.D..a.m.�o 9:30 a.m.or 1•(L�m to 1:30 p.m.on th��nf installation. TelephQne�is(336)751-8Z(.�*** r �,�� U�� +J p � � ( s � ��p � Z M��. a ��'� t� �5� op � G_ � � X a . �� N Pa� u�� _—��,M��. Environmental Health Specialist's Signature. Date: ��y U Z � DCHD OS/99(Revised) ' � �—� � ' DAVIE COUNTY HEALTH DEPARTMENT •, ' . ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33()751-87G0 Account #: 989900610 Tax PIN/EH#: 5861-73-9399 Billed To: Paul Boger Subdivision Info: Reference Name: Paula Goheen Location/Address: �Baltimore Road-27006 Proposed Facility: Residence Property Size: 125 x 400 ATC Number: 3155 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 WASTEWA CO ON I R A PERIOD OF I YEARS. Environmental Health Specialist's Signa e: Date: J`� � �?i 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. .f-�7- ►�-t��SS 2��' s � so x34��i" (,o' � -�io j An�k �� 8�0� (0-3! Septic System Installed By: (�1''� Al�=�� _.---. /� ��2 � Environmental Health Specialist's Signature: D te: , DCHD OS/99(Revised) . � w . � �1� �1� '�� ;T: •� ~ G� „ ..'`• • O� ��' UCATION FOR SITE EVALUATION/IMPR�VEM6°51T PEIiMIT&�ATC ,r" � � Davie Coun Health De artment � ' �G ' �� tY p '�,. � �C�� Environmenta/Hea/th�ection � �,. ,..: O � '� � P.O. Box 848/210 Hospital Street � , ` � ��- � �,� Mocksville, NC 27028 � i��. ' �`�-.,�'� � � �� (336)751-8760 6s � �` �„��_ J(�,�s,,. �" NM��N� �� ' .�,�-: f � *** � � T*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUlfRED 4 � INF TION IS PROVIDED. Refer to the INFORL�,TION BULLETIN for instructians. � /� q,�r��J�;'� 1. Name to be Billed ;r Gt l,� f � �D G1�P �- i,.' �a d . Contact Person Mailinq Address �a.�- � � �i�Y�OY�e pC � Home Phone��9 � ' � / 9 � City/State/ziP �(� (�� 1/C�P YI/C_ O� ��O �, Susiness Phone ��-r.-c—" 2. Name on Permit/ATC if Different than Above Mailing Address ��t��.�((��a!1 P P,✓ City/State/Zip ' � S` �3-�t�- � 3. Application For: Site Evaluation Improvement Permit/ATC ❑ Both 4. System to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People .S # Bedrooms � # Bathrooms � P ��l' {�(� �2�pL AYDishwasher ❑ Garbaqe Disposal I�Washing Machine �Base�ent/Plumbing I Ba ent/No 1 ing 6. If Business/Industxy/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gaiions per day> 7. Type of water supply: �ounty/City ❑ Well p Community e, Do you anticipate additions or expansions of the facility this system is intcnded to scrve? ❑ Ycs `�l No If yes,what type? ***IMPORTANT***CLIENTS t�fUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUB�1fI7TED by the client witli THIS APPL[CATION. )� � Property Dimensions: ��i X y-,�� WRITE DIRECTIONS(from Mocksville)to PitOPGRTY: Tax Office P1N: # �� 7'� . � 3 I��/ 't6lt! r / ��G�� Property Address: Road Name ��f i ��,� � FC� � ; �/,f � e✓ ��I T �tY��Y-� (�� city�zip �� r� � � �� f-f,� r� �-P p�v R►G `i-f �,1�as� If in a Subdivision provide information,as follows: ��1�a n�,0 I�D t5�'� L`P � t lYame: �[ �;,�;,��a � -� Section: Block: Lot: Date Property Flagged: o� � 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 sus�ension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsifed or changed. I,also,understand tl:at I am responsible jor nl1 ckarges i�rcurred from this application. I, hereby,give consent to the Authorized Representative of tl�c Davie County Health Department to enter upon above described property located in Davie County and owncd by to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE GL�� U THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). �� J.�� Site Revisit Chargc � � �� " �f'� s-S l� o z nat��s>: �q,�,,,l�. �.�v�'1 �-e"� Client Notification Datc: � ��--.,..� ,��c'c::� � y EHS: • � � � / � �` kl _�� d..� S 1`5P r `-'� ' Account No. U� l9 � � �Z � �-1-"�� Invoice lYo. / �0 `� Revised DCHD(07/99) � ��?� � � ��f�. �, : � DAVIE COUNTY HEALTH DEPARTMENT . ' � • Environmental Health Section '• • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900610 Tax PIN/EH#: 5869-73-9399 Billed To: Paul Boger Subdivision Info: Reference Name: Location/Address: 522 Baltimore Road-27006 Proposed Facility: Residence Property Size: 125 x 400 Date Evaluated: S�-�5—��- 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 Consistence Structure Mineralo HORIZON III DEPTH �' Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence S[ructure 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-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 CONSISTENCE Mois 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 Mineralogv 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) �a� � � � � �R Y ', 19 �- � �9 � ��. , � . � � � N . 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