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353 Danner Rd. ,, Account #: 990001540 Billed To: Carrie Bolin Reference Name: �r000sed Facility: ResidenCe ATC Number: 2674 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5820-75-2884 Subdivision Info: Location/Address: Danner Road-27028 Property Size: 1.8 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MLTST 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: CERTIFICATE OF COMPLETION Date: � — � �'�� **NOTE** The 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," but shall in NO WAY be taken as a guazantee that the system will function satisfactorily for any given period oftime. ___-.� � ,^'r �/ r 4'V r � � �� i�p' _ J� � V Septic System Installed By: l• ��c;.j-� c.i;, r� Environmental Health Specialist's Signature : � �/ ` / DCHD OS/99 (Revised) ---- ____ _ - Date: �� = �.� C' �/ DAVIE COUNTY HEALTH DEPARTMENT ,r. , •' Environmental Health Section ' P. O. Boz 848/210 Hospital Street ' Mocksville, NC 27028 (336)751-8760 Account #: 990001540 Billed To: Carrie Bolin Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT �� /,/ �/ Tax PIN/EH #: 5820-75-28$4 Subdivision Info: Location/Address: Danner Road-27028 Property Size: 1.8 acres **�E��bsrlmprovemendOperation 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: � Commercial Specification: Facility Type #People #People/Shift #Seats _ Lot Size �� Type Water Suppl D� Design Wastewater Flow (GPD)� Basement/No Plumbing: ❑ Industrial Waste: ❑ Site: New � Repair ❑ // System Specifications: Tank Size/�7 GAL. Pump Tank GAL. Trench Width Rock Depth � Linear Ft�� / Other: Required Site Modifications/Conaiuons: IN[PROVEMENT/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)751-87G0.**** En ��v��`�� —��t � �o r�� i _ � Health Specialist's Signature: DCHD OS/99 (Revised) — %5 r � � Date:Q� �� —��✓ DAVIE COUNTY HEALTH DEPARTMENT ! �•. Environmental Health Section /� y,( � � Q/ P. O. Bog 848n10 Hospital Street � Mocksville, NC 27028 (336)75 ] -87C►0 Account #: 990001540 Billed To: Carrie Bolin Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5820-75-2884 Subdivision Info: Location/Address: Danner Road-27028 Property Size: 1.8 acres ATC Number: 2674 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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: ❑ BasementJNo Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply � Design Wastewater Flow (GPD) �� Site: New�Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �� Rock Depth f�2 _ Linear Ftck�/ �MPROVEMENT/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 8:30 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-8760.**** Environmental Health Specialist's Signature: DCHD OS/99 (Revised) Date: %� � �� Account #: 990001540 Billed To: Carrie Bolin Reference Name: Proposed Facility: Residence ATC Number: 2674 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5820-75-2884 Subdivision info: Location/Address: Danner Road-27028 Property Size: 1.8 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). 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 tion .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT ONSTRUCTION IS V D F R ERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: //Date: /;-,� 7�� CERTIFICATE OF COMPLETION **NOTE** The 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," but 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: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) Date: ,: ,. ��. - ��%n p P�'�� . ;� )�% APPIICATION �Uli SIfE CVALUA�ION/ifl1PROV�ft�➢EYT I3efi�t9i7' & �Q � � Davic County Health Dcpartment � " �� Envir+vnmenta/Hea/di Secb`on � �`/'� P.O. Box 848/210 Hospital Street � . Mocksnille, NC 27028 (336) 751-8760 M ,� � g 2A0{ ***IMPORTANT*** THIS APPLICATION CA2VNOT HE PROCESSED UNLESS AI.I, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFOR2�,TION BULLETIN for instruction3. 1. Name to be Billed �a � i(� � � ��1 �� Contact Peraon 3�3 ��n� ��2 ��► �G � - � �� Mailing Add=esa Home Phona City/State/ZIP �(jL 1�� ) ��1� � � Husiness Phono � � � 1 � l v 2. Name on Permit/ATC iP Di£ferent than Above Hailing Addresa City/State/Zip 3. Appiication For: � Site Evaluation Q�Improvemen� Permit/ATC I� IIoth a, syet� to sez,.ice: ❑ House �Mobile Home 0 Business ❑ Industry ❑ O�her s. Z£ Residence: � People � � Bedrooms � A Bathrooms � � Dishxasher (.l Gasbage Diapoasl [jYWaahing Machine U IIasement/Plumbing CI Duaoment/2io Plwnbing 6. If Duainesa/Induatry/Other: Specify typa � Co�odes @ Shoxers � Urinals # Poople �f sinkn # Watnr Coolern IF FOODSERVICE : # Seats Estima�ed Water Usage (gallona per aay) 7. Type of water supply: �County/City ❑ Well ❑ Community e. Do you anticipatc additions or capaasions of thc facility tLis systcm is intcndcd to scrvc? If ycs, what typc? ❑ Ycs ❑ No ***IMPORTANT*** CLIENTS MUST COMPLETL•'TIIE REQUIRED PROP�RTY INrO12MATlON IiGQULS'I'Cll BELO�V. Either a PLAT or SITE PLAN MUST BESU13MI7TED by tlu clicnt wit� TI{IS APPLICATION. Property Dimcnsions: � . ZS Tax Ofiicc PIN: #_ � O o�i (� =� ��r� gg`I Property Address: Road Name �Gi h��Q �r- �i ol City/Zi� �YIoC�'�U� �� 1\%C o77aZ1' If in a Subdivision providc information, as follows: Namc: WRIT� DIRGCI'IONS (from Mocksville) to PROI'l:lt"1'1': lp O 1 I� .-1-d � Q rl h��r- � 1 r-,-� !� e S�� 5�� Section: Block: Lot: Date Property Flagged: ��' U� This is to ccrtify that tt�e information provided is correct to the best of my knowlcdge. I undcrstand tl�ut Any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use cLauge, or if tLe information submitted in this application is falsified or changecL I, also, undersland that I am responsible for all charges i�rcurred froni lhis applica[iort. I, hercby, give consent to tl�e Authorizcd Represcntative of the Davie Cuunty Hcaltli Departmei�l to entcr upon abovc dcscribed property focatcd in llavic County aad otivncd by to conduct all testing procedures as necessary to determine tLe site suitability. DATE �— d�5 �� _ l -- a o� 1 SIGNATUIt� ��hs�. (�it . i� 8�n-- TIiIS A.REA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includc nll of the following: �aisting and proposcd property lines and �}jmensions, structures, setbacks, and septic locations). c -� -�,� � 9' C �� '�� l � Revised DCHD (07/99) Cu- l �N� �f�° . -�``� . � c1 �s ,,� ,.� ,�' ��.c y � P< < < � � Date(s): Account No. � �� . � Invoice.No. �G�' • ' ,. DAVIE COUNTY HEALTH DEPARTMENT , . , . � �,.c. Environmental Health Section ` Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001540 Tax PIN/EH #: 5820-75-2884 Billed To: Carrie Bolin Subdivision Info: Reference Name: Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 1.8 acres Date Evaluated: %"��— �� Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring �,� Pit Cut ' t ex�ure group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Swcture Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZOP SAPROLITE CLASSIFICATION LONG-TERM ACCEPTA 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 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 - Cn�mb GR - Granulaz ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 OS/99 (Revised) ■��■ ■�■■ ■�■■ ■■�■ ■��■ ■��■ ■��■ ■��■ ■■�■ ■■�■ ■ i i ■ i ■■■■■ ■��■■ ■■�■■ ■��■■ ■■�■■ ■■��■ ■��■■ ■��■ ■��■ ■��■ ■■■■■ ■�■�■ ■�■�■ ■�■�■ ■■■■■ ■�■■■ ■�■■■ ■■��■ ■��e ■■�■■ ■��■■ ■■�■■ ■ ■■■■ ■■■■ ■�■■ ■��■ ■■■■ ■■■■ ■■�■ ■�■■ ■��■ ■■�■ ■■�■ ■■�■ ■��■ ■��■ ■■�■ ■■■■ ■��■ ■��■��■ ■■■■��■ ■s■■��■ ■■��■■�■■■��■�■��■■�e��■■■��■��■■ ■■■��■�■■��■��■��■��■��■■�■��■�■��■ ■�■��■■�■■■��■■■■��■�■■■�■■■■■■�■�■��■■�■ ■■■��■��■■��■■■■��■�■��■��■�■�■ ■�■�e��■��■��■��■�■■■�o■�■�■��■�■ ■■■��■■ ■��■■■■■■■��■��■��■�■■�■■��■�■ ■�■■■�■��■��■��■��■�■■�■■■■��■■�■ ■�■��■��■��■��■�■�■■�■�■�■■�■■��■�■■ ■��■��■■��■��■��■■■�■■■■��■■ ■�■■��■�■��■��■��■�■■��■��■■��■ ■■■��■�■�■■�■�■■�■■■�■�■■�■■��■■■��■ ■■��■■�■■�■�■■�■■■■e�■�■■■■■■��■■��■■■■ ■■�■��■ ■��■��■�■�■��■■�■■■��■■��■�■ ■■��■■��■�■�■■��■�■��■■■■■■■■��■��■�■ ■■■■■■��■��■��•■■�■■■■�■■�■■��■■�■��■�■■■ ■■��■��■■�■��ri�■��■��■��■��■��■��■■ ■■■��■�■■��■��■��■��■�■��■■��■��■ ■■��■■��■■��■��■�■■��■■��■��■ ■��■�■��■■��■��■■■��■��■��■■��■ ■��■■��■�■��■■��■��■■�■��■■■�■ ■��■��■■�■��■■�■ ■��■��■ ■■■��■�■�■��■■�■��■■■��■ ■��n��■�■�■■��■��■�■��■■�■■��■■■■■�■ ■�■��■�■■�■�■��■��■■��■��■■■�■■ ■��■�ri�■�■■■■■■■■■�■■�■�■��■�■■�■��■■��■ ■��■��■��■■�■��■�■�■■�■■��■�■■�■■��■�■�■ ■■�■�■t■��■�■�■■�■��■�■■�■■�■■■��■��■ ■■■■■��■�■■��■�■��■��■��■��■■■�■■��■■■ ■■��■��■�■■�■�■��■��■�■■�■■��■�■�■■��■ ■■��■ ■■��■■■��■��■■��■■■■��■■ ■■�■■■��■��■�■■��■■■��■��■ ■��■■■��■��■��■■■■��■■��■■■��■■■ ■��..==�::::��■i■-,��■�■■��■■��■��■�■■ ■��■■■■�■�■■�■�■■■■�i�■�■��■■��■■■■■■��■■ ■��■�■■�■■■�■■�■�i��■■�■■■��■■■■■��■■ ■�i■��■�■■�■■■��■��i■��■��■■■��■�■■■��■■ �iiiiiii '�iiiiiii�iiiiiiii�iiiiiii�iiiiii�ri ■�i■��■■�■■■��■■■�i■■■�■■�■■■�■��■ ■�i��■■■�■■�■■■��■��i■�■��■��■■��■ ■��■�■�■■■■■�■■■�■■��■■■��■■�■■■■��■a ■i�■��■��■■■��■��■�■■�■■��■■■■■��■�■ ■i��■■■��■��■■■��■�t�■■■■�■��■■■■�■■■■�■�■■ ■i�■��■��...=�::::�■■�■��■�■■■��■ ■��-.��■��■��■■■■��■■��■■■■��■ ■d��■■■ ■�■�■■�■■��■■■■�■��■��■��■ ■�■■o■s■�■■��■��■��■■■■��■��■��■ ■�■■�■�■�■��■■�■��■�■��■��■�■��■■��■■ ■��■■■�■��■��■■�■■�t■�■■��■��■�■��■�■■�■ ■�■■��■��■■��1.'L�■��■■�■�■■��■ ■��■�■�■��■■�Y�I■��■��■��■■�■��■■��■�■■■ ■��■��■■�■■�■II■■�■■�■��■■��■■�■!■��■■■ ■w■■�■�■�■■�■�■■�■■��■�■�■■�■■■��■■■■ ■7I�■�■�■ ■■�■�■■�■■�■��■ I/��■�■�■■�■■�■�■■■■��■��■■�■�■■■o��■■■■■�■ ��■■�■�■�■■■�■■■■��■■��■��■■■�■ ■��■■■�■■�■■��■■■�■�■��■��■■■■��■■■�■ ■�■A��■��■■�■■■��■■■■�■��■�■■�■ ■■�■�■��■�■■�■��■��■�■��■■�■■■�■■■■�■■ ■��/■�■�■��■■�■�■■�■��■��■■��■■�■�■��■■■■�■ ■I■■■■�■��■�■�■■��■■■�■�■�■■■�■■��■�■�■ �■■■■■�■ ■■�■��■�■■�■�■■■��■�■ ■■■■■■■■■■■■�■■�■■��■■�■��■■�■■■��■■■ ■■�■�■�■■��■��■■!��■��■��■■�■■■■■��■■■■ ■��■��■��■��■��■��■■�■ ■■��■��■��■�■■■■��■■�■■�■■■■■■■■■�■■■■ ■��■■■��■��■�■��■�■■■��■■�■■��■■■ ■■�■��■■�■■■■■�■��■��■�■��■■■■��■��■�■ ■�■■■■��■■�■■�■■��■�■■■■■��■�■ ■■■■■■�■ ■■�■��■■�■��■��■■■ ■��■��■■�■��■■��■��■��■■�■■ ■■��■�■■��■■��■■■�■��■■■�■��■■■�■�■■ ■��■■■�■�■��■��■�■■�■■■■■■��■ ■��■■■■�■��■��■■��■��■■■��■��■■ ■■■■■■�■■■�■�■�■�■■■■��■��■��■�■■�■�■■■■ ■