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259 Cedar Creek Rd, DAVIE COUNTY HEALTH DEPARTMENT � � . Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001536 Billed To: Eugene Pope Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT P'C �' ,��— ° / J �./ V �ti. Tax PIN/EH #: 5832-90-7849 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 127'x 558' ATC Number. 2679 **NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 oC #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 ��A�� Type Water Supply � Design Wastewater Flow (GPD) Site: New ❑ Repair � System Specifications: Tank Size/DDa GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �� Rock Depth �� Linear Ft.�OD� �' I1�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 830 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** Environmental Health Specialist's Signature: s��G' `—� Date: �^�� L%� .� DCHD OS/99 (Revised) �` Account #: 990001536 Billed To: Eugene Pope Reference Name: Proposed Facility: Residence ATC Number: 2679 DAVIE COUNTY HEALTH DEPART'MENT Environmental Health Section P. O. Bog 848/210 Haspital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5832-90-7849 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 127'x 558' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISStJED 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 i G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. I Environmental Health Specialist's Signature: , - Date: �� 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: 1��°� � I r � Environmental Health SpecialisYs Signature :^�� Date: � l�—� DCHD OS/99 (Revised) aPP1�CAT10N FUIi SI CE CVALUA�tION/iflli'fi(3Vtihg��Ii I3�fii�9f l� &�i D Davie County Health Department � En vironmenla/ Hea/di Section P.O. Box 848/210 Hospital Street Mocksnille, NC 27028 (336) 751-8760 � �G-�i JAN16� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROGESSED UNLESS ALI, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for ins�ructions. 1. Name to be IIilled L Lf oj�iL��..� /_O�%� Contact Peraon S�i�� Mailing Address a �-�.tJ/--,► CCrCI'��c GJ/-� ��. iZcQ Home Phono �% �/ %�a 3,('� citl./state/zxP f"r��s V/��f /lJ •�°= • Husinos8 Phono 2. Name on Pezmit/ATC if Different than Mailinq Addreas 3. Application For: �3�.te Evaluation City/State/Zip 0 Improvement 7H ❑ Fi0�1 a. syst� to service: GLFiSuse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: � People _�_ � Bedrooms �� Bathroom� �_ (ij�etshxasher [l Garbage Diapossl f�i�sahing Machine ❑ IIasemont/Plumbing ❑ IIunam4uit/2io Plumbing 6. Zf Dusinesa/Induatzy/Other: Specify'typa # Poople li Sinka # Co�odes # Shoxers # Urinala # Water Coolern IF FOODSERVICE: # Seats Estimated Water Usage (gallona por a�y� �. Z�pe of water supply: ❑ County/City �Well ❑ Community s. Do you anticipate additions or eapansions of tt�e facitity tLis systcm is intended to scrve? ❑ Ycs Y1..�kt If ycs, what type? ***IMPORTANT*** CLIENTS hiUST COMPLETCTII E RL•QUIRL•'D PROP�RTY INrOIiMATION 1t�QULS'I'GD BELO�i'. Either a PLAT or SITE PLA.N h1UST BESUBMI?TED by thc clicnt witli THIS APPLICATION. Property Dimensions: /Z 7�`7� d y �.S � i"t WRIT� DIRECI'IONS (from Mocksvillc) to PROI'LR'1'1': Tnx on�� rrx: #.�� 3�- 5 0- 7 P� �% � isd� f� f�r w►�ti� �.� /��D Property Address: Road Namc C��k C'icc��-%t 2� �f-�`t � v j�/ ✓-?��`r �-v l�tp ,�►�-�i` City/Zip fhc�c�LS v i i/,�- If in a Subdivision provide iaformation, as follows: Namc: Section: Block: Lot: U�J �c� tt��r -,�q �.cl�s�.: /Lcf% . /L� sLi/� v� C�- c.p�a� c�. �-.�-/� � �j fp� pJ l�" 7'l� Date Property Flagged: / � /6 - ° � This is to ccrtify that the information providcd is correct to the best of my knowledge. I understand t1�At any permit(s) issucd hercafter are subject to suspension or revocation, if the site plans or intended use cl�ange, or if tl�c infor�nation submitted in this application is falsified or changed. I, also, understand that I am responsible for al! charges i�tcr�rred fronr lhis application. I, hercby, give consent to tLe Authorized Represcntative of the Davic Cuunty Hcaltl� Departn�ent to enter upon a6ove describcd property locatcd in Davic County anJ owned by to conduct all testing procedures as neccssary to determine the site suitability. DATE / � � %� ` v / SIGNATUI2� ��c,v � , ///G,�L.c� TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of thc following: �aisting and proi�oscd property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit C�argc Date(s): Clicnt Notificatioa Datc: EHS• Revised DCHD (07/99) t�ccount No. / � � ?" `�8�✓ Invoicc.No. � , \ 7170 ` D50000004901 _ -� 1.77-A ) o � s � 5832907849 � ��1 7849 � 291 300 Tot � APPLICANT INFORMATION Account #: 990001536 Billed To: Eugene Pope Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Landscape position Slope % 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 HORIZOP SAPROLITE CLASSIFICATION LONG-TERM ACCEPTA SITE CLASSIFICATION: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5832-90-7849 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 127'x 558' Date Evaluated: �/=„�- D�' On-Site Well v Community, Auger Boring ✓ Pit 1 I 2 �� 1�� y� �� RATE I . � LONG-TERM ACCEPTANCE RATE: � Public Cut 3 4 5 6 7 EVALUATION BY: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R- Ridge S- Shoulder L- Lineaz 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 EFT - 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 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) ■ ■ ■��■ ■�■■ i ii ■ ■ ■ ■ i ■ ■�■�■■■��■■■��■■��■�■i ■�■��■■■��■■�■�■■�■�■�■i ■�■■��■�■�■■■�■��■i ■■■��■■�■�■■■��■■■�■�■i ■��■■■��■�■�■■■��■�■i ■■■■��■■■�■��■■�■�■��i ■�■■��■■■�■■■�■■■■�■��i ■■�■��■■�■�■��■■�■�■�■i ■■■■��■■��■e■�■■��■■� ■��■■�■■��■�■��■��■�■i ■�■■��■��■�■�■■�■■�■■i ■■■■��■�■��■■■�■■�i iiiii�iiiiiii�iiiiiii�i ■��■�■■■■��■■��■��i ■��t��■■■�■■��■■��■■■� ■■■��■��■��■�■�■�t■��i ■�■��■■■■�■■��■■■�s■��i ■�■��■■�■�■��e�■�■��■�■i ■�■�■■■��■�■��■�i ■■■■��■�■�■��■�■■■■��i ■��■■��■�■�■��■■■.�■■oi ■��■■��■�■�■�■�■■�■�■■�i ■��■■�■■��■�■�oe■■��i ■�■■��■�■■N■�■■�■■�■�i ■■■��■��■�■■■��i ■�■■��■�■�■�■��■�■��■�i ■■■■■��■��■��■�■�■■�i ■■�■��■��■�■■■�� ■��■��■��■�■�■��i ■■■■■�■��■�■■�r:��i ■�■■�■■�■�■��■�■��i ■■■■�■��■■■ ■��■��■��■■ ■��■��■��■�■■■��■ ■�■��■SS�■��■��■■��■■ ■�■��■�■■■�■��■�■■ ■�■■��■e�■�■��■■ ■■■��■��■�■��■ ■■■��■��o�■��■■■ ■■��■��■■�■��■��■�■■■ ■■��■■s■■�■��■�■��■■■ ■■�■■■�■■�■��■■�■■■■�■ ■�■��■a■■■o��o��■�■ a■■��■�■■�■��■■��■ ■�■��■��■��■��■ ■�■��■��w�■��■■��■ ■�■�■■��■■�■�■■■■��■■ ■■■■■�■■�■�■■��■��e��■��■■�■��■■��■■ ■■■■�■■�■■■■�■■■�■�■��■�■■��■��■■■ ■■�■ ■■��■■■�■��■�■��■�■��■■ ■■�■■�■■�■�■■�■■■■��■■�■■��■■■��■��■ ■■�■■��■�■�■■��■�■��■■�■■��■��■�■■■■■ ■��■�■■�■�■■��■�■■�■��■■��■■■�■��■�■ ■��■��■■��■��■■�■�■■��■��■��■�■�■ ■�■�■■��■■��■■�■■�■�■■��■��■�■��■■■ ■■■��■■��■■■■■■■�■■��■■■��■■��■■ ■■■��■�■■�■��■■■■��■�■■■��■��■■■ ■�■�■■�■��■■■�■�■ ■�■�■��■��■��■ ■ ■■■�■��■��■■■��■�■ ■�■�■��■�■■�■��■ ■�■�■■�■��■�■■�■ ■�■�■��■■■�■��■ ■�■�■��■�■��■■■■ ■■■■�■��■■■�■�■�■■ ■■■■��■��■ ■■�■�■■��■��■ ■ ■��■■■�■■■■■��■ ■■■��■�■■��■■■�■■ ■��■�■■■��■ ■�■��■��■��■��■ ■■■��■ ■■�■�■ ■■■��■ ■�■■�■ ■■■■�■ ■�■■�■ ■��■ ■�■��■■�■ ■■�■■�■■■■ ■��■�■■�■ ■��■■�■�■■ ■��■��■ ■��■ ■��■ ■��■ ■�■��■■��■ ■■■��■�■■■ ■�■■�■�■�■ ■■■■■■■■�■ ■■