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213 Bean Rd
• a DAVIE COUNTY HEALTH DEPARTMENT �I �'���� ` Environmentai Health Section � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990000719 Tax PIN/EH#: 5745-92-081 Billed To: SCott Shaver Subdivision Info: Reference Name: Scott Shaver Location/Address: Bean Road-27028 Proposed Facility: Residence Property Size: 2.84 Acres ATC Number: 2134 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �f #People�_ #Bedrooms �S #Baths�_ Dishwasher:�� Garbage Disposal: Q�Washing Machine:�� Basement w/Plumbing: �� Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � ,. ��t// ��,� v Lot Size �' Type Water Supply Design Wastewater Flow(GPD) Site: New�Repair❑ System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width�rRock Depth,���Linear Ft.�� Other: � /'8 .0 '��a' i • � ,7� � �r 7` Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT 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.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** r �j Environmental Health Specialist's Signature: , . Date: �fli�_ DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000719 Tax PIN/EH#: 5745-92-081 Billed To: Scott Shaver Subdivision Info: Reference Name: Scott Shaver " Location/Address: Bean Road-27028 Proposed Facility: Residence Property Size: 2.84 Acres ATC Number: 2134 • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� Date: �/%/�Y CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. L-! . Septic System Installed By: Environmental Health Specialist's Signature: V Date: —��–/��— DCHD OS/99(Revised) � t ���� � � � oM �n� ' j l�lti'"� APPIJCATION FOR SITE EVALUATION/IMPROVEMENT PERMff&ATC � , ` � / Davie Counfiy Health Department �� � �� Environmenia/Hea/thSecbion �UL 2 � I��� �.�. Box 848/210 Hospital 3treet ��.t� Mocksville, NC 27028 (336)751-8760 ����DAVIE COUNP( LTH ***�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORt�ATION I3 PROVIDED. Refer to the INFORI�TION BULLETIN for i tructions. 1. xam. to b. aill.a �e o7 I ��/T v�/� coataot r.rson fl�e� Mailing Addr�s s ��• (J O}( ( /�Q Homa phon� ��3 Ce� 02�T 'o?��� citY/stat./zxp �ao l�'e�tPP. /��C, 02 7d/`� Husinesa re�ono 7�'S� G s�- Goov 2. Namo on IIarmit/ATC if Difforant lhan Abova J GGi/ �_ ��C6(�°E',� Maiiinq ]sddross City/Stst�/Zip 3. Applieation For: ❑ Site Lvaluation t�'Impronement Permit/ATC ❑ Both a. sYstam to sorQico: D' House ❑ Mobile Home ❑ Business � Industry 0 Other s. if �tesidence: t People � � Bedrooms � � Bathrooms � ��2 F3 DiahrasYs�r ❑ Garbaqa Disposal �aahinq Machino B'Hasomant/Plumbinq ❑ Saeom�nt/No Plumbinq 6. If Husiaaas/Industry/Othor: Sp�cify typa � pooplo � Siaks � Commodas # Shoxors i Urinals # 1tat�r Coolors IF FOODSERVICE: # 3e�lts Estimated Water Us�ige (gallons par day) 7. Type of r,ater supply: ❑ County/City Q�Well 0 COmmunity s. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes [�'1�10 If yes,w6at type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. 07 p[�, 7(e �-oa.�f Fro..9 3 3,��/ � Property Dimensions: f��,S3 �� �OS,�'7 r3��'NRITE DIRECTIONS(frnm Mocksville)to PROPERTY: TaaOfTicePIN: # S��s�- 9a - �o g� �00/ s�'�� �/`i57L Q�cAss! ���Ne!' mAp� /� (�pD o00/o� PropertyAddress: RoadName ��r}tt1 %�ocL� �Or�S� .S e�us�-��� e���'C� ,���/� � City/Zip �OC�Su;�/e, N.C• 02 �voZB� �o�i�c� 7��2 `i��� �/P{�iTJ j`2� G �.`r �6 If in a Subdivision provide[nformation,as follows: � 5 6:-v ']��� �"i�y h-�, ,���/'d k, ��c.c.�ti- Name: �� /14,-�e,..Cao�`�`Y�'��" Section: Block: Lot: Date PropeMy Flagged: �'�J�'%�� 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,jf the site plans or intended use change,or if the information submitted[n this applieallon is falsiTied or ehanged. I,also,understand that I am responslb[e for a[l charges ineurred jrom thls app[icatlon. I,hereby,give consent to the Aathorized Representative of the Davie Coun Health Department to enter upon above described property located in Davie Coanty and owued by sCc� � a- /j'1.chel��S S���c� to conduct all testing procednres as necessary to determine the site suitability. DATE �a 9-9 y SIGNATURE k�'��1�G1 ��/��"%t/�-- THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of the following: E�sting and proposed property lines and dimensions, structures, acks, and septic locations).. ��`J ���`��r Site Revisit Charge -- Date(s): Client Notification Date: EHS• Account Na � Revised DCHD(07/99) Invoice No. __� 1 I � • '. � APPUCATION FOR SITE EVALUATION/IMPROVEMENTS PER � � 2 ��1r12 � ' � � Davie County Health Department LS V L5 � ` ' � � �� Environmental Health Section � ` � P. O. Box 665 J�N — 4 I��� � � �`�� Mocksville, NC 27028 � �� i �- . � n/� ._ i 1. Application/Permit Requested By .��I U �n f\,G��� � `� 'U 1�qa n i�lr' ; � Mailing Address 1315� �a¢fe v��n S-� Home Phone ��I '"����n Z D � G�1��Za l r011� , IV C � ��Z� Business Phone � 0 7 2�0� � 2. Name on Permit if Different t�an Above ` � 3. Application for: General Evaluation a Septic Tank Installation Permit � t 4. System to Serve: f�iouse ❑ Mobile Home ❑ Place of Public Assembly ' � ❑ Business ❑ Industry ❑ Other ❑ Unknown ! � � 5. If house, mobile home: Subdivision Section Lot # E O BasemenUPlumbing ; ; No. of People ❑ BasemenUNo Plumbing � No. of Bedrooms O Washing Machine � No. of Bathrooms ❑ Dishwasher E Dwelling Dimensions O Garbage Disposal . � 6. If business, industry, place of public assembly, other: Specify type ; No. of People Served No. of Sinks r No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public ? O Private O Community j 8. Property Dimensions � � � �� Sewage Disposal Contractor � 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0 No If yes, what type? i 'NOTE: . Improvements Permits are subject to � revocation, if site plans or the intended use change. Effective October 1, 1989. � � i DirectionstoProperty: �ROPERTY INFORMATION REQUIRED: i i;�Q I J ��d�� � � � l� •l.G' k��C �'� Tax Office PIN �� <`� ��7 '_'/.���.�Sl �, --�-� lJ�G�.,� � � � ' � �(�-��2- �G�� � ! � '' ��'� Road P�ame a , > �F � �lG Box �� (if available) ^ �� ,� �1�1�,f 1"* �'t. t�"�a:�'�"� �.� .��_: ."'` ; � C�ty �"C� �l✓f l�f�"'� ..- �:, 1 r: J 9 t i.,.-t ��+`�� /��.,C" ���'�'�;� � �� ---.�:f �/ '� ` � � ? , � � .�.�, �. �, • ��i __ � - � . . � �� � , - . , . � �_.. j. ,�_ i i , � ....j :'.: , . �' /t��1.�4�,5.,�4 r _�".��,.1 r r.:rl��.:., + }' �'.�� �'l.k..�.-'�.� , :� � 1 !,� � r, �,J�1..,� ,,,'`;'.' �' <.. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges � incurred fr m this ap lication. �. � � Cj � ; DATE SIGNATU ; > t r P CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIB D PROPERTY R MUST CHECK ONE: ❑ 1. I OWN the property. — � 2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner. I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie Counry and owned by to conduct all testing procedures as necessary to determ' e aid Site�-swt bility,�ff ground absorption sewage treatment and disposal s stem� �GZe,��- �/ O✓���'./y � � 'A ���/ � ����i�i DATE SIG ' URE DCHD(1�93) . . � `^ . - ' .i-.��-..,.,..�,x- .,� - - .. --.. .......-.. `7r+=}•'"(*r Yc*,. :r.J�,,. ._,�:iT.xC-' - ' ��::_�_ ;._-:.r .r3sc^�s+-,'vx r„-.cr�-F .� " -. . . .. ��� { t ♦t aks..� �-y_+" " �<-" -> .. _ . . . 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' Soil/Site Evaluation NAME ��\� '�\� � �"�A3�- DATE EVALUATED I ~ a S ' c7 � ADDRESS � p'�� PROPERTY SIZE �� �S 1 C�-s.T�.1� PROPOSED FACIILTY �o� S� LOCATION OF SITE �-�'A`N R� Water Supply: On-Site Well _ Community Public Evaluation By:��� Auger Boring Pit Cut FACTORS 1 2 3 4 Landsca e osition 5 Slo e Z '� '�. +° HORIZON I DEPTH `'' � Texture rou l� Consistence Structure C�. Mineralo ' HORIZON II DEPTH ' 2�' Texture rou � � Consistence Structure l� Mineralo ' ` HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Minezalo SOIL WETNESS �s SS RESTRICTIVE HORIZON � — SAPROLITE -� --- CLaSSIFICATION LO�1G-TERM ACCEPTANCE RATE � SITE CLASSIFICATION: �` �• EVALUATED BY: ���o �Zr���-� LANG-TERM ACCEP ANCE RATE: �� OTHER(S) PRESENT: ���� �d��s�-N— REMARKS: �s� � �� �� ��i, a ��`Jti���.T� ' P�J�,��S.��, — LEGEND Landscape Position R-Ridge S-Shoulder L-Linearslope FS-Footslope 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-Silt,y �;lay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vccy 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 ,iC--Siny�le grain M-Massive CR-Crumb GR-Cranular �K-MSular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralaicy 1:1, 2:1. Mixed Notes Florizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) 5oi1 wetness - Inches from land surface to free watet' 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/ftz DCHD(01-901 ■���������/�������������■�������������������/������������� ������� ■���■��■�■�����������■N�����������nr���������\■ ���■�����������■ ■�������■��� ��■��■■���������������������� �����■ ��■■�■�������■■ ■���■\�����■�■■��������■�������� ■������������������������������ ■����������������������■��■��������������■ ■�■�����■■\������������������������■�����■■■���������������■�����■ ■��■����■������������������������/�������������������■�����������■ ...........................................�■.._....�............. .......................................... ... .... ............. ..............................................■...._ ............. ■����������■������������������\� . 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BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634-99�5 �'y6� January 26, 1996 Calvin Roscoe Morgan, Jr. 1375 Patterson St. ' . China Grove, NC 28023 Re: Site Evaluation Bean Road ; Tax PIH: #5745-92-7081 Dear Mr. Morgan: As requested, a representative from this office visited the aforementioned site on January 25� 1996. Based upon the information provided on the , application for eite evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site ' sewage disposal system. If you have any questions� please feel free to contact this office. Sincerely, ; ��..�.,� � ,���� � .> Charles E. Little, R.S. ; Environmental Health Section ; _ I f CL/wd - : ; Enclosure(s) � , i ; � ; � ; � ; _ f � � . , � � � ;