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322 Cedar Creek Rd0 � • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 � � �,� (336)751-8760 • Account #: 990002813 Billed To: Jerry Oxendine Reference Name: Proposed Facility: Residence ATC Number: 3489 Tax PIN/EH #: 5842-02-6004.A Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: SEE MAP AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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: T,%�/ Date: � ,� 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 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a gu r�.te� th, t the system will function satisfactorily for any given period of time. � �`r � 1�.1k-�� -1-Z1 Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) I �C,,, T2o IZ7� t_U_':� VO� /� �� , �� ? . Date: _ i r? �� , DAVIE COUNTY HEALTH DEPARTMENT �- j � „ �' , Environmental Health Section � d �o-- � �' P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-87fi0 IMPROVEMENT/OPERATION PERMIT Account #: 990002813 Tax PIN/EH #: 5842-02-6004.A Billed To: Jerry Oxendine Reference Name: Proposed Facility Residence Subdivision Info: Location/Address: 340 Cedar Creek Road-27028 Property Size: SEE MAP ATC Number: 3489 **NOTE** 'fhis ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHOWZATION 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 _ Lot Size Type Water Supply �B ��sign Wastewater Flow (GPD) �� System Specifications: Tank Size�/�� GAL. Pump Tank Other: Required Site Modifications/Conditions: Industrial Waste: � Site: New �Repair � Width �` �iock Depth �J Linear Ft.��C� IMPROVEMENT/OPERATION PERMIT LAY - APPROVED EFFLUENT FiLTER. RISER(S) iF C> " BELOW FINISHED GRADE. ****NOTICE: Contact a represent ' e 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 13p0� p.m. e day of installation. Telephone # is (33()75]-87G0.**** //�ld�'— G �1,� /o��s r� �_5 � '� ' �- � �� `��t� � � �� ' �� r� � Environmental Health S ecialist's Si ature: / Date: / '� r � DCHD OS/99 (Revised) . ' r� ' : DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002813 Billed To: Jerry Oxendine Reference Name: Proposed Facility: Residence ��Q`7 /��-3 Tax PIN/EH #: 5842-02-6004.A Subdivision Info: Location/Address: 340 Cedar Creek Road-27028 Property Size: SEE MAP ATC Number: 3489 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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 STTE 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: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size Type Water Supply � l Design Wastewater Flow (GPD) �.3 �� System Specifications: Tank Siz%GAL. Pump Tank Other: Required Site Modifications/Conditions: Basement/No Plumbing: � Industrial Waste: ❑ Site: New �epair ❑ � � �l ! GAL. Trench Width �� Rock Depth /.� Linear Ft � IMPROVEMENT/OPERATION PER1�91T LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF C" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33()751-8760.**** ' �� c�U�`''u�' � / li� -) I �„� �y �l r � �� 7'�� Environmental Health Specialist's Signature: /��( Date: �olo�-% /? ✓ DCHD OS/99 (Revised) � , • APPUCATION fOR SITE EVALUATION/IMPROVEMENT PERMR & nn • . � • .' � Davie County Health Department � � � � V � • Env�►ronmenta/He�/dn Secb►on D P.O. Box 848/210 Hospital Straat . Mockaville, Nc z�oze � JU�J � 3 2003 (336)751-8760 ***Il�ORTANT+�** THIS APPLICATION CANNOT BS P120CaB3�D UNI.L�88 ALL THa RE ��, , �pU�y INH'ORbATION I$ PROVIDED. Refer to �the INH'ORtrATION BULI,aTIN �or . i. x.�. to b. nsii.a ,�e �v �� .X�P_ �il�/ i�/ c_ ��..._I_13 Roxb�yy cmvr,.7— ��8�.�.�z=p � d v�a�� e�v c� 7 o a� Z. 1iaa� on n�rait/11TC 1! Ditt�s�nt thaa 71bov� ��t.at �.� �7e�►-� � ��xe.�d�i�e Q�. ��. � l� 0 3 �. � � Hu.ie... rtson. lfailinq ]►dds�s• Citp/etat�/Eip 3. J►pplication For: � Site avaluation � Improvement Permit/11TC � a. sY.t.0 to s.r.so.: f�Houa• ❑ Mobila Home 0 Buaiaoas O Iaduatry 0 Oth�r s. I! Residance: � Feople � _ � Bedrooma � � Bathrooms � �d Di�hMa�h�r Q iarbaq� Di�po�al .�Xuhinq Maahiss� O Haa�n!/?ltsbinQ �Bssu�nt/No Dlvabinq 6. 2! auai��/Zndu�try/Olh�rs Sp�oilY typ� E Coa'od�• ; Bhor�rt � Orinal� i P�opl� i Sink� i /hbr Cool�r� I�' D�OOD3ERVICE: � 3sats astimat�d 1Patar Osaq� ��ioa. y.r esY� �. Typ� o! Mat�r supply: 0 County/City �lf�ll e. Do yoa anticipnte Additiooa or e�anstons of t6e fncility thia syatem la intended to �erve? U yes, w6at type? ❑ Community D Yes ❑ No *"*IMPORTANT"*" CLIENTS MUST C�OMPLETE THE REQUIRED PROPERTY iNFORMATION REQUESfED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by t6e elleat w�ith TN13 APPLICATION. Pro� im�ns: �- /"'-'' � _ _ WRITE DIRECTIONS (from Maksvtlle) to PROPERTY: � "r C°c�v `/'� �78 Ta:Odice PIlV: � 5��i �� f-��C�-- ��"'" C,.-� ,�, r�o c_�c v,`i l P To ��1 � . �,,, ,� �r' o Property Addreas: Road Name �r� C e a�3.,.� ('�eeK..R�f F�� ,��,'.�a To �V I�� TD �- 4� Clty/Zip /%%C� SL��//P �74zg __ %'udd�,v� �►d4 e /�c� �'o � If in A Sabdiv[sion pravide information, as followa: d/t/ e e�,�e�-. C�� P,� K/�ol ,� 2,u� NS�1l: SecHon: Block: Lot: ��J �JJ /\ t 9 �i % /Y� �� 2 !vt / � e- 5ee �r �9�1/r Date Property FLg�ed: C� �� — c�� This is to certify t6st the Information provided i� correct to the best of my knawledge. I anderebnd that any permit(s) L�sned 6ereaRer are snbject to easpension or revocaHon, li the aite plsaa or intended aae c6snge, or If the IntormsNon aabmitted in this spplication i� faLtified or c6anged. I, also, u�dnstand tha� I Qm responslblt jor alJ charges IncWmd jrom thls appllcadon. I, 6ereby, give conaent to the Aathorized Repreeentative ot the Davie Coanty Ae�lth Depsrtment to enter npon above deacribed property located in Davte Coanty and mvned by %4�� f/a-��.�, to coodact sU teating procedares ns neceaaury to determine the site auitabillty. DATE �� 3�D 3 S1GNA � � THIS AREA MAY BE USED FOR DRAWIIVG YOUR STI'E I.AN (Inc nde All ot the tollowing: E�atiag and prnpoeed property Unes aod dimenaions, etractarea, eetbacic�, and eeptic IocaHons). Reviaed DCHD (07/99) C L� ./�'� Site Revisit Charge � Date{s): � Client NoNticuNon Dste: EHS• Acconnt Na v � � Invoice Na ` � ✓ � �J�scow C �-�`- ��-� � o (�� -1 �� ,� � ! . � 1, _ \` \ r ... l, `i . , - � � . V � . ` .: ' - ari J �- _ ,� .-. w � � ... . �, , _ . . . i . � �, � � f:4 � :` � ;� (S1£6) `�` � � � . ,908 v r:i � � - Y;�=:.� • . . � : �: . , { •. , �,. �L� l4 • � � } ,r. � 3 ��, �� k F�t�'.N�, r �i � � — .. �' � � . i'y ' f _ � "' iY ..-s . J J� . . • .�Zr �' .. .. L. . , � � � • y ;+ _ `��• : �r . 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Y ,�r ) . + a x' , t µfii r, LLL� �,, � ' � 3srT " �=-�� .,M� �� . . . . .. .,. . � _ � � 9Z'b v oe ° � , . zE'��7 ibl.0'Z) ..i - - ' � � � DAVIE COUNTY HEALTH DEPARTMENT `� � Environmentai Heolth Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002813 Billed To: Jerry Oxendine Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5842-02-6004.A Subdivision Info: Location/Address: 340 Cedar Creek Road-27028 Property Size: SEE MAP Date Evaluated: �� '�Q� Water Supply: On-Site Well �/ Community Evaluation By: Auger Boring Pit 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 ACCEPTANCE RATE SITE CLASSIFICATION: DJS LONG-TERM ACCEPTANCE RATE: REMARKS: Public Cut EVALUATION BY: OTHER(S) PRESENT: 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 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 l:l, 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) ■■ ■■ ■■ �■ ■■ ■ ■ ■■ ■■ ■■ ■■ ■ ■ ■■■ ■�■ ■�■ ■■■ ■�■ ■ ■� ■■ ■■ ■��■ ■�■�■ ■��■■ ■��■ ■�■�■ ■��■■ ■�■ ■�■ ■■■ ■■■ ■■��■�■�■ ■��■�■��■ ■��■ ■��■�■■ ■�■��■ ■��■��■ ■��■ O■��■��■ ■�■■■��■ ■��■�■�■ ■��■■ ■��■■��■ ■■■��■��■ ■■��■ ■�■�� ■�■ ■■■ ■��■ ■��■ ■��■■■ ■�■■�■ ■�■■�■ ■��■ ■��■ ■■�■ ■■■ ■�■�■ ■��■ ■��■ ■��■■ ■�■ ■�■ ■■■ ■■■ ■�■ ■�■ ■��■ ■��■ ■��■��■ ■�■��■■ ■�■��■■ ■�■��■ ■\��■�■ ■��■■�■ ■��■ ■■�■■� ■��■ ■�■��■ ■�■■■�■ ■��a ■��■ ■��t��■ ■��■ ■��■�■ ■��■�■ ■��■�■ ■��■■ ii ■�■ ■�■ ■�■ ■��■ ■��■ ■■�■