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373 Cherry Hill Rd (5) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health SectionP.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002367 Tax PIN/EH#: 5756-61-7539.TB Billed To: Terry Burton Subdivision Info: Reference Name: Location/Address: 373 Cherry Hill Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3213 **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 -,—V #Baths Dishwasher: E-!r Garbage Disposal:❑ Washing Machine:Z Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type n #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply`1L Design Wastewater Flow(GPD) 26;� Site: Neyr!1'1 Repair❑ System Specifications: Tank Size 100 GAL. Pump Tank GAL. Trench Width,9 Rock Depth/,-?'.' Linear FtD0,I) Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) 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.**** I AQEnvironmental Health Specialist's Signature: 11,4,4ee Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002367 Tax PIN/EH#: 5756-61-7539.TB Billed To: Terry Burton Subdivision Info: Reference Name: Location/Address: 373 Cherry Hill Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3213 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 1 I of G.S.Chapter 130A,Wastewater Systems, ion.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA R O STRUCTION IS VA ID 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 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 O AY be taken as a guarantee that the system will function satisfactorily for any given period of time. (O r Septic System Installed By: / 1 Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVE31ENT PERRIIT Davie County Health Department 0 ' Eli wrlonmentaiHeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 JUL 1 2 2 ) _ (336)751-8760 ENVIRONMENTAL HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL QUA ., INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed / 2 V Contact Person l / )ey Sy Mailing Address heeev Afl J Home Phone gq� �IJT City/State/ZIP 41d i4ke NC z 702" Business Phone /Q g Z ZDS 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 1J.-STIte Evaluation ❑ Improvement Permit/ATC it'Both 4. system to Service: mouse 0 Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People 3 # Bedrooms 3 # Bathrooms 81"Dishwasher 1.1 Garbage Disposal 1411ashing Machine IW15-.sement/Plumbing CI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: fir~ Seats Estimated Water Usage (gallons per day) 7. Type of water supply: j-county/City ❑ Well ❑ Community ©. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED I3F.LOW. Either n PLAT or SITE PLAN MUST BESUBMITTF.D by the client with THIS APPLICATION. 1� ) Properly Dimensions: / >' WRITE DIRECTIONS(from Mocksville)to PROPERTY: t Tax Office PIN: # Y� — 75_3y.'f8 �O I l � � lar° /ZT l�Il( /fid Properly Address: Road NamO P2 3 C AC gg V t/,��� City/zip /'/6C�5 v. /%t .j�-Ay l e7rf 424 5 If in a Subdivision provide information,as follows: � 'L°�I�C�7► l} le Name: Section: Block: Lot: Date Properly Flagged: Z �' This is to certify that the information provided is correct to the best of my knowledge. I understand that 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 am responsible jar 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 and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE f �— Z— SIGNATUR THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the followig: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Ditc(s): f cy— Client Notification Date: EHS: e Account No. Revised DCHD(07/99) Invoice No. , .., 1.r,,, s „a r" f4!! 131,.A 13a...3 3 a`r f, lr ..fM a - ,3y13Ev3E 3 3 ..e,:` ? ,.�',. 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Evaluated: r�=4 fez: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring__ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON 1I DEPTH u Texture group Consistence — 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: ; L' 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 Mois 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) ■■■e/tt■e■■■tt■■■■■tt■■■ere■■■■■■t■■■■■■■■■■■■■■/■■■■■■■■e■■■■■■■■ ■■■e■tt■■■t■/■■■■■■■■■■t/tt■■■■■/■■■■■■■■■■■■■■/■■■■/■e■■■■■■eee■■ ■■■ttttttttt■■ttettt■■t■/■■/■■■■■■■■■■■■///■/■■■■■■/■■■■eee///■/■■ ■eee■■tt■■e■■t■■■■■■/tt■■■■t■■e■■■■■etee■■e■■■t■/ee■■■■■■ee/eeeee■ 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