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841 Cedar Creek Rd (2) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002346 Tax PIN/EH M 5842-14-3650 Billed To: Patricia Sawyer Subdivision Info: Reference Name: Location/Address: 841 Cedar Creek Road-27028 Proposed Facility: 'Reside a Kenntt Property Size: see map ATC Number: 3196 **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 616 ople/Shift #Seats Industrial Waste: ❑ Lot Size AN Type Water Supply Design Wastewater Flow(GPD) 1��2a _ Site: New Repair❑ System Specifications: Tank SizeMGAL. Pump Tank GAL. Trench Width 2,1•Rock Depth Linear Ft.,Idd' Other: !—(L����i/e Pl Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISERS) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002346 Tax PIN/EH#: 5842-14-3650 Billed To: Patricia Sawyer Subdivision Info: Reference Name: Location/Address: 841 Cedar Creek Road-27028 Pro osed Facility: Property Size: see ma ATC Number: 3196 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,S ion.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA N TRUCTION IS VALID F R A PERIOD OF FIVE YEARS. i Environmental Health Specialist's Signature: , - Date: 71 627 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 I 1 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. /�J �3 t Septic System Installed By: Environmental Health Specialist's Signature: e,L/Z� / Date: DCHD 05/99(Revised) �. ----- P 11 TION FOR SITE EVALUATION/IhIPROVEMENT PERMIT&ATC � TT Q C; Davie County Health Department H l E Environmental Health Section r' P.O. Box 848/210 Hospital Street U JUL Mocksville, NC 27028 (336)751-8760 F •jmi4jAL HEALTH ***IMP r I PLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. I. Name to be Billed _ r4)6d LI GhA V. S AlM1f t- Contact Person ?AT P_;Cla V SRT— Mailing Address u t eed6 r 1- 'r Po Pa Home Phone 9(t9-2 ab 1 City/state/zip Business Phone 10Sr 31-C- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 10 Site Evaluation ❑ Imp ovement Pe t/ATC �f eeBoth 4. System to Service: ❑ House ❑ Mobile Home �r Bust ss ❑ Industry ❑ Other &Jll S. If Residence: # People # Bedrooms # Bathrooms II Dishwasher 1.1 Garbage Disposal M Washing Machine ❑ Basement/Plumbing II Basement/No Plumbing G. If Business/Industry/Other: Specify type "e.I'1Ylr,U # People #Sinks I # Commodes ( # Showers # Urinals # Water Coolers IF FOODSERVICE: #1 Seats Estimated Water Usage (gallons per day) a•p 7. Typ© of water supply: ❑ County/City aFell ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 1Z No Ifycs,what type? *IM1'0R7AN7'***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED IIE.LOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. 11 Properly Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: 1 Tax Office PIN: # J7 �0 56 -FAt=mi 6aoa1 26An le F► or✓-ta u.W;1)r, Property Address: Road Name 841 Cedar Creek kaft Tie)n P_ Rt Al>, + )4 orf ro City/Zip MoCLsyiIIG C �-lo��' � � fIoai), Aprex_ 34y'; P ooj If in a Subdivision provide information,as follows: taf'f. - YDvSt. AFrTer Ced•tr. CrfEL Name: �A ;b4 ulut2xt° Section: Mock: Lot: Date Properly Flagged: o 1" 7-1 4_0 'Phis is to certify that the information provided is correct to the best of my knowledge. 1 understand t tat any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I, also,understand that I ant responsible for all charges incurred front this application. 1, hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County an v by to conduct all testing procedures as necessary to determine the sit uitabili DATE - SIGNATURE THIS ARCA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): A',, rDA� Client Notification Date: EHS: Account No. Yj Revised DCHD(07/99) Invoice No. `/ c L . m9b'6LZ 66 5'£93 b'.. '9fZ bZ CO. pelt �Z 6Zb �pv 4 °.:(ol al) > __-� Kd m0 p, �' ..LG Ov £Z � .PveZ'ZI) ;4+ b92� i > w � �� ' �z IZ9. T'• rf.9L + X r m�� lo`L O r., }o id m `r 'VL5 01YZ4'2by ! ; � i^x 9F lBl 2. �ao •- I -' b� t , o 4 , 0�B2/ ( ` 9 < .. ZZ bZOZ ov 9L'b) ov 9L i 10' s OV IN, , 8 W, ,i DAVIE COUNTY HEALTH DEPARTMENT ✓ Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002346 Tax PIN/EH#: 5842-14-3650 Billed To: Patricia Sawyer Subdivision Info: Reference Name: Location/Address: 841 Cedar Creek Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: �2_ Water Supply: On-Site Well / Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 41 Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH - Texture group Consistence l /- Structure b/ 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: 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 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-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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 05/99(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■til,■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■//■■■■■■■■■■ MENNENiiiiii iiMENNE■ EMEMii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■/■■■■■■■■■ ■/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■MEMO ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■