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260 Duke Whitaker RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003135 Billed To: Russell Hicks Reference Name: ATC Number: 3732 Tax PIN/EH #: 5801-80-0252 Subdivision Info: Location/Address: Duke Whitaker Rd -27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **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). 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: &4� Date: J11,I/Al CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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. D`t r% Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) t;7f DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section _ o ► ' r P. O. Boz 848/210 Hospital Street l Mocksvi Ile, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003135 Tax PIN/EH #: 5801-80-0252 Billed To: Russell Hicks Subdivision info: Reference Name: Location/Address: Duke Whitaker Rd -27028 Proposed Facility: Residence Property Size: see map **NOTE * This Improvement/Operation 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 CONTRA/C/TOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _Z #People _ #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 Type Water Supply All I/ Design Wastewater Flow (GPD) Site: New,2!r Repair ❑ System Specifications: Tank Size`( GAL. Pump Tank GAL. TrenchWidth,?,L Rock Depth ," Linear Ft& Other: As stated in 15A NCAC :18A.1909(5 accepted-S"yTfri-5 may uISO DU 050 Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the ealth Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:3 o on. elephone # is (336)751-8760.**** l/ Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) oma.• • - APPLICATION FOli SITE- [VALUATION/IA1PHOVDIEN'f 11L'11MIT & A•hC Davie County Health Department �5 Enyiromneata/Hea/t/i Section P.O. Box 848/210 Hospital Street 04 Mocksville, NC 27028 (336) 751-8760 T** IS APPLICATION CANNOT BZ PROCESSED UNLESS ALL T11L REQUIRLD _ I FO IS P�ROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be billed _[ j(,(5`�� V , I��S Contact Person Mailing Addresso?(oo —DClItp— jJf O-ker RJ- Itowe Phone 13131- - _C;b` City/State/ZIP/'/0�5/,Me tYCi 2712-- Business Phouc 2. Name on Permit/ATC if Different than Above Mailing Address City/Stale/Zip 3. Application For: zoite Evaluation Improvement Pei-Init/ATC ❑ 1)oLli 4. Syatem to Service: ❑ House X Molzile Home ❑ Businets ❑ Industry Cl Other 5. Type system requested.* Conventional 13conventional modified ❑ innovative G. If Residence: It People a Bedrooms 3 11 Bathroom:; *Dishwasher ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Dasoment/No Plumbi:ig 7. If Dusiaess/Industry /Other: verify type II People It Sink 0 Commodes II Showers 0 Urinals II (Vater Cooleru IF FOODSERVICE: D Seats Estimated Water Usage (gallons par day) 8. Typo of water supply: ❑ County/City Well ❑ Community S. Do you anticipate additions or expausious or the facility this sysleul is iulende(1 to serve? ❑ yes *nu If yes, what type? _ ***11111'ORTANT'°** CLIENTS Al UST C0d11'LET1- TIIE RLQUUMGD 1'lt01'LeItTY INF0104ATI 0N I Z E Q 1) 1 -1- ST ED IIELOIV. Eitlier a PLAT or SITE PLAN MUSTBESURK17TED by the client ivilli THIS APPLICATION. Property Diulensions: Tax Office PIN: lE -58� ) $0 -o 5 z PropertyAddress: RoadNanic t?,4 City/Zip if in a Subdivision provide information, as follows: Namc• Section: Block: Lot: )VR1TE ll11tL'ICNONS (fruiu A-luclisville) lo PRUI'I;ItTY: {i - 6- HWtiJq Pes.4 -+urn —994 Or) -fu r yl l2;ut0 .i�nf na- 3 d r'y tJ4 D n jc,&Jn to a- A icken a.0� Date lionic corners flagged: Slaflwl This is to certify that Elie information provided is correct to Elie best of my knowledge. I understand that any perniit(s) issued liereaftcr arc subject to suspetision or revocation, if the site plans or intended use change, or if we information submit(ed in this application is falsified or clianged. I, also, understand that I ani responsible fur all charges incurred.rain this application. I, hereby, give consent to the Authorized Rcpreseutalive of me Davie Cu(uity IIealth 1)ep:u tuicnl to enter upon above described property located in Davie County and owned by f-aci L', HAS to conduct all testing procedures as necessary to deterutine the site suitability. DATE •3136I6 SIGNATURE TRIS AREA MAY BE USED FOR DRAWING YOUR SIT.[ PLAN (Include all of Elie following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). cz�tk Sign given Revised DC (05/03 Site Revisit Charge Dalc(s): Client Notification Date: MIS: Account No. <-�s 00\11%InYeiee N0. __. 4—/0 _ _� SA) r — 398 y {59Q) Y "-•. i - 195.15 ---------- 09A) y t 3293 38g -- �`` 13.26 A � (11.44 A) 6069�� � 11 A134 � z w 11.69A) 0820 y � LgF \H15LIN, 36 1' 117 t ` 77A) � US ----------- �f " o ----- , p INDEXED ON 5 INDE 91 e w (4.73A) 01 26? h� C�Lo3' P � • A 91 275 �Q (369) roS O 270 1.50A) ,,_ ` tl� 140 87 U 4 6R 1313 (120.34 A) 4659 „ ; µ�a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section «° SoiVSite Evaluation APPLICANT INFORMATION Account #: 990003135 Billed To: Russell Hicks Reference Name: Proposed Facility: Residence Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5801-80-0252 Subdivision Info: Location/Address: Duke Whitaker Rd --27028 see map Date Evaluated: FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy A l 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: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 Mineralozv 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 05/99 (Revised) Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy A l 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: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 Mineralozv 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 05/99 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■MN■■E■■■■ ■■■■■■■■■■■■■■■■■■■■Mme■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ i i ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■Nee■■■�■■■■Nee■■■■■■E■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■MOON■■■■E■■■■■EE■■■■■■■■■■■■■■■Nee■■■■■NE■EE■■NNE■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■NNE■■Nee■■M■■■NEN■N■■■■■■■■■■■■ecce■■ ■■■■e■■■■■■NE■E■■■■■■■■■■■■■■■■■E■■■■■■■■Eon■■■■ME■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■NE■■■c■■■■■■■■■■ENE■■■■■■■■ENE■EE■ ■■■■■■■■■■■%NOON■ ■■■■■■■■■�%NOON■■ NOON■■■►./■■■■■■■■ ■■■■■I NPWROME ■ ■■■■U■■■MMIIMMM■■■ Neal■■■■■c■■■■EM■ ■■N■n■■nm■■■■■■■■ ■■■■■■■JIM■■■■■■■■ ■■■■■non■■■■U■■■■ ■■■■■■■u■ ■E■N■■■IM■ ■■M■E■■e■ ■■■■■■■IN■ ■■■■■■■n■ ■■■■■■■u■ ■■■■MEMO■ ■■■■■E■■■ ■■■■■E■■■ ■■■■■■E■■ ■■■M■c■■■ ■■■■■■n■■ ■■■ME■■■■ ■■■■MONO■ ■■■NOME■■ ■■■N■c■■■ NONE ■■E■ ■N■■ moon moon NONE MENU ■N■■ ■■■■ ■■c■ moon ■■■■ ■■N■ ■■■■ ■UMMEM■ ■■M■EM■ ■EM■■E■ ■MEMMM■ ■■■M■■■ ■■■■EM■ ■MEMEM■ c■■e■U ■E■■■ ■c■■■■■ ■■■■■■■ ■■■M■■M ■■■■■■■ 4,55d I Cl; I�fawl Yk� b 0 /1 _ I,