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336 Blevins Rd (2) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Moclksville,NC 27028 n (336)751-8760 ((/�/ O J IMPROVEMENT/OPERATION PERMIT Account M 990001543 Tax PIN/EH#: 5823-08-6891 Billed To: Steve Hauser Subdivision Info: Reference Name: Location/Address: 336 Blevins Road-27028 Proposed Facility: Residence Property Size: see map **N01 Li�islmprov9ement/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 IN,STALLING SYSTEM. Residential Specification: Building Type #People -!!5- / #Bedrooms `� #Baths Dishwasher: 0 Garbage Disposal:R!r Washing Machine: Mr' Basement w/Plumbing: 121"� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size` 06 A02Type Water Supply -Llr Design Wastewater Flow(GPD) L?W Site: New Q/Repair❑ System Specifications: Tank Size1W GAL. Pump Tank GAL. Trench WidtOL9;I Rock Depth 12!' Linear Ft. &CO1 Other: q DIM-'&)fi or� `604ES , INMALL 1.I•se-s T o.C, K1,-1, Required S it e Mod i f i cat i on s/C on d it i on s: Iti' TaL, tr?—I as V.EEI I5'cK-0wszf P c(PP 124W.C.h�rc IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROV LTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representati the lth ent for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p n th tion` a one#is(336)751-8760.**** r � 1 DD, C- d Px oau- 7 f` � L-J Vs 10 :S bQ DG� D.C. -X tvl 'ff2%IJC1J PTN lie ,b.X � 1-lot:sr`. 1J�l3 +� •t P,..1 IW3 Environmental Health Specialist's Signature: Date: D/ DCHD 05/99(Revised) i DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001543 Tax PIN/EH#: 5823-08-6891 Billed To: Steve Hauser Subdivision Info: Reference Name: Location/Address: 336 Blevins Road-27028 Proposed Facility: Residence Property Size: see map ATC Number. 2928 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). 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 WASTEWATER CONS IS V ID FOR A PERIOD OF FIVE ARS. Environmental Health Specialist's Signature: Date: ©/ 77 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 I I of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a gy antee-that the system will function satisfactorily for any given period of time. 1400L6 Qy to /Zd to 1129 JZo' V 44Cpf z Septic System Installed By: l V Environmental Health Specialist's Signature: JDate: �� d 2 DCHD 05/99(Revised) !Z1 LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department TY Environmenta/Heaith,Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS..��PROVIDED. If . 1Refer to the INFORMATION BULLETIN for instructions. 1. Name to be BilledE�/f- �A45E(2L Contact Person,5"jEVF- f-1Ae-rS£l2- Mailing Address 1'0.-RE'SF-&Delve- Home Phone ��.Q98. 9309 7�$do AGrFR- City/State/ZIP Af6 27cee,, Business Phone 's �3� ��3� 7ai2u 71-7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation VImprovement Permit/ATC ❑ Both 4. System to Service: O"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People P S # Bedrooms 14 # Bathrooms cgxg Er'Dishwasher W-Garbage Disposal R-Va-shing Machine Wl�asement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: D County/City Dell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? 9-Yes D No If yes,what type? %D-sst ft�ii (i iat_ C at S11t ?�5Eh-tF-a i ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: #S—& 3 -� / �v� ( Jo+aT6-k to F���,u� o�D �!s Property Address: Road Name -C-4 I-1 s �� Rol 5 o LIEF i D.J7o 6g ft eS Z4. City/Zip�Q�IC��1tJ���E�ti!C rnoa-Caw cz r). to L£Fi o,./ d3G£✓ixrs ?D.. If in a Subdivision provide information,as follows: R i D —1a SITE o.-I Kf Cqu T '&N1'-tom Name: 35C- Z(..Eywcs ei ]. " Int YAnV-1«J Cc,, Section: Block: Lot: Date Property Flagged: Ju L7 G, Zc+ol 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,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. 1,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE /.IZ�/ SIGNATURE THIS A MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). '.t/ Site Revisit Charge ( Q Date(s): LVA Client Notification Date: \n EHS: z or ��Account No. Zra `i t/ Revised DCHD(07/99 Invoice No.Vast- ltoo'1i Pt,�Z--il-S E -5�TA"S 6" n �fQIU17 (� CoGrtitotif or 6L-Ep Z £ FLA— 1 + 1 STrt�ES SWI cEjGOOQ WALL REALTORS 3367513931 01/22/01 11 :50 0 :01 No:263 WALL KCxL t utca 33t>t'71 SyS'1 01/18/011 0 •3 Lj :01/01 N0:210 Ple se complete the highlightCd areas C" H"A rettlrrr. � )Md IMIMfts sr.o. so: eiwag UIPL at st s"t AV 2 2 20 Noaka*ilir " tic *'lose ENVIRONMENTAL HEAL TA •r■ +yp,�t■• ms tiR"Acutco +t UMV n M=Mw 1I=01, 111.E !R/ IRNNOL112?10tt 18 VDMD>ZD. N&LIg a to t" Z09 310UMD1 for instsuetions. :. MAW to he 'taxed�#us. sw- CMeAft eaffeea N",+Y /� 'T�J� ✓ cif lN`..��.�1 b .. None, Mwoft /�rl 4t l�ttstila+. 1� �7I� t, - I'. pawso kema--++M� to *fitgomn5 ftleft ��—.•. 11111��-Y1 IIIIIY� 1 tousss >ra.ae. CJ /aYta�s<y d. hwi cation rose B1s1. #oslttation Q 2weva"at. ssaltitlm 0 loth s. ow"M to "w"01 �U" d Il *Uo low 0 Desi mss 0 =aipst y 0 poor s. T! maidarw.z ♦ "$llo .r, i laiasoasts ,,,�� r aatAso�s ��� !!'btes•eesror n a Okwo ntWa•elt e'C.OitK moi+ x>I+ew.ritlsl+wttaQ u ti....�sh. .1uUmg ■. u ss.�eae��ute,eYlow.� a0.eesF s� • �a �..,�,,._ • ssrofw �,,.. � Cowee�iea �„�„�„ �, i et+letwss �, � t�ttLolas�,� R t+w4s Ow1as. .�r, ZIP 1001183MC'l: I Nat' .� let"atod hats)' Dsats (sauwne WO aw) 7. �'Dd o= wtatr �PPi>r: 0 Cehml;r/Gift w'ws1/l 0 t;7stttssRit3T I- be To eadaipata sddidon or"Ulm of lkt bd*tkb testes is latesded to mom? O Yts ow 1[res►what gpet 4�1 .ealMPORp51Alf' 60 C M$JW9UT=WU=Tll2 RWUD 1PROPUM 1NR101ll mrjoN MtjwrttD UL0*. lutber■PWT or Irrg FIAN As1WASSMUITTlyd 67 the cheat wkb THIS APPLICATIOPC Prop"Dia nswriu. 3q A 33'%X I,I g��80 VVIUTt DlRJ=OMS(twa MotipMlle)to PROPERTY: Ta:w.Lk-M 0 n(1 s� on PA ISO prepney Addt'er: Rand hlaM 3.3�.� lei i[e5 Let Ti- o n Fo v r Uh s ftwl Yips psw ishnu rGv1 h lita,ar�ibtrr: ti Nlmltt: Sri r IY r��� I luillir�*111.11 �11111� SOMME .mow 510kr Inset Dab pllA"Mn d: Thls H to eortlty that tis laftrtnetlos provided b correct to At bast of say k000daits. I tlsdse+tt+sad that any prwit(s) trse.i bereatier or■'object to eaopew"or ralwatiew,It t4s site,plow or Issteaded ase ebauge�or Ir the lstbranda sobatlttsd Is this o"liattot is bWAed w el MaL t,01606 ariN&P ew itbat ION mow j&?e far all uirtowts rMCA,0rrt fro0 lift spylltdlas, Ia hereby.ghe eoutat io tit ANM*rkod Rapreaestativo of tha A rle Coaaty Raa11 bspattmtnt to enter apes above dasertbed property tosstad 1s Dar1e County sad orrsod by �i r-_kj t-Li S Itv t h3 to eadact all testes!ptnesdwn as swoesery to dttendas the site bWt1. DATE / DI 1iIGNA Ftioc er y THU ARU-14AY BE UUD FOR DRAWING YOUR SM FLAN(IvdWe A of the Pollowlist: Edalat and proposed properly tines sad dinsendons, ntrdelor+ai, sr ebsclat and rtptle lotatbes). - " �t Ra.►Wt Cbsrle ctl w lwoo oomew laeb: twt • � .AoeonatNa ReyMd rCH!1171!!) ink N r MN c a. p�—r� -�J���. j �• � ►�1.r.L 3e32ITC �= v N� '. 1Cil� = 11'1tt�• N t a� W O N Lr%q rd r Y N A g'� AM= 2.242 AC. t R N Q : L� •� y op � J A! 0%0 .., f ' �o .� O �P[Z ILLI M \ 3171! cS rtsf& v1 J - k —r trsfu' s r , Un O a d -2 Ll 1 LD N i _ rt• �;. ' Ola L.0 S Z 0 AON 0 ��j p DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001543 Tax PIN/EH#: 5823-08-6891 Billed To: Steve Hauser Subdivision Info: Reference Name: Location/Address: 336 Blevins Road- 7028 Proposed Facility: Residence Property Size: see map Date Evaluated: q Water Supply: On-Site Well Community Public Evaluation By: Auger Boring `� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscapeposition L Slope% (Ab_ 7 HORIZON I DEPTH c�- - - 10 o —L Texture group Gtr Consistence r SS Structure' Mineralogy l'•1 HORIZON II DEPTH - 1 • LA- Texture group C >.C Consistence ; :E> S l=; P • s Structure A6 5--r1kk Mineralogy M!XA�-f> •-/ 1; 1 HORIZON III DEPTH A Z-3Z so- -3 •y Texture groupC 4 S'a Consistence S S Structure vY A6 k Mineralogy ,ate HORIZON IV DEPTH '70-4/y 3 - 21 Texture group -</-- Consistence Consistence (,/S Structure SEX Mineralogy1 SOIL WETNESS Z RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE p.25 0.35 1 0.2' SITE CLASSIFICATION: EVALUATION BY: 4, P LONG-TERM ACCEPTANCE RATE: 011 OTHER(S)PRESENT: REMARKS: A.* �$" �'�^4,,4 wzzoJC-44 "Z>' 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 ois 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 AB -Angular.blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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-gal/day/ft2 DCHD 05/99(Revised) ■■Ips■■■■■s■■/■e■■■■■■■■■■■■■■■■■ ■■e■■■■■■■■■/■■■■e■//e■■■■■■/■■■ ■ell■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■a■ee■■■■■■■/■■■■■■■/■■■■■■■■/e■■ ■■■/■■■/■//■/■■/■e/■■i's�s�■■■■■//■■■■■■��:w�!��■■//■■Iii■//■//■//■■ ■■//■/■■//■■■/■■■■■■■/■■/■■■■■■■■ I■■■■■■■rii■■/■■■■■■■■■■/■/IIIA■■■■G' ■■■i■■■■■■■■■■■■ee■ee■■■■■■■■■■■■■■1■■■■■■■■■■■/■■■■■■■■■■■■11111■///■■ iiiiiiiiiiiiiiiiiisiiiiiiiiiiiiiiiiii ■■■■■Ile■s■■■■■■■■■■■■■■■■■■e■■■■■I�■■■■■■■■■e■■■■■■■■■■■■ee■e■■■/■■ ■■////11■■■/■//■/■■■■■■/■ee■e■■■■�1■■■■■■/■11/■■■■■/■■iii%■■■■■/■■■■/■ ■■■/■ell/■■■/////■/■■■//■■■/■■/■■ 1■■■■■//■`iiii:��:�ii��CC���■■■■//■ ��D