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183 Ben Anderson Rd n DAVIE COUNTY HEALTH DEPARTMENT �����2��� ' Environmental Health Section ���� P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001218 Tax PIN/EH#: 5802-44-7291 Billed To: Brenda Harris Subdivision Info: Reference Name: Brenda Harris Location/Address: Ben Anderson Road-27028 Proposed Facility: Residence Property Size: 1 Acre **NOTE�'�Thi b�inprovement/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�., Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �G- Type Water Supply�l Design Wastewater Flow(GPD)�� Site: New�Repair❑ System Specifications: Tank Size/�� GAL. Pump Tank GAL. Trench Width��Rock Depth,�� Linear Ft,���/ Other: y� ��� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Deparhnent for final inspection of this system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.**** � Environmental Health Specialist's Signature:�/G� Date: �b `�!� � DCHD OS/99(Revised) I : � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990009218 Tax PIN/EH#: 5802-447291 Billed To: Brenda Harris Subdivision Info: Reference Name: Brenda Harris Location/Address: Ben Anderson Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2453 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED 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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:�����Gti'.(X Date: �s� �6 `�v CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation 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�� �p 1 �, '5 � . ��l � � � `�� s �o�' i � a � '� . �-�U Mx� f ����� Septic System Installed By: '�1� �Q��� S Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) ' ` � L� � � � l'/ � � APPLICATION FOR SITE EVAIJJATION/IMPROVEMFNT PERMIT& Davie County Health Department � .. I 2000 Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksnille, NC 27028 Er�YIRONP,IEP�TAI HEALTH (336)751-8760 DAVIE COUNTY ***IMPQRTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed � ��� d� �(v� ��MY Contact Peraon ���� /'7 ��r�S Mailinq Acidreae I u t� I�f/1 ��j�S C�� '\� Home Phone �3��� r/02 "' �7�/Y City/State/ZIP M u 5 u���lQ � a 70�$ Bnainasa Phone (�����D� ���T� 2. Name on Permit/ATC if DiP erent than Above Mailing llddress City/State/2ip s. Appiication For: � Site Evaluation ❑ Improvement Permi.t/ATC �YBoth a. syatem to sezvice: ❑ House L�bile Home ❑ Business ❑ Industry ❑ Other s. =f ttesidence: � People �„_ � Bedrooms � � Bathrooms � iehnasher ❑ Garbaqe Diaposal �yW3shing Machine ❑ Basem�ent/Plumbing ❑ 8asement/No Plumbing 6. It Suaineaa/Induatry/Other: 3pecify type Y People N Sinka � Co�odea � Showera # Urinals # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (Qrsiona per aBY� �. Type of water supply: ❑ Cotuity/City C!-��11 ❑ Community e. Do you anticipate additioas or eapansions of the facility this system is intended to serve? ❑Yes � If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Pro Dimensions: t AC, WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taz Office PIN: # J`g�02—��'"�oZ-�f� �('0� A� 'Tb� (,i ,r� �u.c.r'C�. �� _ Property Address: Road Name �' ` ��f�i� ��- bi�l Le-�h �zc�1 � �'`�'� � � c�r�iz�p MOC�SUi J�e I���� �,t"u.(L Cd-�c,�rc,�, R� bc� L�-F-f' If in a Subdivision provide information,as follows: P/ (1�1(,��- � �J I�,�/ S 0}1 Name: 1�l�4,;o,h�"`� /�l'����'.. (� ���� —� Section: Blcek: Lot: Date Property Flagged: /'(Q/� �r[�^(� V This is to certify that the information provided is correct to the 6est of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revceation,if tLe site plans or intended use change,or if the informatioa submitted in this applicallon is falsi6ed or cLanged. I,aJso,understand that/am responsible for al!charges incurred from thls application. I,hereby,give consent to the Authorized Representative of t6e D e County Health Department to enter upon a�ove described property located in Davie County and owned by �/'-C hc{c� �'�►'c ua r i-� to conduct all testing procedures as neces�.ry to determine the site sui� �lity. _ DATE O V SIGNATURE / �� � THIS AREA MAY BE USED FOR DRAWING Y07JR SITE PLAN(Include all of the following: Ezisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. o O Revised DCHD(07/99) Invoice No. /��� . _ . _ , . . .. , . .. ,. _ . • . , ., . ` : ` � 1 z , �,, � N �� ���" ��������tutiiui►�ir������ . � � �' ' - `���`Np. �'n��'�� .... �m y Herndon F. Pya , Jr., �O��''� ��'''• ' � L-1508 � Q;o�P bo.'��• : �L'•y r cn 'j;�:7' BFAR C. " � v%W W� [r: CL' ��� � � Iron �2�0 �� �:'�� '+o c �G � Q O1"d Brenda Shore Harris ���cs�r�d �.P�oo=� � x 3 Deed Book 306, Pa e 308 �ii`� ' E(�������` � . � � I �-. Part of Lot 2 g /�����IIN1111N11�����\ �'C��� Division of Clarence C. Shore Properfy ��°.N � c � ^o Plat Book 7, Page 42 ^� J LOCATION MAP I ro"' ''��� � NOT TO SGLE Z 2 I . N 02°11'39"E 204.33'--► lron Sef lron � Sef NorEh Reference Plvt Book 7, Page 42 +� N � _ � ^ � � i� N ^ 1Q 3 N � 1.000 Acre � �, 3 � DivTsion of: � N Clarence C. Shore N nl Divlsion ot: Pro�� � � Claren��e�Shore Plat Book 7, Paye 42 ^ N Plat Sook 7, Pvys 42 � � , Z � a Iron Found Iron __---—--�'_ - Found ���— "' � ��� � 0 � 184.33' RR S �ke r. S 03°56'19" E Arc= 184.38' Found RR Spike ' RR C L Radius= 2341.16' 184•3� Found � „ � o--,� S T 2Uo� Found gEN ANDERSON ROAD ____---- _�-�—�-S. 1321 PAV. PUB. R/W Survey For Brenda Shore Harris Deed Book 306, PQge 908 Parf of Lot 2 CLARENCE C. SHORE Properfy Plet Book 7, Page 42 CL4RKSVILLE TOWNSHIP DAV1E COUNTY, NORTH CAROLINA May 31, 2000 50 0 50 100 150 GRAPHIC SCALE — FEET SCALE:�"= 50' Pyatt Land Surveying 4161 BENTON CREEK DRIVE WINSTON—SALEM� NC 27106 • (336) 922-4045 Job No 2001 � ' ' i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001218 Tax PIN/EH#: 5802-44-7291 Billed To: Brenda Harris Subdivision Info: Reference Name: Brenda Harris Location/Address: Ben Anderson Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: �=�1��ir� 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 " (fl �' 6�' Texture rou Consistence i / Structure � S�,� 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: F��( LONG-TERM ACCEPTANCE RATE: • T� 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 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-Subangulaz 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) ■��■����■���■�■�■�■■�����■��■�■�■■■�����■��■�■�■■�■■■���■■�■■��\�■ ■■■��■����■��■■��■���■��■�■■���■����■■■■�■■����■����■��■�■����■�■■ ■�����������■■�■�■�■■��■��■��■�■����■��������■�■���■��■���■�■��■■ ■■���■����■����������■■■■�����■■ ■■����■�■■■���■■�■■■�■�■���■��■■ ■■���■������■�■■■es00��■����■■��■■■������■�■�■��■0�■■■■■����■■■■■■ ■��■��■����■�■������■■��■�■���l������■���■■��■��■��■■�■��������■�■ ■���■��■■■■�■���■����■��■s■■����■���■■■����■t■ea■�ovet■�����■■��■■ ■�������■■����■�■����■��■��■��■�■■■����t��■■�■■■■��■■�����■�■■■��■ ■�■�����o�■�■�■�■■s�e■■��■■�■�■��■��■�■���■��■�■v■�■■■■�����■■■■�■ ■�■�������■�■�■�■����■���■■�■���■■■��■■���■■���■■��■■■■��■��■■���■ 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