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180 Dwiggins Rd+ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990004030 Billed To: Jody Hamm Reference Name: ATC Number: 4458 Tax PIN/EH #: 5717-64-2679 Subdivision Info: Location/Address: 180 Dwiggins 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 CONSTRUCCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �/ Date: 1� 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. _ „ � X. Septic System Installed By: _ Environmental Health Specialist's Signature DCHD 05/99 (Revised) Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 a 0 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004030 Tax PIN/EH #: 5717-64-2679 Billed To: Jody Hamm Subdivision Info: Reference Name: Location/Address: 180 Dwiggins Rd -27028 Proposed Facility: Residence Property Size: 23.8 acres *,*N OTE* T hris 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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People _ #Bedrooms #Baths Dishwasher:Z' Garbage Disposal -)2TO Washing Machine: 0"� Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seeats Industrial Waste: ❑ Lot Size �Type Water Supply kelZ Design Wastewater Flow (GPD) '�,-� � Site: New 12K Repair ❑ System Specifications: Tank Size //6CGAL. Pump Tank Other: GAL. Trench Width (51�' Rock Depth Linear 1`01,47 Required Site Modifications/Conditions: As statad in 15A NCAC 18A.1969(5Qct;epted-items-riay�tso IMPROVEMENT/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 rlav of installation. Telephone # is (336)751-8760.**** it Environmental Health Specialist's Signature: Date: / nV4 DCHD 05/99 (Revised) Al JUL, 5 20 _ 4 SITE EVALUATION/IMPROVEMENT PERMIT .& ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC ` 27028- (336)751-8760/ Fax (336)751`-8786 /Improvement Permit ❑ Authorization To Construct(ATC) Votlh ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed _Ja cy 4amfn Contact Person _� o V �Gt MM Billing Address tf5o Home Phone qfila_af2M City/State/ZIP >M,,.1 Sui11 Ai G- 270,8 Business Phone Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address 1$1) City_Me I j� TaxPIN# �%/7 -�o�i'%� Subdivision Name Secti n/Lot# Lot Size re -5 ection To Site f O n, ' If lWie- a "Ieav,' M, - LO" bAd-0 A Date House/Facility Corners Flagged If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? XYes ❑No Does the site contain jurisdictional wetlands? ❑Yes NNo Are there any easements or right-of-ways on the site? ❑ Yes kgNo Is the site subject to approval by another public agency? 110Yes XR0, Will wastewater other than domestic sewage be generated? ElYes'5?No IF RESIDENCE FILL OUT THE BOX BELOW # People .. - q # Bedrooms 3 # Bathrooms Z- Garden Tub/Whirlpool XYes ❑No Basement: )CYes ❑No Basement Plumbing: ❑Yes JoNo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats - Type system requested: Conventional ;f Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ;4 New Well XExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes J$ No if ves_ what tvne? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in Davie County and owned by JL1 C1 y m M, Pr erty wner's or owner's legal representative signature Date _ Sign given es ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # �— Invoice # DW IGGINS ROAD I e4 (11.07A) 5969 xs 4W 1151 (4.08A) 0255 i i� '1 � _s C 171 Ms D P ` PcC2 01.07A) 5969 • r u a MsD PcC2 „ m 26 3A 161 ki' MsD D` i P D a g rr IWO PCC2 Pc 47A} 1936 a f J d o e a�u� (36.84A) 24 -..� -_... 1221 APPLICANT INFORMATION Account #: 990004030 &Iled" to: Jody Hamm Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTtl DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 571 - - Subdivision Info: Location/Address: 180 Dwiggins Rd -27028 / Property Size: 23.8 acres Date Evaluated: On -Site Well Community, Auger Boring Pit Public Cut FACTORS l 2 3 4 5 6 7 Landscape position _ Slope % e .1 HORIZON I DEPTH Texture group Consistence Structure 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: 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 - Veryfriable 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 SBI - Subangular blocky PL -Platy PR - Prismatic Mineralogy 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 (Rcvisc,l) C :'::::ssimm :::::::::::::::::::::::::::::C:::::mMIMENERE1::•• E ::■ ............■Mission ■■■.■■.■■■■m■am■NM■Mmmammmm■N■mm■m■Mm■■■ . ...■■■■.■■■■........ ....■....■■■.■■■.■■■■■■■■....... 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An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. I System To Serve: GSr Wastewater Design Flow(GPD): %?IO Valid: Years ❑No Expiration System Type: C7Conventional PpAoccepted ❑Innovative ❑Alternative ❑Other Site Modifications/Permit Conditions: i.p.letter 7/06