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145 Correll Rd
, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section •. P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Account #: 99Q001580 Bilied To: Charles Bell Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5746-81-0168 Subdivision Info: Location/Address: Correll Road-27028 Property Size: 10.07 acres ATC N�� be�r: 2730 **NOTE** This mprovement/Operation Permit DOES NOT authorize the construction ofa 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 INT'ENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type /%i� #People 1 #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 �J9C Type Water Supply Design Wastewater Flow (GPD) �1i Site: New � Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank GAL. Trench Width �G,� Rock Depth l,�L„ Linear F�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATiON PERMtT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G`� BELOW FINISHED 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• . o : p. . the day of installation. Telephone # is (336)751-87G0.**** _ -�� a � _' � � � �ro I ��„�� != Environmental Health S ecialist's Si ature: G� Date: "�� " r � j DCHD OS/99 (Revised) � ��-�/�/�� • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001580 Bilied To: Charles Bell Reference Name: Proposed Facility: Residence ATC Number: 2730 Tax PIN/EH #: 5746-81-0168 Subdivision Info: Location/Address: Correll Road-27028 Property Size: 10.07 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 WASTEWATE NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �> Date: �-�Sr �� CERTIFICATE OF COMPLETION �**NOTE** T'he 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," bnt 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: , r� . �-� �' ( ^� I ' 1 �� C 1 � ' �'� � � �� � f ,,,� � � � _ . �%� Qr' v �Environmental Health Specialist's Signature :__Z��%� Date: '� DCHD OS/99 (Revised) 1 ,. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department i Environmenla/ Hea/th Se�ction P.O. Box 848/210 Hospital Stxeet . Mocksnille, NC 27028 (336) 751-8760 `-' � � L�/ lj F �� EB I 4 2001 VIROfdil�EP1TA! HEA(TH I ***I2�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALI, THE REQUIRED INFORI�►TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed /��� � i �C" � /� �"'` / ,� � Contact Person ( � i�? :': J" �-" "? '�`� r=� / � Mailing Addresa � 5 � C� =' 1 + � r' /' f �"C" / �P Home Phone %? � �� i"�� r �"" -} •'. � /�� "�,� , City/Stttte/ZZP t/ � %;�G^ r"5�. S I r*9 ; �/ r' �> f� ? ' ?°) ,� �' Suaineas Phone � � ( ' J�`,%� lr� " � � i � Name on Pe=mit/ATC if Different than Above �� � M�iling Addreas City/State/ZiP 3. Application For: Q°Site Evaluation �rT`mprovement Permit/ATC � Both a. syat� to service: ❑ House G�" Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: � People �_ � Bedrooms �_ A Bathrooms � O Dishwasher ❑ Garbage Disposal �Washing Machine � Basement/Plumbing ❑ Sasement/No Plumbing 6. If Huainess/Induatry/Other: Specify type # People � Sinks i � Commodes i Shorera � Urinals # Water Coolera „� .,. IF FOODSERVICE: # Seats Estimated Water Usage ty�iona per a8y) �. 2�pe of water supply: ❑ County/City � Well ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑ Yes �] No If ycs, w6at type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the clieat with THIS APPLICATION. Property Dimensions: �if � D% !-'r f:? .S WRITE DIRECI'IONS (from Mocksville) to PROPERTY: Tax Office PIN: # �/ � �/7r� / (� � �2n1-'� ��? L✓ � -4� r�'�'`-�:� r�� (. 'f "�a�1 i:.{','`�., /� Property Address: Road Name C.- u� f` ir` E �� �.'. �'': � i c� -r -- ...r''` s i l ., c� _ �' .� r' 'r .r 3 W, ,. � � � t'� . ,/ ' � City/Zip r,`; � . �:',<.,si �l�` � %OZ� ;''�.�,r,�, d.� �,'� .►._ t1f�,�� ;yi�?3 �_r - , , `A � lf in a Subdivision provide information, as follows: �°✓- «.7:>-�_� l, aj,� �� _;':.►, -f'*c;,� � r-, �,,�1ji-�.,�,.��� ��% � Fv�' ` Name• (._, i�2-�-�r �:; - G��1 •G�� �„��^�,iif �_;,�*, �c,,=�' �,.;f`� .�t,•' , '�� �.:. `,, �, � . Section: Block: Lot: Date Property Flagged: �! � L�n / 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 ia this application is falsitied or changed I, also, understand that I nm responsible jor al! charges incu�red from this application. I, here6y, give consent to the Authorized Representative of the Davie County Health Department to cnter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATIJRE � .�-,.>ry� ��ta.. ,� c�:1 -P.�L�;'� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). �� � � �� �� � �-°7 t �-- � �,� ; �� , � � ��� � �✓L �-- C�� �•-� �,�-.� _-� � �. Revised DCHD (07/99) Site Revisit Charge Date(s): ' Clieat Notification Date: ' EHS: Account No. I � � � Invoice No. � � `� . � .: r 9. ,,�� �, � � � � �� " � . .� :- 1t � �.. 1. � �� 1��� '�� - ��� �" �k�a y ��.. � w � ��� � g8G!, �f 3 ' �'�+;"'it,-��. �, . h � . �' � (t � � �� �,{� � � . ... . . i � bfi'H`r ...'4A� �{ ,�(� C1� [ t i(M 1 .i ,C a i ,� "f �:�. � � k '�r� ._, e �r . 'y . aQ' ,�. 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Environmental Health Section � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001580 Tax PIN/EH #: 5746-81-0168 Billed To: Charles Bell Subdivision info: Reference Name: Location/Address: Correll Road-27028 Proposed Facility: Residence Property Size: 10.07 acres Date Evaluated: ��� �/ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut HORIZON II DEPTH SOIL WETNESS �LH��1ri�H i i�i� SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE REMARKS: OTHER(S) PRESENT: LEGEND Landscape Position R- Ridge S-$houlder 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 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 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) ii ■ ■ ■ ■ ■�■■�■ ■�■■�■ ■��■�■ ■■�■�■ ■■��■■ ■■■�■■ ■�■��■ ■■■��� ■�■■■ ■�■■�■ ■��■�■ ■■�■�■ ■■���■ ■�■■���■■���■■ ■■�■���■���.�■ ■��■■■��■■■oe■ ■��■���N�■�■■ ■■��■���■����■ ■■■�■�■�■■���■ ■■■���■������■ ■�■���■��■�■�■ ■�����■■�■��■■ ■������■�■��■■ ■��■�■�■■■���■ ■�■■���■■■■�■■ ■■�■■���■�■��■ ■����■�������■ ■�■�■���■�■■�■ ■■■���■�■����■ ■■���■■■����■■ ■��■�■�■���■■■ ■■�■■���■�■��■ ■■���■■�■�■��■ ■�����■�■�■■�■ ■■����■■■��■�■ ■�■■���■���■�■ ■��■�■�■�■���■ ■■�■�■■■■■■■■■ ■ ■■■■ H�■ ■■■��■■■ ■�■■�■�■ ■��■�■�■ i�����■■■ GV���■■� ■�I■���■ ■v■���■■ ■��■���■ ■����■�■ ■��■�■�■ ■■■■��■■ ■■■���■■ ■■��■�■ ■�■�i�■ ■■■�i�■■ ■■■■ ■�■■ ■■■■ ■■■■ ■■�■ ■■�n ■���i ■���i ■���i ■■��� ■�■i� ■�■�� ■■■��■■�■ ■��■����■ ■�■■�■■�■ ■�■■��■�■ ■��■��■�■ ■�■����■��■�■ ■�■■�■�■■�■�■ ■��■�■��■��■■ ■■��■■■■■■��■ �■■�■�■ ■��■ ■■■■���■■�■ ■■■�■�■■��■�■ ■�■■■�����■■■ ■�■■�■��■��■■ ■■�■■■■�■■��■ ■■��■■���■�■■ ■■����■��■■�■ �■■�■�■■�■■■■ ■■■��■■��■■■ ■■■■��■ ■�■�■�■ ■���■�■ ■���■■■ ■���■■■ ■■���■■ ■��■��■ ■��■■■■ ■■����■ ■��■■■■ ■�■���■ ■■■�■�■ ■���������■ ■������■��■ ■�■�������■ ■■■■������■ s■■■��■■�■■ ■�■���■���■ ■�■�������■ ■���������■ ■■��������■ ■■■�������■ o�■�■�■���■ ■�■�������■ ■�■�■�■■��■ ■■■��■��■�■ ■■�■����■■■ w■�■■���■■■ ■■�■�����■■ ■■■��■■�■■■ ■■■���■��■■ ■■��■��■■ ■■��■■��■ ■■��■■��■ ■�■��■■�■ ■�■■��■�■ ■■■■��■■■ ■�■■���■■ ■■�■■���■ ■■■�■■��■ ■■■�■■��■ ■�■�■■��■ ■■ ■■�■ ■■�■ ■■�■�■ ■■■■�■ ■��■�■ ■��■■■ ■��■�■ ■�■■�■ ■■■��■ ■■���■ ■■■■�■ ■■���■ ■���■■ ■�■■�■ ■�■��■