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309 Cedar Creek RdAccount #: 990000890 Billed To: Jerry Banks Reference Name: Jerry Banks Proposed Facility: Residence ATC Number: 2210 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r. o. Bog sasmo xo�p�tai s��t Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5832-81-8204 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 150 x 250 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. � Environmental Health Specialist's Signature: Date: ___/(������/� 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 : DCHD OS/99 (Revised) � �c.l X���� , ��� . '�� 4.. DAVIE COLTNTY HEALTH DEPARTMENT ' Environmentai Heaith Section P. O. Boz 848/210 I�ospital Street � Mceksville, NC 27028 (336)751-87G0 Account #: 990t?00810 Billed To: Jerry Banks Reference Name: Jerry Banks Proposed Facility: ResidenCe IMPROVEMENT/OPERATION PERMIT �d ,a �'9�' ia Tax PIN/EH #: 5832-81-8204 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 150 x 250 ATC Number: 2210 **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: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size /,�"'� Xc3�('> Type Water Supply L�/Pl / Design Wastewater Flow (GPD) ��l� Site: New �" Repair ❑ System Specifications: Tank Size �� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width ��Rock Depth�� Linear Ftc` �' IMPROVEMENT/OPERATiON PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6`� BELOW FINtSHED 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.**** .� � �`� � � -r J �� � � Ii � rl �� Environmental Health Specialist's Signature: � Date: �/.�2/�� DCHD OS/99 (Revised) � ' .�' . i. Z. � ' APPLlCAitON FOA SRE EVAWA710N/1MPROVEMENT PERMR & Dav1e County Heatth Oapartment � Envitvnmental Neu/th Se�abion p.0. eax 818/210 �o�pitsl etrNt . t�ook�vill�, ttC 27028 � • (396)fisi-6760 ;��uv� , �D'�s�� *s*Ii�ORTANT+�'** TRIS 11itQLIC�ITZON � HiS �ROCCBB�D UNLZSS I1LL TR3 A�QtT2A�D I uis'Ott�ATi42i IB �RGV20V�D. itaf�r to th� 'itii'ORMATION BULT.TETiN !or iastructions. �t�a. to b. a�u.a t%Fl�`-'� f�it/�IKS contact �r,on ,,,�E�S/ ���1//�S N�iitoq 11aes.•• .�1?q l.€Dfi�2 �LEE'K %Zp% ao.. �t►oa� �'19� g���i c�hN�t.r..�::p �nc Ks v � LL e; /� G� r7 p 28 s�.�a... �t►on. 1tw oa Nsatt/I►2C i! OitL�s+aC tAan �ba�� i4iliaq �das��� Citylflab/sip �. �piiastioa lor: 1��Si4� �loalnatioa D improv�at Q�rait/1lsC Hoth �. t=.t.e. to ar.so.s �Bon�� 0 Mobii� Hom� O Bu�in�s• O Iadustsy O Oth�r s. I! R�ssid�ao�s i p�opl� � ! S�drooms �_ i B�tbrooms �_ �Oi�hru!►�r O Oasb�q� Oi�po�al �ttaa2�laQ ltao]�l.s� O Saawnt/altsbiaQ 0 Du�ntlNo pluabiaQ i. I! �hiait���/tY►duatsYlOtf�st tp�oii� lyp� i tl�opl� !/iak� � Coeod�� i tAox�s� � vriaal• ! ttat�s Cool�s• I* �'OO�D$sAVICi: � 8�at! =stim�t�d Mit�r ti�aq� Ivailon. par aa�r1 7. ?yp� o! Ma�r wppiy: t] Couatiy/City �1��11 U Co�uaily '. oo yan wnNcipate wddiHons or e�s�ulau af the fac{llty thb ryftem b tatended to scrve? ❑ Ya ��No If ya, w6�t typet •*'�IMPORTANT"**CLiEKfSM[�LTUOMPIETSTHE REQUIREDPROPERTY[NFORMATtONREQUFSTED � BEWW. Eit4ec � PLAT or SITE CI.AN MI�ST B� S[/BMITIED by t6a cUent rrit6 TNl3 APPWCATION. PropsrtY Dimen�iow: �.5� %���� f T�:081ce FIN: ��� 3 2-�l- �a o y� r�� �aa�: ao�a N.ma ('F�r� �e �x �� Ciry►/Zip flc KSwtLE� �tle �r1fl2� Itln a SubdivLioa pcovide Intorm�Hon, �� %limv�s N�me: SeeHoa: Blxlu Lot: WRITE DiREGTlONB (trom Maluville) to PROPEaTYs .1 � � -�1�� �7T 11�bF'1ltDe/ i� lrJEy77�N �( ' �•��I�%t� �� bYl 7".L�Xt� � �L/ ! f��J T�,���, �.�z �,� -� �:� �6-Pa�Z 3o g �� � ��.Z.� c��w� s v+�.�/ ' D�te Properip Fla�edt - /U /l i ( � � Thb b to cerNt�y th�t t6e lntocmallon pe�o�rtded d aorceet to the bat oimy knanrtedaa t anderrq�nd th�t �ay pecmit(�) tuacd 6ereAttec �ce tabject to �wpewtou or revoeaHoa, l[ t4e ttte plaw oe tatended mta c6�nQe, or li tho In[ormallon •abmitted to t6b appUcallon V tabltted or ehsnQed l, a/so, aaderataad �at I a�n rupansJ6k jor alI c�argu lncumed, j(ront �is appitcadoa. I, henby, �lve wn�ent to the Aatborhed Aepcaentsthre ot the Dsvts Coanty Halt Depactmeat to eater apoa �bave dacttbed property located In Dsvie Coanty �nd owaed by �1� �r�l"KS to eaadact all tatis� proudara u naeaary to determine the dte inita . DATL j�� R SIGNATURE THIS AREA MAY 8E USED i�'OR DRAWQiti YOUR 81T� PLAN de �11 tha ioilowinas EiLt�na snd prnpaed rnparty Una an8 dimewion�, �tractora, retbsctrr, �na �epNc loatiow� f ._ - . - _ _ . . _ � ��� . _ _ _ _ _ � ( � Site Revbit Ch�r�e � .r--- �� � - - Revieed DCBD (0'U99) j�lb�r"�j , �� , - 1 ,�` � ! �� , v� r + _ _r�w�P _ _ �� IDste(�): � Cllent I�3otiacation Datet �As: Accoont Na ��� Invoice Na �%�. ,. N , ��, �{ � � , ' � ,�8 6 2 � \ �� .� � � � �l . , ; , � � � . ; s— �'!—s'�,� � G w � N� _ u � \ , � • ��r� � f �"��S r? ✓E � r8 /�' -�► �U /y(�. / r.. . . _ _ o,•� � � , '. ✓ 7�l.; _ . � ,�, _ .�z�r� . .7 } f,..•'r): � =f7 L���� _ p .,'J�T ),' � . APPLICANT INFORMATION Account #: 990000810 Billed To: Jerry Banks Reference Name: Jerry Banks Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATTON Tax PIN/EH #: 5832-81-8204 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: 150 x 250 Date Evaluated: /0122�11�_ Water Supply: On-Site Well Community Public ' Evaluation By: Auger Boring v Pit Cut HORIZON II DEPTH SITE CLASSIFICATION: 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- Tenace 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 frm 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 Strncture 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 DCHD OSl99 (Revised) ■ ■����■ ■��■0■ ■■���■ ■■��■■ ■����■ ■��■■■ �� �� ■■ ��� ■ ■�■�■ ■��■■ ■■��■ ■■■■■ ■■�■■���■ ■��■����e ■��■����■ ■��■■■�■■ ■■�■■■��■ ■ ■■�■�■ ■�i�■�■�■ ■■■�■■■�■ ■■■�■■■�■ ■■���■■�■ ■�■�■■■�■ ■■■�■�■�■ ■■■���■�■ ■■■����■■ ■■■■����■ ■��■����■ ■��■�■��■ ■�■■�■��■ ■���■■■�■ ■■��■�■�■ ■■■�■�■�■ ■��■■■■�■ ■■■■■■■�■ ■���■�■�■ ■�■�■�■�■ ■�����■�■��■■��■��■■��■■■����■■■■■����■w���■ ■■���■������■■�■�■�■■��■���■��■■■■���■�����■ ■�t■■��■�■��■■■■��■■������■���������������■ ■■��■�■■�■ ■�■�■�����■��■�■■��■�■������■■�■ ■o���■�����■��■■■■����■�■■��■s��■■���■���■�■ ■ ■■■�■ ■■■�■ ■���■ ■�■�■ ■■�■■ ■��■■ ■■��■ ■�■�■ ■■■�■ ■�■�■ ■�■�■ ■ i ■ ■ ■■ ■�■■�■■�■■�■■■■���■■■�■�■ ■■■�����■��■■■■��t�■■���■ ■■�■��■��■�■��■■���■■���■ ■���■■■��■■■■���■������■■ ■���■e■■�■���■��■■���■��■ ■■��■�■■�■■�■�����■��■■■■ H■�■■■�■■�■■■■■■■��■■■■■����■■■■■ ■■■�■■■��■��■■■��■■�■■■■■■�������■ ■�■��■■■�■���■■���■��■�■■������■�■ ■�■■�■■■�■■�■�■■��■����■■■■�����■■ ■��■���■������■■■�■���■�■�■■�■��■■ ■■�■���■■�■��■�■■��■����■■■��■■��■ ■■�■■�■�■■�■�■��■■�■■■�■������■■�■ �■■■■■�■■�■■�■��■���■�■���������■ i■■■■��■�■■����■■���■������■■■�■ ■■■�■■■��■�■■i■r�■■�■■■■�����■���■ ■■■��■■■�■■�■�■r�■■��■■■������■■�■ ■■■��■■■�■��■�■��■■��■■■���������■ ■■■��■■■�■����■���■���■■���������■ ■�■■�■�■�■■����■��■�����■■■�■�■�■■ ■�■■■■��■�■■����■��■■■■�■��■■■��■■ �■■■��■ ■■�■�■ ■■■��■ ■■■■�■ c:::��ii��■■■��i��■��■�i■��■�■ ' ■■�■■�i■�■��■�■■�■���■■■������■■■�■ ■���■�i���■�■��■■����■■■■�■������■■ ■■■����■■�■■■■�■��■■���■�■��■■■�■�s ■■■��u■������������������■■■������■ ■■■��i�■���■��■��■�■■■�■���■��■���■ ■�■�����������o������������■��■■■�■ .�.■._a�■■�■■■■��■■�■■�������■■■■■■ iii■����■����■■�■■�■■�■■�■���■���■ ■�■■���■■�■■����■���■������■�■■■�■ ���■�■�■■�■■����■■�■■■�����������■ ��■u■■■�■��■■�■��■���■�■■■■■�■��■■ ■�an�■■��■�■■■■■■■■������������■�■ ■■i�Y��■�■��■■�■■�■■■�■■�������■�■ ■■■�■�■���■�����■■�■■�■■l��������■ �■��■■■��■■�����������■��■����■�■ ■��■■■�■�������������■��■��■�■�■ ■������■�■■��■■�■■�■■■■�������■■■■ ■������■■���■■■■■■�■■■■■�������■�■ ■�■■�■■■■�■■■■■■�■��■■■����■���■�■ ■����■�■■�■��■��■■��■■■■■��■�■■■�■ ■���■■■■■■■■■■■■■■■�■■■�■■■�■��������■■ ■�v�■■��■��■�■��■��■��■���■��■■■■��■�■■ ■�■��� ■■■�■ ■■■■�■■ ■■■■■■■ ■��■��■ ■��■��■ ■�����■ ■�■■��■ ■��■■� ■■■■■ ■�■���■ ■■ ■■■�■■■■■�■■■■ ■�■��■�������■ ■�■��■■������■ ■���������■■�■ ■■■�■■■������■ ■�■■■�■��■�■■■ ■��■��■■■■■■■■ ■�■■■�■■�■���■ ■����■��■■■��■