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520 Chinquapin Rd. � , DAVIE COUNTY HEALTH DEPARTMENT - ' Environmental Health Section � P. O. Boz 848/210 Hospital Street �/(� —� Mocksville, NC 27028 � / (336)75�-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990001802 Tax PIN/EH #: 5813-56-6097 Billed To: Tommy McEwan Subdivision Info: Reference Name: Proposed Facility: Residence Location/Address: Chinquapin Road-27028 Property Size: 4 acres **N(3"I'�'� 'Chi b�mprovem�ndOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 7/ #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 `// C Type Water Supply t�� Design Wastewater Flow (GPD) � Site: New �Repair ❑ , �D� System Specifications: Tank Size/Q� GAL. Pump Tank GAL. Trench Width�� Rock Depth �� Linear Ft� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATiON PERMiT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. t�'3II'i:H�e�.th�dav of installation. Telephone # is (33G)751-87G0.**** Environmental Health Specialist's Signature: Date: �=-�� DCHD OS/99 (Revised) J/ � � � . � � ' � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Account #: 990001802 Tax PIN/EH #: 5813-56-6097 Billed To: Tommy McEwan Reference Name: Proposed Facility: Residence ATC Number: 2910 Subdivision Info: Location/Address: Chinquapin Road-27028 Property Size: 4 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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: ��G�.�" l Date: �— �� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall has been installed in compliance with Article 11 of ( Disposal Systems," but shall in NO WAY be taken a given period of time. Septic System Installed By: I Environmental Health Specialist's Signature : DCHD OS/99 (Revised) S described on ImprovemendOperation Permit Section .1900 "Sewage Treatment and he system will function satisfactorily for any Date: G � / � � I 1 2. IN FOR SITE EVALUATION/IMPROVEMENT PEfiMIT & ATC Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***s��_.,. ��JiFfIS APPLICATION CANNOT BE PROCESSED UNI,ESS ALL THE REQUIRED INFaiu�1T• S PROVIDED. Refer to the INFORL�ITION BULLETIN for instructions. ame to be Billed �j3'j �� t//�q6� � C�[,J1G!/1 Contact Person v�� e Mailing Address L. ✓� V �• ✓• (/ v� s6 U'1"� Home Phone �336 ) Z�� -2 5� 2 City/state/ziP �OG/f,sv/l/t" rJ�/• �• �-�/Q20 susiness Phone �33b% �S�—�� Name on Permit/ATC if Different than Above r��c �c. +C Mailing Address City/State/Zip 3. Application For: LiYSite Evaluation ❑ Improvement Permit/ATC Both 4. System to se�„ice: House � Mobile Home ❑ Business ❑ Industry ❑ Other 5. =f Residence: � People J # Bedrooms � # Bathrooms Z ❑ Dish�rasher ❑ Garbaqe Disposal LL/FTashing Machine ❑ Basement/Plumbinq (] Basement/No Plumbing 6. If Business/Industsy/Other: Specify type �k Commodes # Showers # Urinals # People Y Sinks # Water Coolers IF EOODSERVICE: # Seats Estimated Water Usage (gaiions per day) 7. Type of water supply: ❑ County/City I�J'well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to scrvc? If yes, what type? ❑ Ycs ly'1Vo ***IMPORTANT**'� CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by t6e client with THIS APPLICATION. Property Dimensions: 7' CC � � �.� Tax Ofiice PIN: # �O � ��b D � / / Property Address: Road Name C'!r T n�u�z� in City/Zip ��kru�/� 2 %b ?� If in a Subdivision provide information, as follows: 1Vame: Scction: Block: Lot: WRITE DIRECfIONS (from Mocksville) to PROPG127'Y: �G / /t��r t`, q�,z�,�c8•�:/ss ?V r/� C ��'�Osi �'!� � /� �jl uc��%-� /��_ ��'�� /��;/s -�2��o�P� �a ��. 01. l��vCj `i'�S� �e ut�-e�'�c,S�'�ScJc C� ��X✓'t°!vS Gt o�•..e l�C�- Datc Property Flagged: �o ` > � l� � This is to certify t6at the information provided is correct to the best of my knowledge. I undcrstand that any permit(s) issued hereafter are subject to suspension or revocation, if the sitc �lans or intended use change, or if the information submitted in this application is falsified or changed 1, also, ui:dersta�:d t1:at I nm responsible for a!! cltarges i�rctrrred fra�� this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property locatcd in Davie County and owncd by to conduct all testing procedures as necessary to determine the sitc suitability. DATE � / 0 � �Gb� SIGNATURE ��• �' ` ��- THIS AREA MAY BE USED FOR DRAWIIYG YOUR SITE PLAN (Includc all of thc following: Existing and proposed property lines dimensions, structures, setbacks, and septic locations). '`"`�ouse w�ll6�. /oc4-Ft�� '� �j 1 Qk.u��SY' .S�vlY'Ovn0i1`Nd �t�f• C�� J Revised DCHD (07/99) � �,�-"` 0 (.�i �� rty s �h e�/� �LV Date(s): Client Notification Date: EHS: Account No. 0 U Z Invoice No. � � � • • � ' . DAVIE COUNTY HEALTH DEPARTMENT � '� �� ' <' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001802 Tax PIN/EH #: 5813-56-6097 Billed To: Tommy McEwan Subdivision info: Reference Name: Location/Address: Chinquapin Raad-27028 Proposed Facility: Residence Property Size: 4 acres Date Evaluated: �%'"�—� � Water Supply: On-Site Well i� Community Public Evaluation By: Auger Boring Pit Cut KhJ 1 Kll; l 1 V b t1UK1GVIV Q A DD /lT iTC SIT'E 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- 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 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 Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralo�v 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 ■■�■��■■■■ ■■�■■�■��■ ■�■��■�■ ■■■■■�■�■■ ■■■■��■■ ■■�■��■�■■ ■��■�■■�■■ ■■�■��■■ ■�■�■�■��■ ■■■�■�■■�■ ■■■��■��■ ■��■�■�■ ■■�■��■ ■■■■�■�■■■ ■��■�■■�■■ ■■■■■�■�■■ ■��■�■■■ ■��■■��■ ■■■��■�■■ ■■��■��■ ■■■�■■■�■ ■��■��■�■ ■��■■■ iii ■ ■�■■ ■�■■ ■��■ ■��■ ■��■ ■��■ ■■�■ ■��■ ■■�■ ■■��■��■�■�■�■ ■��■�■��■ ■�■�■�■��■��■■�■ ■�■�■��■■�■��■■ ■�■■��■��■�■�■■ ■��■�■�■■�■��■� ■��■■■■�■�■��■ ■■■■��■�■��■■�■■ ■■■■��■�■■�■■��■ ■■■■�■■��■■�■■ ■■■■■�■��■��■ ■■■■��■��■�■■■ ■■■�■�■��■�■�■�■ ■��■■■��_ ■�■�■■■��■■■■ ■��■■�■■■ ■■■�■■��■�■��■�■ ■■ ■■ ■ ■ ■��■ ■�■■�■■ ■■��■■ ■��■�■■ ■��■�■e ■��■■■ ■��■�■ ■■�■��■ ■■��■�■ ■■■�■�■ ■■■�■�■ ■■■��■ ■��■ ■�■�o■■ ■�■■�■■ ■�■■�■■ ■��■■■■ ■■■■��■ ■■�■�■■ ■■�■■�■ ■�■■■�■■■■ ■�■��■��■■ ■��u■��■■ ■■��■��■■ ■��■■■��■ ■��■��■ ■�■��■■ ■��■��■■ ■��■■■ ■■��■■ ■��■��■■ ■��■ ■��■��■■ ■��■■�■■■ ■■��■■■■■ ■■��■ ■■■��■■�■ ■�■��■■■�■ ■�■■�■■■�■ ■��■ ■��■■��■■ ■■��■ ■■��■■�■ ■■��■ ■��■■��■■ ■■��■��■■ ■■■�■��■�■ ■■■■■■��■■ ■■■■■■�■■■ ■■��■�■��■�■■■��■■■■��■ ■■��■�■��■�■■■�■■■■■■��■ ■■��■■��■��■■��■■■�■��■ ::��■�■��■�■��■��■ ■�■■i��■■■�■■��■��■��■ i�iiiiiii�iiiiiii�iiiiiii ■■■■t��■�■■■■■�■■■■��■■ ■��■i��■��■�■��■��■ ■��■■�■■■■■��■■■■�■ ■■��■�■��■�■■��■��■ ��■■■■�■��■■�■��■■■ ■�■��■��■��■■��■ ■�■■��■■■■■■��■■��■ ■�■■��■■■�■��■ ■�■■��■��■ ■�■■��■��■��■ ■��■■■■��■■■■■��■■■■■�■■ ■■��■�■��■�■■�■��■■ ■��■■■■■�■��■■■��■ ■��■��■■�■■�■��■■ ■■��■■�■��■��■ ■■■�■■�■■��■�■�■■��■■ ■■■�■■�■■��■�■��■ ■�■��■��■��■ ■�■��■■�■■�■��■■■■��■■ ■�■■■��■■�■■■■��■■ ■��■■■�■�■��■■ ■�■■��■��■�■��■�■��■■ ■��■■��■■�■��■ ■��■��■��■■�■■�■��■�■ ■■��■■��■��■��■■■ ■■�■■■�■■■■��■��■■■■■■ ■■��■��■■��■��■��■ ■■ ■■ ■■ ■■ ■■