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173 Dance Hall 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 #: 990001698 Tax PIN/EH #: 5833-93-2568sc Biiled To: Sherry Campbell Subdivision Info: Reference Name: Proposed Facility: Residence �� s �l—�l Location/Address: Dance Hall Road-27028 Property Size: see map ATC Number: 2823 **NOTE** This ImprovemendOperation 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 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: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �/�� Type Water Supply L� � Design Wastewater Flow (GPD) � Site: New � Repair � System Specifications: Tank Size l�0 � GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Widtt� Rock Depth � Linear Ft.� INIPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6`° BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8: 0 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** � r Environmental Health Specialist's Signature: Date: ��� �l � DCHD OS/99 (Revised) �A �, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Account #: 990001698 Tax PIN/EH #: 5833-93-2568sc Billed To: Sherry Campbeli Reference Name: rivNvacu f dl.11ll�/. RGSIUGIII:G ATC Number: 2823 Subdivision Info: Location/Address: Dance Hall Road-27028 � r1UjJGllj/ JILC. �CC AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental �'i Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to I 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). TI-IIS � AUTHORIZATION FOR WASTEWATE�2 C�1STRUCTION IS VALID OR A PERIOD OF FIVE YEARS. ' �/� / ° Environmental Health Specialist s Signature: � , / Date: � CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall in ' ate the system described on ImprovemendOperation Permit has been installed in compliance with Articl G.S. hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO W tak a guar�ntee that the system will function satisfactorily for any given period of time. � � Septic System Installed By: —���,� yo� x�x1�U �� Environmental Health Specialist's Signature :�/ r/�(.% Date: ��[� !/l � DCHD OS/99 (Revised) �+ � � � � � � 1 I�•••. ' � � APP r , ., ! :� • � - �. ._...�J � ENVIRONMENT^.L HEALTH UAVIE C� . . aTY I�I FOi� SITE EVALUA7tON/IP�1PROVEMG'�!T �'�(t1�91T & A�'C Davie County Health Department Environmenta/ Hea/th Se+ction P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 I�C�g��� a r U' � APR 1 '� 20�1 _--•,..r.rrtt t".wtll�il ***IMPORTANT*** THIS APPLICATION CANNOT SE PROGESSED UNiESS ALI. THE REQUIRED INFOR2�TION IS PROVIDED. ReEer to the INFORMATION BULLETIN for instructions. Name to be SilledShc_�r� L..(X�. ll.i.�(Y1'��-',`1 Contact Peraon � I /L('�� � l��.l�_��. � Mailinq Addreas � �—� ����1C � . M� A� � 2 C7� Home Phone �� � �i 7f ` ���1,�, city/state/z=r (i1��C'.��71�1� � RJ. C. `��C��i�`� ausinea$ Phone � �C.s `(��;7C� '�C y 1 � � �k �� r, � ,_, �K Z���J Name on Permit/ATC i£ Different than Above �l���L Msiling Address `��1�[' - CitY/Stats/Zip �i�'�1i . Application For: 1�Site Evaluation 0 Improvement Pexmit/ATC Both `� �/ syec� to se���a: �19CHouse ❑ Mobile Home ❑ Business D Industry ❑ Oth r l ` s. =f Residence: # People ��-�_ �k Bedrooms ►J � # Bathrooms ylf�(�-�-. Dishxasher ❑ Garbage Disposal � Wash.ing Muchine ❑ Basement/Plumbing ❑ Baaament/No Plumbing 6. f Buainess/Industxy/Other: Specify type �k People # Sinka � Commodes # Shoxers � Urinals # Wator Coolers IF FOODSERVICE : # Seats Estimated Water Usage (gallona ��r �y) �. Type of water supply: 0 County/City Lv1�We11 C] Community e. Do you anticipate additions or ezpansious of the facility tt�is system is intended to servc? If ycs, what type? ❑ Ycs 1s�'�10 ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATIUN EtEQUGSTLD BELOW. Either a PLAT or SITE PLAN h1UST BESUBMI7TED by the clicnt with THIS APPLICATION. Property Dimensions: � �� �.�1� ����( T��-� Tax Oftice P1N: # �(; � �q � �J�� � Property Address: Road Name r�?..r�C�, Tt �� �� c�tyr�;P rt�.-����,,11 e I �'�o� lf ia a Subdivision providc information, as follows: Name: � I � Section: Block: Loh �VRiTE DIRECI'IONS (from Motluvillc) to PROPLR"Tl': I�� � o.._'s� �,c) c��:�, � T��n ��-� G c� �m � � �� M �r� ) � � �c7 �-C�J,.i.,c.-�' ; t1�A. �.- � G�t� } �����T �l_�.r, LP:� can-�� `�`�� � ���Z m; �e� �-r=�..�- r�,, .�� ��� �� -��, c���c� 2 � �� �J � L !�� M ',1 e .> �xrr� 1 e�-� cx� -�c� ��r��_ �� �;' ��" � � Gn 2,; �v.� A� �c�s� �'��0 Date Property Flagg d: �1 - � q_ o� 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 iutended use change, or if the information submitted in this application is falsificd or changed I, also, undersland lhal I am responsible for all charges incr�rred fronl this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above descri6ed property located in Davie County and owned by7n-b�� CY:�_�, (�z_f.nrinQT,� ��. �Sy��c'�"�\ �=�-�'�'�(��`-�� to conduct all testing procedures as necessary to determiue the site suitability. � - �J DATE G�R?cJ� �`� h,��C��� S[GNATURE � �/`/� � � �� TiiIS AREA MAY BE US�D FOR DRAWIl�IG YOUR SITE PLAN (Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Revised DCHD (07/99) Aczount No. W / � . Ji/ Invoice No. � � � / J ��,,� - _(1643�_ __--�--- _- � I 287 ------- � Oo � -p � � � � � � I � -- �5Z � -_ � - -_ - _ 7� 0 --- - _- --- m DAVIE COUNTY HEALTH DEPAR'I'MENT � -, � � Environmental Health Section � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001698 Tax PIN/EH #: 5833-93-2568 Billed To: Sherry Campbell Subdivision Info: Reference Name: Location/Address: Dance Hall Road-27028 Proposed Facility: �t�Ce Property Size: see map Date Evaluated: �/��fl �/ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut_ HORIZON I DEPTH Texture group Consistence Stn�cture 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: 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 Mineralo�v 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fll - 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 DC�ID OS/99 (Revised) ■■ ■■ ■ ■�■ ■�■ ■�■ ■�■ ��� ■��■��■■�■■■■ ■��■��■■�■■�■ ■��■��■■■�■�■ ■��������■■�■ ■��■������■�■ ■�■■���■��■�■ ■�■�����■�■�■ ■�■��■�■����■ ■���■■���■�■■ ■■��■■��■■��■ ■■■���■■�■�■■ ■■■������■�■■ ■ ■�����������■ ■■■■■■■■�■■■■ ■�������■■■■■ ■■■�■����■��■ ■■�■��■�■��■■■■ ■■■��■■■���■��■ ■■■���■■�����■■ ■■■������■��■■■ ■�■�■�■��■�■��■ ■�■�■�■■�■■��■■ ■�■■■�■��■��■■■ ■�■■■■■■��■��■■ ■�■■■��■��■���■ ■■���■�■■�■���■ ■��■�■��■�■���■ ■■�■��an■��■��■ ■■�■■�■��■�■■�■ ■■■■■■■����■■■■ ■■����■�■■�■�■■ ■■��■�■�■��■�■■ ■■■�■�■�■■�■■■■ ■�■������■�■■■■ ■���■�■■�■���■■ ■■��■■�■��■�■■■ ■�■�■■�■�■■�■�■ ■■�■■■�■■�■���■ ■■�■■■����■�■�■ ■■�■�■��■�■■■�■ ■■�■���■■�■�■�■ ■■■■�■�e===:::: ■■�■��■�i■�■■■�■ ■■�■��■�i■��■��■ ��aiiiii�iiiiiii ■r�����■�i■■�■�■■ ■■u��■■��■■�■■■■ i i ii ■■ ii ■■ ■ ■�■■���■ ■���■��■ ■���■��■ ■��■■�■■ ■��■■0�■ ■�■■��■■ ■�■��■■■ ■��■���■ ■��■�■■■ ■■��■■■■ ■���■�■■ ■■�■��■■ ■■���■■■ ■������■ ■■��■��■ ■■�■■�e■ ■■�■■��■ ■■■��■■■ ■���■■■■ ■■■��■■■ ■■■�■�■■ ■■■�■�■■ ■�■����■ ■����■�■ ■����■�■ ■��■���■ ■�■■�■�■ ■��■�■�■ ■�■��■�■ ■������■ ■��■■■■■ ■��■■�■ ■��■��■ ■�����■ ■�\�■�■ ■��■��■ ■�\�■�■ ■�■�■�■ ■��■■�■ ■■����■ ■■��■�■ ■�����■ ■�����■ ■■����■ ■■���■■ ■■■��■■ ■■����■ ■����■■ ■�■��■■ ■�■�■■■ ■��■■�■ ■����■■ ■■■���■ ■■■���■ ■�����■ ■■■��■■ ■■■���■ .■�■�■■■■��■��■�■■�■���■■��■■��■■�■ ■�■■�■�■■��■����■�■■��■�■��■■��■■■ ■��■���■���■■■■�����■■��■■■����■�■ '�iiiiiii��iiiiiii�iiiiiii�iiiiiii� ■■��■�������■■■■�■■�■■�■����■■■��■■ ■■�■�����i■��■■■■■���■■■��■■■■■■��■ ■■■■����u■��■��������■�����■�■�■�s ::::ii��r■��■■■■�■■��■■■������■■■■ ■�■�■■■■�■■�■■�■�����■�■�■��■�■■■■ ■�■����������■�■■�■����■■��■■�t■■■ �■�■�■■�������■■�■■����■■■■����■■ ■�■�■■�■■��■■■■�■��■�■��■����■�■ ■�����■■�■���■��■�■��������������■ ■������■�����■��■�■■��■■■��■■■��■■ ■�■■�■■■■�■��■�����■�����■■�■����■ ■��■���■■��■■■■�■■�■■■�■������■■�■ ■��■����������■■����■■■■��������■■ ■■���������■�����������������■■■■■ ����������■��■��■■�■■■■���������■ ■■����■��■■�������■■■■������■��■ ■��■�■�■■��■�■■��■�■■■��������■■�■ ■�������■��■■�■■�■■■���■��■��■■■�■ ■■��■��■■��■��■■�■�■�■�■���■��■��■ ■���■���■���■�■■�■■��������t�■■��■ ■■■�■����■�����■■■■■���■■����■■�■■ ■■��■■■■�■■■�■■■■�■���■�■■�■��■�■■ �i■���■■�■■��■�■■�■■����■■��■���■■ i��■��■�■■�����■�■���■�■■■■■���■■ ■�■��■�■�■■■■■■■■■�■■�■��■■■■���■■ ■�■■■■�■■■■■■���■■�■■■■��■■�■■���■ ■�■��■������■■■■■■�����■�■■■■■��■■ ■�■■�■�■�����■��■��■�■���■■�■■■�■■ ■��■�■�■■■■■■■��■��■■�■�■■■■■■■�■■ ■��■�■■■■■■■�■��■��■■■■�■■■�■���■■ ��■�■�■��■�■■��■��■■�■��■��■■��■■ ■����■����■■■■■��■��������■■��■■ ■t���■■■■■■�■■�■■�����������■■���■ ■�■����■■����■■■�����t������■■��■■ ■■■■�■�■■■■■■������■�������■�■���■ ■■���■■■��■�■■����■��������■■■��■■ ■����■■�■■■������■�������■■■■■�e�■ ■��■�■��■�����■■■■���������■■����■