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489 Calahaln Rd. � . �f; DAV� COUNTY HEALTH DEPARTMENT I fa � 25 �% ' � Environmental Health Section � a � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000780 Tax PIN/EH #: 15709-37-7161 Billed To: Josephine Anderson Subdivision Info: Reference Name: Josephine Anderson Location/Address: Calahaln Raad-27028 Proposed Facility: Residence Property Size: 68.52 Acres ATC Number: 2206 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � #People _� #Bedrooms _ �� #Baths _� Dishwasher: � Garbage Disposal:la Washing Machine: 0 Basement w/Plumbing: ❑ Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ' Type Water Supply ��� Design Wastewater Flow (GPD)1��-/,� Site: New �Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �� ��Rock Depth �� Linear F�lj)v� Ib'IPROVEMENT/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.**** �� l � Environmental Health Specialist's Signature: v'/✓� Date: �� o�� � DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990000780 Biiled To: Josephine Anderson Reference Name: Josephine Anderson Proposed Facility: Residence ATC Number: 2206 r. o. Bog sasnio H�p��i sr��r Mocksville, NC 27028 (336)751-87G0 Tax PIN/EH #: 15709-37-7161 Subdivision Info: Location/Address: Calahaln Road 27028 Property Size: 68.52 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �� **NOTE** T'his Authorization for Wastewater System Construction MUST 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 pecmit(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. Envuonmental Health Specialist's Signature: �� Date: ��!���/�� T CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletion 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. Septic System Installed By: Environmental Health SpecialisYs Signature : DCHD OS/99 (Revised) Date: � '.2� � / d APPUCATION FON SRE EVALUATION/IMPROVEMENi PERMii & Qavie County Hes{th Depattment Envirohmenta/ HesJt�i Se�ctJon p.0. Box 849/210 Hospital 8tr�st Mack�vill�, tiC 27029 (335�?51-9760 �(�f,[��- � cF�uE i ti�, ... � � ' ■ I➢/f E 6�'v' N'� :t#i�a�sari'r•t• ssis ��ira�s=o� c�rrrnos a� rxociissrisi �i:iai$s �►zs+ sHai �riQtiix�'D ILirOIi�9l�IO2i I8 pAGVZDSD. R�lor to th� i2i�'ORMIITZON S�LL�TiN !os iastruatioas. 1. �Iw eo e. uli.d ,��� 1'K ���, `P Y.S 1'�onta�ot �.s•on S� fh G �is� aaa�... /��lT�7i�lAJ ^ � sa.. �,. �,"%��g`?3 '�`7� 9 c�hN�tat./sss r �. llw on P�sait/�C i! Li!l�s�at tAan �bo�� s�.sa... aban. "" lOtiliuq �dds��• City//tat�/iip �. 1lppiiastioa lor: �it� =vl�lnatiou ,�improv�nt II�sait/1lTC �Soth �. �.t,.a to as.so.� �8ona� 0 tiobii� Hom� � Hu�ia��s [] tadu�try U Oth�r s. I! F+�sidana�: � Qsopl� �� � B�drooms -� • 8athrooms � D Di�hKasb�s a oa�.q. oi.po�ai �,✓xa,� x.o�sa. o sa..�tilaiv�s,� p sa..�tJ�o aiu�� i. I! suai���/i�stsY/OtL�rt fp�oil�! tYP� � ��opi� � Coa�ods� �, � Yho�s� � Csis�als 7. .. i �i.nlc� i 1ht�s Cool�s� t* 1�00D8T,RYICt: # Saatis �stims�tad I�atsr Osaq� ��ioas p.r a.Yl lyp� o! ratar �upply: O Couaty/City � N�11 0 Commuaity co yoo.�����ce �aain� o� e��►n.��. or�ee wtwr� teu �tew � mc�na�a to K�►et � Ya f�No If ya, whst type? I***IMPORTANT*** C41ENT8 MUST CIDMPL�TBTNE REQUIRED PROPERTY INFORMATION AEQUESfED BELOW. �Itber s PI.AT or SITE I'LAN MUS1' Bfi SUBMI77ED b� t6e cUent ait6 THIS APPLICATION. Prop�rt�r Dimeo�low: �D D � J� � C� � S T�:08Ice PII�: # l� /� i—� 7� � �� r Property Addren: Awd Name ��,v-� I a rl ��'r� l�� CIty21p 4Cf�5 � 1 �(Pi l�' � If la � Sabdivi�fon pravide ipform�tion, a� fo{lonv�: 7a Nsmes Seetioat Block: Lot: L•�,f� WRITE D1REG'tIONB (iirom Makivllle) to PROPERTY: _ �� � L� �" �Jn�.D,� '� �� �0� �L� �7C �� l /Yl � ��i !� � �a �d ll c3 � j�� s Ps, �l�e�cP o� 1 e�. �°Ph, ci i �%�uS��s � � �,�1 � �� fo��� . . r [� � � yPS �J �-� ��'` s �� 5'� �v�- - ca perty trtts�eds � -..�D - 9 '� Thb b to eettlt�r t6�t the inMrmaHan pravtded b eorreet to the bat oimy kamnled�a I ande�nd ttiRt Rny pecmiH�) luaed heceattoc ace �nbjat to �wpewton or revoa�Hoa, l[ t6e dte plaai or Intended a�e ch�n�e, or li the tnformadon �abaritted ia t6L appqealloa V faLlQed oe ch�n�ed l, also, aadirstaad �a� 1 am rupoasl6le jor all cA�argu lacumed,Ji+orn tbls appJkadoa. i, benby, Q,ive eonknt to tha Aatharhed Aepcaenqtive ot the ihvie Coa�nty flalth Departmeat to enter opoa sbove deucib�d property lacated In ihvte Ceaaty aad o�vned bp to condact all tatin� praedara u oecaacy to deterailue the rlte �nita6Wty. DA'TL � " I'� � � � � � � 8IGNATURE THiS ARL+A MAY BE USED FOR DRAWINt� YOUR $1TL PLAN (Inclnd� �11 ot the idiawinet E=LNuQ snd propaed prnperty Uaa and dimen�lone, �traotnra, utback�, snd uptie locstioa�� /�% �0 ���cfc'�,%/ � R�viaed DCBD (07/99) { �»te(�)� I Cllent NottBaHoa Datet `LNS: Aceeant Na �� Invoico Na ��-3 y � •�� , T•�i�.p` '�g'a�� c�,� ��� � �t.`�,.� .p + � ' . r '��� { sAr �`� ;3 . ' ,. � `. r�����5. _+f �` v"�:� s - . � . �� r .. . ��- a , ,�, . 7 .�F �i�s.��, 'd...�` : � _ . ,'., v..� 4 � -'� � a'¢`�6 • F � � ;-�' � -e',�'� „` i; � � ' . . � ` � . t �, '' - s� ���' ` !�� �r�. � ; �'- '' �' � , r r. � . . ., � 7 ♦ :;K ,�z `- �" -�r' e �s'� ,�, j7�p' � ts,�' 4 s z �: ' :.� _ . � - ., � ��� Y!' tis. 1 �� 2..�' P ...' 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DAVIE COUNTY HEALTH DEPART"MENT � Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000780 Billed To: Josephine Anderson Reference Name: Josephine Anderson Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 15709-37-7161 Subdivision Info: Location/Address: Calahaln Road-27028 Property Size: 68.52 Acres Date Evaluated: � fj �`�� Water Supply: On-Site Well !/ Community Evaluation By: Auger Boring L� Pit HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence SWcture Mineralogy HORIZON III DEPT� Texture eroun SOIL WETNESS Public Cut SITE CLASSIFICATION: �j EVALUATION BY: .x- y!� `'� LONG-TERM ACCEPTANCE RATE: � 1 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 - Granulaz ABK - Angular blocky SBK - Subangular 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 DC�ID OS/99 (Revised) ■ ii ii ■■ ■���■���■��■■■■■�■ ■���■���■ ■�■�■■�■ ■■��■����■��■■�■■�■ ■■��■�■������■��■■�������■�■��■■��■�■■�\�����■■�■��■�■■ ■�■��■�■�■�■��■�■■��■■■�■■�■��■�0■�■�����■■■■■������■�■ s�■�e■���■��s■■��■�■��■��■■■��■�����■�e■�■■�■�������■�■ ■■���■�■■���■�■��■�■��■�■■■■��■■��■■■��■�■��■�������■�■ ■■���■�■�■�����so■■�■■��■��������■���a■�■■■�■■���■■�■�■ ■�■��■�■�■����■�■������■�����■��■�■��■■■■�����■�■��■�■ ■�■■�■■�■��■■�■�■��■■ ■■■��■■■��■����■�■■■■���■�■■■■�■ ■�■������■�■■�■��■■���■��■�■�■■����■�����■■■���■��■���■ ■�■��■���■�■■�■■■■���■■�■■�■■■■���■�■�■■■■�■■�■■�■����■ ■������■�■��■�■��■�■����■■���■■■■�����■■�■■�■■■■■��■��■ ■■�■■�■�■��■■■■■���■��■��■�■��■��■■■■�■��■w■■■��■��■�■■ ■■t�■�■�■���■�■��■�■�■■������■■��■�■����■■��■�■�■���■■■ ■���■�■�■■■�■�■����■��■�■■���■■��■�e��■■�■�■■���■■��■�■ ■���■■■�■■■��■�■�■�■����■���■■�■■�■�■■��■■■■����■��■■■ ■�����■�■�■�■■�■��■�■ ■�■■■�■■��■■���■�����■��■�■�■�■■ ■������■����■������■■�■■�■■■�����■�■��■�■���■■�■���■��■ ■���■�����■��������■��■��■■■��■��■�■�■■�■■�■■■�■���■��■ ■�■�■■■n��■��■��■��■■�■■�■■■��■�■��■��■��■�■■■■■■�����■ ■�■��■■�.c�■■�■�■■�■■■�■■■■■■��■�■■�■��■�■■■�■�■����■■�■ ■�■�■■�■i.i■�■�■■�■■■�■■��■■■�■��■�■■�■■�■■�■�����■�■�■ ■�■�■■�■���■�■■�����■�■■�■■■■�■��■�■��■���■■■�■����■��■ ■�■■�■�■�■�■�■��■���■�■��■■■�■��■�■��■■�■■��������■�■■ ■���■■�■�■�■�■■�����■ ■���■■���■■�������■■�■�����■■■�■ ■������■���■�■�■■���■�■■�■�■��■�■■■■�■■■�■■■■�����■■��■ ■�■��■���■�■�■■�■���■■■■���■■�■�■■■■��■■��■■■■����■■��■ ■�■■■■�■�■■■�■■■■���■■■��■����■�■■■■��■■�■■�■��■����■�■ ■�■�■■���■■■�■■�■���■■��y■■■■�■�■■���������■■���■�■■��■ ■��■■■���■�■��■�■■��■�■■���■��■��■�■��■■��■■■�����■�■�■ ■����■��■■��e�■�■�■��■�����■��■■�■■�■���■����■■■■■�■■�■ ■��■�■�■�■�■�■■�■���■ ■������■■��■�■■�■■����■��■■����■ ■■�■���■�■�■��■�■���■ ■�■■■■�■�����■��■■���■■��������■ ■■�■�■�■■■�■��■�■���■■�■■�■■■�■■���■■�■■��■■■■����■�■�■ ■��■�■�■■■�■�■■�■■��■■�■■�■�■�■■���■■�■■���■■������■��■ ■■�■e��■■■�■����■■■�■■������■■■■��■■■��■■�■■■�■���■���■ ■�■■�■�■���■��■�■���■■�::::���■■■�■�■��■���■■���■��■■�■ ■���■■�■���■■�■�■■����-------.���■��■�■��■�����■■■■��■��■ ■�■�■■�■����■���■•_::�■■�■���■■�i■■�■�■■�■■��■■■■■■■�■��■ iiiii�iiiiiiiii�iiiii�iiiiii��iiiii�iiiiii�iiiiiiii� ■■��■�■��■�■��■����■�����������■���■�■■����������■���■�■ ■■��■��■■■�■■■■���■���■�■■���■■��■�■�■■�■�����■■■■■���■■ ■■��■��■■■■■�■■��i�■�■■�■■��■■■■��������■■�����■■�■���■s ■���■�■����■��■��i�■��■���■■�■■�����■���■■■���■■��■■�■■■ ■�■�■e■�■�■■��■��i■��■■��■���■■�����■����■■������■■�■■�■ ■■■���■�■■�■��■�ii����■■�■����������■�■��■■�■�������■��■ ■■■���■�■■■■■������t�������......�■��■�■■�■■■■■��■�■■■■�■ ■�■�■�■��■�■��v���=�:.��■�■iiii���■����������■���■���■■ ■��■■■■v������■��■■■�■��■■���■��■����������■�■■■■�■��■■ ■�■�■�■ve■�■��■��■�■���■����■■��■■�■��■�■■�■��■■�■■■�■■ ■■■N�■��■�■��■�■■■■�■■■ic�■�■■��■■■■��■�����������■■��■ ■�■�■�■���■■��■��■�■�■�■i■■��■■�■■�■■■���■�■■�����■■■�■ ��� ■■■ ■�■■ ■�■■ ■■ ■��������■��■��■���■■�■■ ■�■■�■���■��■■■■■����\�■ ■■■■�■��■�����■�������■ ■�r■������������������■ ■��■■���■��■■■■■���■��■ ■■��■�■�■�■■��■����■�■■ ■�■��■■■■�■■■■■■■■■■�■■ ■��■■��■■�■������■����■ ■■��■■�■��■��■���■■■■■■ ■■��■��■��■�����■■■■�■■ ■■��■�■■��■������■■■�■■ ■����■■�■■■�■■�■■��■��■ ■■■■■■�■■■��■■■■■■■■■�■■ ■�■�■■�■■�����■��■■■■■■■ ■����■�■■�■��■■�����■��■ ■�■��■■■■■■���■■■■�����■ ■■ ■