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322 Blevins Rd (3) � . DAVIE COUNTY HEALTH DEPARTMENT �t��'�'a a � Environmental Health Section � - P.O.Boz 848/210 Haspital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001066 Tax PIN/EH#: 5823-09-9209 Billed To: Robin Boyer Subdivision Info: Reference Name: Robin Boyer Location/Address: Blevihs Road-27028 Proposed Facility: Residence Property Size: 2.239 Acres ATC Number: 2402 **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� Dishwasher: XJ Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � Type Water Supply—�'�vr,/ 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: 4. IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RIS R(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health epartment or final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the da ]lati n. Tele ne#is 3G)751-87G0.**** � � Environmental Health S ecialist's Si ature: � � Date: � .. P � DCHD OS/99(Revised) � � f� ' Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section r.o.Bog sasnio x�p��i s��t Mocksville,NC 27028 (33G)751-8760 Account #: 990001066 Tax PIN/EH#: 5823-09-9209 Billed To: Robin Boyer Subdivision Info: Reference Name: Robin Boyer Location/Address: Blevins Road-27028 Proposed Facility: Residence Property Size: 2239 Acres ATC Number: 2402 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This 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 Of�'ice 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 SpecialisYs Signature: Date: �—��� CERTIFICATE OF COMPLETION ��2��? **NOTE** The issuance of this Certificate of Completion shall indicate t�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 sha ' s guaran e system will function satisfactorily for any given period of time. 3 2 � � .�dX� ��� �1�� �,_�3.�� 7�� „� : S��c �/�S�` �S �� = e�'/" JeJ`I ��� �O{� �/i �G� Ur'�� (' /,�,� '�I�xW� �� �a,l���, �D �� �h � I A�,2�'��� �fl��' �J��' � ;�`�� ,r��d � �o � %��`� e " 1���s� �����,� n° �►;t( . i Septic System Installed By: Environmental Health Specialist's Signature: 1��/ Date:_�/'�� v DCHD OS/99(Revised) . ', 1,/��-���/ � ,i,oa A�_— /f' �seG�l� ��1�-��� � C� C� � DaC� /"j� A,PPUCA710N fOR SfTE EVALUATION/IMPROVEMFM PERMIT&A � /�' �o.�� Davie County Health Department � 2 7 200Q �-�'i7U�`� � Environmenta/Hea/th Se�ction P.O. Bou 848/210 Hospital Street ��� y ����r e' Mocksnille, NC 27028 ENVIRONI�9ENTAL HE�LTH � (336)751-8760 DAVIE COUNTY ***I1�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED L)NLESS ALL TIiE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nsme to be Billed �['�b f rl 1' � • I�L�C.+��� Contact Peraon � Q LQ Li)(e/�(� Mailinq Addreaa /� � ►7�r'1 't ���C� '�. Home Phone �� a' ���� City/State/2IP �,V- S r�� a �,�3 Susiness Phone (Y�?yj, �� 3 � �'� 7S/ � 2. :�a� cr. :erait/'n:C i� Di�Perent than Above n� ��2'� � c"""��"T��7— Mailing �1dd=eas City/State/Zip 3. Application For: C+]�Site Evaluation ❑ Iraprovement Permit/ATC � Both a. syratem to sesvice: [�'House 0 Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People � � Bedrooms 3 � Bathrooms � tYsishMasher CI Garbage Disposal l�ashing Machine fi Basement/Plumbing LI Basement/No Plumbing 6. If Bueiaeaa/Induetry/Other: Specify type Y People � 3inka � Commodea � Shoxera � Urinals �1 Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gaiiona per aay� �. Type of water supply: ❑ County/City f{h�ell ❑ Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes C�To If yes,w6at type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIIZED PROPERTY INFORMATION REQUESTED �E�i.�::'. E:t6e:«;:..r.;u�•�f:���i,�i:�::ii�T�s::S�t/�3iKii�cD'oy tne ciient with`1'Hi5 APPLICATION. Property Dimeasions: o� ���l i/C��'-r WRITE DIRECf10NS(from Mocksville)to PROPERTY: Taz Office PIN: # J'��.?�-- C��� %�U� �l�J o� 1 ( L� nn �t Property Address: Road Name�/eUi�f�G� d LC�-�-�- tJrl -�{\u(' � c\��("`��(�'S City/Zip,i�ac`��cl/� ��.�� �P -�-� C�r� ��C U i r1S � _ . If in a Su6division provide information,as follows: �Ot k� `�-}- i n�d, �Q t.�.lc�,_�, Name: m�-rlul�� c�n IP-�- 1 anc( on� Section: Block: L,ot: Date Property Flagged: ��o�`i" c��C� This is to certify that the information provided is correct to the best of my knowledge. I understand t6at any permit(s) issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in t6is application is falsified or changed I,a/so,understand thal I am responsible jor a/[charges incurred Jrom thls applJcation. I,6ereby,give consent to t6e Authorized Representative of the Davie County Health Department to enter upon above described property located io Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE J�`o�7��CT�O SIGNATURE ,� �. �j�r�,r� THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of t6e following: Ezisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notificatioa Date: EHS: �� ��K� ������ �` ��� � ������ Account No. Revised DCHD(07/99) Invoice No. ✓�� , , , ; ,. S1 rax�oe a� rox Alap e-3 n/f June Woyne Cleory ond wHe RuDy Kay C1eary DB 187 O PC 26 1 � ' ' � i . 1/2"EIR O � i Approxlmate � ; CL S.R. 1426� ' i � 3/4"EIP � � _ � � ' ' I � ' � ' . � � �T���f 1�1/ � �j ; � ' , , , , �. i � Tie Une �X�e , N 02'OS'18"E CL S.R. 142E � r � 267.64' g � �H� i' 1 �1� ��� ; t" ;, ; ; y Part of Tax Lot 52 � � ' i� Refe►enee Survsy by Stons Land Surveylnq Co. ^py�r wte ' � i I � CL SR. 1426 � � ' � Dated 1-06-2000 ,�� � � Job No. 521699 ��'� ' �j � Polnt O ( � i 3/4" EIP 8ent Apprvxfmate i � CL S.R. 1426 I i i � � i � Port of 7cx Lot 52 � i I Tax Alop B-J �� i � ' � � � f/2"OR O i � � P ��0 � 1 ' t/2•E1R "`-' a s.x. f�2e ' � S 88•J1'49"E 474.61'Total � i�Ogden 444.81' �/7"� i i � ' 30.00' i � TJs Llns � � i N OS•03'26"E �� � 327.78' ( �� � �� r Parcel 2 Point o � ; � Part of Tax Lot 52.07 c�°°sR 4� , � N � � 2.?39 Acres +/- � ' i I o ��j � i ~ J " � ' N 88'33 56"W � ' � 59.82' N __i � i � �� Concro �c � � �� S d8•31'49"E 476.92' [:�SR. 1420 � � — W L'gnt Vo1s � � � ^ �--------------- ------- � � "U"Channel lron ------ r----------- o"wn'�. j ' Fnd Bent � � --------- - i i I �_J � � � � i � `- iatu• "� � Z New I � ' Doubk W(ds � �� � ; � Mobile Home I� � ( i � o • � � . � a�.r � i � + � 1 Parcel 1 '"''T � � , � I Pa►-t of Tax LOt 52.07 Approx�lm°te ' � � � � 2.762 Acres +/- = CL S.R. 1426 � � :s � h o we�� � � ' N 8�8•3`1'49"W �� i 17.19' Potnt 'A" � � -''•' � Totol A to B: . ��,���_��� '� „r �-.n .q. ' � , , ,' . '�' DAVIE COUNTY HEALTfI DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001066 Tax PIN/EH#: 5823-09-9209 Billed To: Robin Boyer Subdivision Info: Reference Name: Robin Boyer Location/Address: Blevins Road-27028 Proposed Facility: Residence Property Size: 2.239 Acres Date Evaluated: ��;%���j Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L� L. L� Slo e% �— HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH O '' '' �' "' g�� Texture rou Ci Consistence / Structure ,� 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: 7 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 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 . 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 DCFID OS/99(Revised) ■������\����■���■��■����■■��■�■��■��■■■■��■���■��■�■■■�■�������■■■ ■�����■■��■����■�■�������■����■■�■■■�■�����■�����■■■■■�■���■�����■ ■�■����■���■��■�����■��■��■���\■�■�����■��■��■���■�■■�■������■�■ ■�����■■���■�■��■�■����■��■�■■�■ ■■�■��■■�■■��■���■�■�■■��■ ■�■�■ ■�■�����■■������■�■e��■�■�������■����■��■���■�■���■�■■�■�����■���■ ■�������■����■■���■o���■�������■��■����■■��■■�■��■��■�■■�■��■■�■■■ ■�����■���■�■■■■�■������■��■�■�■■�■■����■��■■�������■■■■�����■■■�■ ■�����■�����■■��■��■■■■��■�■�������■�■�■■��■��■��■�■��■�����■■��■■ 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