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991 Davie Academy RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)75]-8760 IMPROVEMENT/OPERATTON PERMIT Account #: 990001208 Billed To: Michelle Dwiggins Reference Name: Michelle Dwiggins Proposed Facility: Residence Tax PIN/EH #: 5717-76-4011 Subdivision Info: Location/Address: Davie Academy Road-27028 Property Size: 2.0 Acres **NOTE�* Tlii b�mprovem5 endOperation 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). THLS 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 /%i /f #People % #Bedrooms � #Baths �_ Dishwasher: �1 Garbage Disposal: ❑ Washing Machine: �- Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �i�G Type Water Supply � Design Wastewater Flow (GPD) c's�d D Site: New �Repair ❑ System Specifications: Tank Size/pD(� GAL. Pump Tank GAL. Trench Width�G �rRock Depth /.2 ��Linear Ft.�' Other: ti��GCi►, l%� � � o� ' � %�"�/�'S Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 130 p.�ry� 9n the day of installation. Telephone # is (33G)751-87G0.**** Environmental Health Specialist's Signature: �G��` Date: �i `�� �� DCHD OS/99 (Revised) J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001208 Billed To: Michelle Dwiggins Reference Name: Michelle Dwiggins Proposed Facility: Residence ATC Number: 2454 Tax PIN/EH #: 5717-76-4011 Subdivision Info: Location/Address: Davie Academy Road-27028 Property Size: 2.0 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I**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). 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 i G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS ! AUTHORIZATION FOR WASTEWATE CONSTRUCTION IS VALID FO PERIOD OF FIVE YEARS. ' � /� Env�ronmental Health Speciahst s S�gnature: � Date: � lb �� 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. J Ir Septic System Installed By: Environmental Health Specialist's Signahue : DCHD OS/99 (Revised) /-s—� X3a,�2�, Date: � � - ✓ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & C Davie County Health Department D Environmenta/ Hea/th Se+crion P.O. Bou 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 VE � 3 I 2000 ***Ilrl'PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL°iTiiE'�RE�tr� INFORI�TION IS PROVIDED. Refer to the INFORbIl�TION BULLETIN for instructions. 1. Name to be Billed �^C � �� I g Contact Peraon � q R� � W'��' ��� Mailing Addreea Q � Home Phone T1 �—^% ��� r �i city/state/z=P �� �} O n/ V i�, �� .�-� as�' suainesa Phone 2. Name on Permit/ATC if Different than Above Mailinq Addreas 3. Appiication For: ❑ Site Evaluation City/State/Zip ❑ Improvement Permit/ATC �Both a. syatem to service: � House 9�Mobile Home ❑ Business ❑ Industry ❑,.Other s. =f Residence: # People _� # Bedrooms ..3 " l �k Bathrooms �. GYDiahwasher ❑ Garbage Diaposal L`i�Waahing Machine Q Basement/Plumbing ❑ Sasement/No Plumbing 6. If Suainese/Induatry/Other: Specity type � Commodea # Shoxera # Urinala �F People N Sinka � Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallone per aay) �. Type of water suppiy: ❑ County/City ❑ Well 0 Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? If yes, what type? ❑ Yes B'1�10 ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PLAN MUST BE SUBMIITED by the client with THIS APPLICATION. � �.i � .O �lC, Property Dimensions• �g � G�� X 3�S ��$ x 3 ba�G X WRITE DIRECTIONS (from Mocksville) to PROPERTY?� TaaOfTcePIN: #.57/7--7�-��/ G o oN ��v: �, �c.,���►►-,�) �A, ' S,R. /� 4 7 Property Address: Road Name p�}v •� �. q c� o� w�y R�, � fJS� �o� Q��. B����; �� � O City/Zip n?o C�SV � �.�-� ��C,, .Z'�' If i�t a Subdivision provide information, as follows: Name: Section: Block: Lot: bv�/��q��JS Rc�, �a-r� is,juSl N�d� � � LJ % Sc ; �( � �, c�-•� .� � fi 1 �/ � u, 4L V e, Date Property Flagged: �- �- g' �' d 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 applicatioa is falsified or changed. I, also, understand that I am responsible jor all charges incurred jrom this application. I, hereby, give consent to the Aut6orized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by C, ���C � v� • g�2 i�1 S' to conduct all testing procedures as necessary to determine the site suitability. DATE O S 3 / " f3 � SIGNAT[JRE �' • � ^ � THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN (Iaclude all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). �i rRG1�e.Q � �� Revised DCHD �07/99) Site Revisit Charge � Date(s): I Client Notification Date: I EHS• Account No. �0 � Invoice No. .�T / � / ����i.ir Ra � � / ar� �s,� � � / t , G1��6�, � 5� G � , ` `� � �avF[ — , ` 1 �� QG, / _ �' �°`' / w ,�� ,�. � � ,� �� � � s ,� I� 2:� VICINITY MAP � � . ��. � c� � � ���� z W � t +4• °D ,�" ,9�'� N - Q � � O ��� � d b � 00 z "' b- � � b �0�� w ,J 'z' � � � � � � Q ( � �� � � � � � � �� Q� .r �- � I 7` � G'��',�' �• ♦ M I � � v, a � i d�r,� � j y � �'��`�9s � • ` ��1� 'N� { � � L�� B ���� � A , �;� � ��� D�`� ��; -� ;� a �_ � ' ►�� � ,_- � �,,,oN � AREA= 2.000 AC. � ^ � 3 ���r � •,���`s-� .--------------------- _...--. . `'(� � Q INCLUDES S.R. 1147 R/W — 1 u� c� �� �• � � o I / � � � � z � y � �o a z � s � 0 36p•6$ �. �I R°i � g "12�5r � . o� � z W � G�INS . � � N`P �, D�pG. 862 � ED$ g4. c� D N � . � � LEGEND `� � P.I.P.= PLACED IRON PIN � � O N.I.P.= NEW iRON PIN � q � = P/K NAIL ❑ = SQUARE STONE + =UNMARKED POINT IN C L OF RD. � s � o+ I, GRADY L. TUTTERON, CERTIFY THAT UNDER MY DIRECTIDN AND SUPERVISION, THIS MAP t�N� NAS DRAWN FRQM AN ACTUAL FIELD SURVEY S MADE BY TUTTER❑W SURVEYING COMPANY. z --------------------------------------- PROFESSIONAL LAND SURVEYOR 1-2527 TUTTEROIP SURVEYING COMPANY 124 S�UTH SALISBURY ST, - MOCKSVILLE, N, C. 27028 (336) 751-5616 • 50 25 0 50 100 ' 150 - SCALE IN� FEET PLAT [�' SURVEY F�t� CARL D WIGGINS REv t s td+s 1" = 50' �ones �r� 9 dc J MAY-22-2000 G.L.TUTTEROW Ft� � �WIG— AR a' sa. SroNE BEING 2.000 AC. OF THE CARL QWIGGINS PROPERTY , ' —" — — — — +" — '—' — — — — — (E3.B. 94, P�. 862) LYING tN THE CALJ�HALN TOWNSHIP DAVIE COUNTY NORTH CAROLt13A 1RA1+111G IX/1�,1U . TAX MAP REF.: K-3, P/0 9 14700�3 , . . .; _ . . « , • . .. , . . :;. , , . Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001208 Tax PIN/EH #: 5717-76-4011 Billed To: Michelle Dwiggins Subdivision Info: Reference Name: Michelle Dwiggins Location/Address: Davie Academy Road-27028 Proposed Facility: Residence Property Size: 2.0 Acres Date Evaluated: (9 '/� '� � Water Supply: On-Site Well � Community Evaluation By: Auger Boring 1� Pit FACTORS Landscape position Slope % HORIZON I DEPTH Texture group Consistence Swcture 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 WET'NESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: _ 1 0 ,. � �.� .. Public Cut 3 4 5 6 7 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: .� OTHER(S) PRESENT: REMARKS: �"u!I �aG�✓ Ud�— LEGEND Landscape Position R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope CC - Concave slope CV - Convex slope T- Tenace 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 - Firrrt 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 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)