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196 Call RdAccount #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)75]-87G0 IMPROVEMENT/OPERATION PERMIT �pl.-' � � � C �� Tax PIN/EH #: 5758-31-1925 Subdivision Info: Location/Address: Call Road-27028 Property Size: 56.896 acres ATC Number: 3559 **NOTE** This ImprovemendOperation 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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � #People � #Bedroozps � #Bat� , Dishwasher: � Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � E'�fDesign Wastewater Flow (GPD) ��oU Site: New-O�Repair ❑ / / • �� System Specifications: Tank Size /�AL. Pump Tank GAL. Trench Width c3 ` Rock Depth � Linear Ft.�f Other: Required Site Modifications/Conditions: INIPROVEI�IENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" 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 (33G)751-8760.**** f/J2in �� F �. `i Environmental Health Specialist's Signature: / Date: DCHD OS/99 (Revised) � Account #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility: Residence ATC Number: 3559 DAVIE COUNTY HEALTH DEPARTMENT Environmentai Heaith Section P. O. Boa 848/210 Hospital Street Mceksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5758-31-1925 Subdivision Info: Location/Address: Call Road-27028 Property Size: 56.896 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ✓ � **NOTE** This 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 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 CONSTR CT N IS V LID FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signature: Date: �� U� CERTIFICATE OF COMPLETION **NOTE** The issuance of this 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. Septic System Installed By: Environmental Health Specialist's Signature : ,�(�,/�'�� Date: DCHD OS/99 (Revised) . ,p�,,* , .}, a � 'y '�:� � � � �tUG �' 0 �0�3 EN'�IRONMENTAL HEItLTH n-. Fr'n'!"dTY CATION FOR S17E L-VALUAT(UN/lhlPliUVLAf[NT !'LIi�ti11I� & A7 C '• Davie County Health Department Environmeata/Hea/t/� Sectiaa P.O. Box 848/210 Hospital Street riock3ville, NC 2702a (336)751-8760 ***IDSPORTANT*** TIIIS 11PPLICATION CANNOT D� PROCLSSLD U2dLLS5 11LL '1'iIL iZLQUIItL:ll .� INFORMATION IS PROVIDED. Rei-ar to Lho INFORMATION IIULL�TTN tor in:�LrucL:ioii�. _ _ _ __ 1. 11amc Lo be Dilled ��h � `„ 0.0 �e � ConLacL I�cr�oii �Cj-`� I'� .�C�C�e � Mailing Addres3 ��.�D�( �� I Ifanc l�honc /s�' I 7�__1__ � City/State/ZIP r��lZs�;_�I� NC. �ra1r� Bunine�a Plione 7s1� �d�I ______.__ 2. Namo on Pezznit/ATC if Different Chan Above Mailing Address City/Statc/'Lip 3. Application For: ❑ Site Evaluation � ❑ ImprovemenC PenniL/ATC ��fioLli . A 4. syatem to service: � House ❑ bSobile Home ❑ I3u�ine�� ❑ IndusL-ry ❑ OL-her _______ 5. Type system requcated: ❑ Conventional ❑ conventional modificd ❑ itinovaCivc G. If Residence: I� People �_ 1F Bedrooms _�_. tf I3at-hrooniu _�___. �Dishwasher ❑Garbagc Di�po�al �Washing Dfachino �Daseinent/Plw�il�ing ❑Ua�emenl-/No l�luiubiu� 7. Zf IIuainess/Indu�try /Other: veriLy type f1 Peoplc iF :;ink:: tt Commodea I� Showers �� Urinaln I'r Watcr Coolcr� IF I'OODS�RVICE: ¢� Seata �Btimated Water U3a e(�alion� er aa ) �J J P Y --- ----.__---.. e. Type of waL•er 3upply: ❑ County/City �S9e11 ❑ C011llllll111L"}r 9. vo you anticipato additions or cxp:uisious of tlic facility this systcni is iulc►iticd (u scr�-c? ❑ Ycs �I n'u � , If ��cs, �ti�lial tppc? ' ' ***Idll'OR"l�1NT't** CLILN'CS DIUST C0�11PLGTG'TI1� R1iQU!/tEU PIZOI'LR'1'Y 1Nt�OlilltA'i'lON l2I;QU1;5'I'I.0 (3LL01V. Isi(I�cra PLA7' orSITL PLr1N �1IUST6CSUIIdfI7"f6D b)� tlic clicnt �ti•iU� 7'tI1S APPLICA'('IOiV. q __.^I Propert)' D1I11C11SI011S: �� r'" 6� }IyRITL lliKL;C7'IONS (1'run� 11lucics��illc) tu 1'ItUI'1�:1:'1'1': trncap#,� Ir�70O •t:�aocr�cl�l�: , � �'7�S'�3119a5' ...�al)�'�s-z- �c�r�. Ze�-�- c��----- I'ropertyAddress: RoadNamc Co�il �ccx�c� '�G�j�h �ra�,S K.c)1. 1"�j•.'�- City/zip �'�(i oc�CSvi I i� �70�� Cc�`co �ca.. � 1 14�C . I—, rS � Qr �` v� If iii a Subdivisioii proviJc infori�ialioii, :is follotivs , f>� If i G�� f�� c�. �� Nat�ic: ..}..o -e�u �._.-� Scc(ion: Block: Lot: llatc honic curucrs ilabecd: This is to ccrtify tl�at tiic iiifoi•matioii providcd is corrcct to tlic bcst of niy Icno�vlcdbc. I undcrstaiid lluil :uiy peru�il(s) issued hereafter are subject to suspeusion or revocatioii, if the site plans or ii�teuded use cl�ai�be, or if tlic ini'oru�atiou subinittcd in tl�is applicatioii is L•ilsircd or cliangcd. I, also, cuidc�stund t1�at I rrur rca/�onsiGlc for nll cburgcs iircurrc-r! fi•ruii rl,is a�,plicurion. I, licrcb�•, bi�•c cunscnt to tlic Authorizcd Rcprescntativc of tlic ll:lti�ic Cow,ty Ilc:�lUi 1)c��:�r(u�cni to cn(cr upon abo�•c dcscribcd properly locatcd iu Davic Couuty :utd on•uccl b�� ______ lo �onduct :ill lcstinb proccdures as ucccss:try� to dctcri�iiiic Uic sitc suitabilil��. llATI; _ g��0-03 SIGNATUi2I: �?�' �� TIiIS AIZEA MAY BL USLD rOR DRAtiVING YOUR SIT� PLAN (Licludc al! of ll�c 1'ollo�viiib: i:sistiiib ancl proposccl property lines and dimeus'►ons, structures, setbacics, and septic locations). � ��s f. .z..�-�r1 ��' � �- � -e: �'�' � �`"�'� � ,�,�� c—,t�-`�`� Sign givcn C�� / b Rc��iscd DCHD (05103 Silc ltcti�isil Cli.u•gc ll.�<<<s�: Clic►it Notii'icatiu�i llatc: ��,�r rr�. �-�� 6 Livoicc No. �� J � �� , ,-. w . ' . APPLICANT INFORMATION Account #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPART'MENT Environmental Heaith Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5758-31-1925 Subdivision Info: Location/Address: Call Road-27028 / 56.896 acres Date Evaluated: �G �� Property Size Water Supply: On-Site Well Community Public �� Evaluation By: Auger Boring b,/ Pit Cut HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTAr SITE CLASSIFICATION: 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 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 - gal/day/ft2 DCHD OS/99 (Revised) ■ ■ ■ ■ ■ ■ �� ■■ ■■ ■■ ■��■�■��■ ■�■��■��■■ ■��■ ■�■ ■■■ ■ ■ ■ ■�■■ ■■�■ ■��■ ■�■��s�■��■��I ■��■�■■■■��I ■�■�■C�■■■��I ■■��■��■��I ■�■■��I ii�■��■■■��I ■��n��i ■��■ .��i��■��i ■�■�■�!��■��i "===c�:::��i i��■■t■■�■�i ■�■■��■��i ■■�■��■■��■i e��=�CC:iii/�i ■��■�■��■��I ■�■�■ ■■■■��I ■��■��■■��■I ■�■��■��I ■�■��■��I ■■�■�■ ■■��■ ■■��■ ■■■�■■ ■��■■ ■■■■�■ ■■�■�■ ■■■��■��■■�■■��■��■■■ ■■■��■■��■■�■■��■��■��■ ■■��■�■��■■■��■■��■ ■�■■ ■■■■ ■��■ ■��■ ■■ ■■ ■■ ■■ ■�■■■�■ ■�■��■ ■��■��■ ■■�■ ■�■■ ■�■■ ■��■ ■��■ ■��■ ■■�■ ■■�■ ■��■ ■��■ ■��■ ■■�■ ■�