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281 Double A Trail" . DAVIE COUNTY HEALTH DEPARTMENT � � ' � Environmental Health Section � "' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87C►0 Account #: 989900647 Billed To: Anthony Allen Reference Name: Anthony Allen Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT �°d �� Tax PIN/EH #: 5863-90-3758 Subdivision Info: Location/Address: Double A Trail-27006 Property Size: 1 Acre ATC Number: 2093 **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 Deparhnent prior to the construction/installation of a system or the issuance of a building permit (in compliaoce 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 /�' #Peo le �. #Bedrooms�_ #Baths-� P Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �G� _ Type Water Supply G�/f` Design Wastewater Flow (GPD) C��l� Site: New la Repair ❑ System Specifications: Tank Size�(� GAL. Pump Tank Other: Required Site Modifications/Conditions: i� ir i GAL. Trench Width '�L Rock Depth�� Linear Ft.�� IMPROVEMENT/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 830 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)751-8'7G0.**** Environmental Health Specialist's Signature: �,( YG2r;/ � Date: %��' DCHD OS/99 (Revised) �� Account #: 989900647 Billed To: Anthony Allen Reference Name: Anthony Allen Proposed Facility: Residence ATC Number: 2093 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5863-90-3758 Subdivision Info: Location/Address: Double A Trail-27006 Property Size: 1 Acre AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MIJST 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). TI-IIS AUTHORIZATION FOR WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � �, Date: �l�/�� CERTIFICATE OF COMPLETION **NOTE** 'The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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 syst will function satisfactorily for any given period of time. l Cns � l�°� a . � ��i A�s�` .� � Septic System Installed By: Environmental Health Specialist's Signature : �� Date: /'ti �% '� DCHD OS/99 (Revised) APPLICATION FOR SffE EVALUATION/IF.�PROVEMENT PERMIT & ATC Davie County Health �epartment Environmenta/ Hea,'tfi Sedion P.O. Box 848/210 Hos�ital 3treet Mocksville, NC 27028 • (336)751-8;60 � C��C�OdC� .1�V 2 $ �999 ***I1�ORTANT*** THIS APPLICATION :ANNOT aE PROC�SSED UNLE33 ALL THE REgOIRED '� �_ir'FO�T=ON IS PRO�IDEII�. Refer to 'r,hs ID7r'ORi�3ta�ION EUI�LETIIZ £or instructions. _� c l��ntl� L.�n�i:JKo i. x�. to v. si.ii•a A►� i HoNy LC�E A��1 Contact P�raoa ?N i-H�NY lu.i�N 13ailinq Addr�es �i5� DC>V 6UC P T2�� - soma phoaa �1�5 -' `J' 77� � citY/stat../z=r /1DVPNLE . N L 2.700lo susine.s phon. 2. Nama on ?armit/ATC if DifPoront thaa Abow �� fi ON y �LLE 1�1 ♦ Mailiaq ]1ddr�ss �bl Dovt3iE {� T{zA11� City/Stato/Zip /��vPNc.E, rv c. 2�ovl� s. Appiication For: �Site Ensluation ❑ Impronement Permit/ATC 1�� th/�u-1� 9s � a. s�st� to s.z.►saa: � House ❑ Mobile Home ❑ Business ❑ industry � Other ~' 5. If Residence: Ik People � Ik BedrOoms ..3 �Dishrashor �Garbaqo Disposal ��Pashiaq Machino ��Hasom�nt/PlumbisQ 6. IL Huainass/Industsy/Othar: Spocify typa i,�oopi� e N Commodas � Shox�rs � Urinals � # Bathrooms 2. Z � Has�at/No Blumbinq � Sisska � �Patas �colors iF F0093ERViCE: # 3eats Estimated Water Usage cgaiioas p.= aaY) 7. Type o� Yater supply: ❑ County/City � Well ❑ Community s. Do you an�icipate additions or eapansions of the facillty this system is intended to serve? ❑ Yes �No i#� �9z. wti.9t �Bi ***IMI'ORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED iBELOW. Etther a PLAT or SITE PLAN MI/ST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: � P G�� Taa Oflice PIN: # 58�3 - q o-�-15 $ WRITE DIRECTIONS (from Mocktville) to PROPERTY: TPI�� S�{ o E -�� ;�. ,'� E`�� ►;`tf l. Property Address: Road Name Z`� � C�U U P� l.E P. T Q_A1 L LC i� i� �'� �J ��' I �-t' o, t Ctty/Zip h�dP'`�F� ,s� Z7oo(o `/�.r%'s' 1 rJ �I/'- �.� T�! CZ P. Uo 1'-;�i�� o�' , If in a Subdivision provide information, as follows: Name: SecNon: Block: Lot: , � I�iIL(�. � ��' 1 C�f`� f.�JU;'•!,r; �. Date Property F7agged: C� < ;•�-' ; % `� `� This is to certify t6at the information provided is correct to the best of my knowledge. I anderstand that any permit(s) issaed hereafter are snbject to saspension or revocaHon, if the aite plans or intended ase change, or if the information sabmitted in this application Is falsified or changed. I, also, understand that 1 am responsible for al[ charges incurred from this application. I, hereby, give consent to the Aathorized Represeatative of the Davie Connty Health Department to enter upon above described property located in Davie Coanty and awned by G( � M� �. Pt-�N Lw � �A �� :wn�i�+,� � �'V�� - w ��.4 . "�.�.. :^ � �L 5�.�� 2�5.4. �� .�..��v+�� w w�rb `1� •!�v Y� VO NJ YV�W�I�lAl� M1V �LvrW�L�aIiW iYY GI�Y �1Y��IMY�W��• DATE � � �Z 4y' � % SIGNATURE ��i THIS AREA MAY BE USED FOR DRAWIl�iG YOUR S1TE PLAN (Inclade all of the following: Eristing and proposed property lines and dimensions, structures, setbacks, and septic locations). _ �2c� ��'i.:_4=:''i `d L; �� .'_, , .,J; ;�/ t�> Revised DCHD (07/99) [-� `_U('i L ��=.t• � _'�_., Site Revisit Charge � Date(s): � Client Notification Date: I EHS• Account Na �� Invoice Na _ � • __{..-i,' APPLICANT INFORMATION llAVIE CUUN'TY HEALTH DEPA1tTMENT Environmental Health Section SoilJSite Evaluation PROPERTY INFORMATION Account #: 989900647 Tax PIN/EH #: 5863-90-3758 Billed To: Anthony Allen Subdivision info: Reference Name: Anthony Alie� Location/Address: Double A Trail-27006 Proposed Facility: Residence Property Size: 1��,, Date Evaluated: �<.�� Water Supply: Evaluation By: rexture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HnRIZON III DEPTH On-Site Well .�/ Community Auger Boring_�__ Pit SITE CLASSIFICATION: �� LONGTERM ACCEPTANCE RATE: � / _ �/ _ , I REMARKS: EVALUATION BY: Public Cut OTHER(S) PRESENT: �- LEGEND L�ndscape Position R- Ridge S- Shoulder L- Lineaz 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 Ioam 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 is 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 t ucture SC - Single grain M- Massive CR - Crumb GR - Granular 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 - gallday/ft2 bCHb (Revised OS/99) ■■■ ■■■ ■■■ iii iii iii iii iii iii iii ■■■■■ ■��■ ■��■ ■�■■■ ■�■�■ ■�■�■ ■■■�■ ■��■ ■��■■ ■��■ ■��■ s�■�■■��■ ■�■��■��■ ■��■ ■��■■■■��■ ii ii ii ■■ ■■ ■■ ■■ ■■ ■■ ■■ �� ■■ ii ■�■ iii ■■■ ■�■�■■■■ ■��■■ ■■■��■ ■■■■!V■■ ■�� ■ ■�■■i� ■ ■�■■■��■ ■��■��■ ■��■ .......��.. ----- ■■�■■■■■ ■��■�■ ■■■�■ � ■ ■■��■ ■■■��■ ■��■ ■��■�■ � �----- ��..� ■��■■■■ ■��■�■ ■■■■ ■��■ ■��■ ■��■ ■��■ ■■■■ ■■�■ ■■�■ ■■�■ ■��■ ■�■■ ■■�■ ■■ ■��■��■��■��■��f■■��■�■ ■■■�■��■■�■�■■��■��■��■ ■�■��■�■■�■�■��■■�■�■�■ ■��■�■��■��■■��■■��■ ■��■�■��■�■��■��■�■■�■ ■��■�■��■��■��■�■��■ ■■■�■��■�t�■��■�■■■�■ ■■��■■�■�■��■■■��■��■■ ■�■��■��■��■��■��■�■■ ■■��■��■■■��■��■��■■■■ ■■■■■■�■■��■��■��■��■■ ■��■��■��■��■■�■■ ■■��■■��■■��■■■■ ■��■��■��■■�■�■�■ ■��■��■��■■�■■��■ ■��■■■■�■�■■�■�■��■ ■��■��■■�■��■■�■■■ ■��te■■��■�■■��■��■ ■■■■■■■��■■■■��■■■■■��■■��■ ■■��■■■��■��■��■�■�■■ ■■■�■��■��■■ ■■■��■��■■��■��■■■ ■��■■��■��■�■�■��■ ■■��■�■■■��■■■■�■�■��■ ■��■■��■��■�■��t■�■�■■��■■ ■��■■��■��t!��t■��■��■ ■■�■■��■J��■■��■ ■■�■��■■�■■■��r��■■■■■■ ■��■��■■■��■��■■■�■■ ■��■��■�■■�■��■■��■■ ■■■��■�■■�■■■��■��■■ ■■■■��■��■■■��■�■ ■■�■�■■��■��■�■ ■■■■ ■■■■ ■�■■ ■�■■ ■■�■ ■��■ ■��■ ■■ ■�■■��■��■ ■■■■��■ ■�■■■�■��■■��■ ■��■■■■��■��■�■ ■��■■��■■■��■■�■ ■��■�■■■ ■■��■■■■ ■■■■��■■■ ■�■�■��■��■�■ ■■��■��■■�■�■■■ ■■��■■■�■■�■ ■■■■��■�■■ ■��■��■�■■ ■��■■��■ ■��■■��■■��■�■ ■��■■■■■■��■■ ■��■■��■��■��■ ■��■■��■ ■�■■■��■ ■■��■��■�■■ ■��■■�■ ■��■��■ ■�■■■■■ ■�■■��■■■ ■��■��■�■ ■��■��■