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146 Everhart RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002198 Tax PIN/EH M 5767-27-8210. LB Billed To: Linda Branon Subdivision Info: Reference Name: Location/Address: Everhart Rd -27028 Proposed Facility: Residence Property Size: 1 acre **NOTEC *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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type /l� #People '& #Bedrooms �-2 #Baths Dishwasher Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift !#Seats Industria173l Waste: Lot Size � Type Water Supply Design Wastewater Flow (GPD)VT�d Site: NewZ Repair ❑ System Specifications: Tank Size Z&GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width ,-� Rock Depth 1-2 "/ Linear Fklio 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 day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002198 Tax PIN/EH #: 5767-27-8210. LB Billed To: Linda Branon Subdivision Info: Reference Name: Location/Address: Everhart Rd -27028 Pro osed Facility: Residence Property Size: 1 acre ATC Number: 3092 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 WASTEWATE O _STRRRUCTION IS VAL D FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �lJ `�Date: 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. Septic System Installed By: Environmental Health Specialist's Signature: Dater 4r DCHD 05/99 (Revised) IN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Enwronmenfa/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. '':Name to be BilledAAli Contact Person ,L AWA .13 /"AA10 A % Mailing Address 1JL19 rn&-CL,-�/� K� Home Phone City/State/ZIP IV— 2710 i Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: VSite Evaluation ❑ Improvement Permit/ATC @'Both 4. System to Service: 0 House Mobile Home ❑ Business ❑ Industry ❑ Other S. Zsidence: # People �. # Bedrooms 3 # Bathrooms Z. LY Dishwasher ❑ Garbage Disposal VWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City WWell ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 I If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERi'Y INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: / �CK- WRITE DIRECTIONS (from Mocksville) to PROPERTY: 4 Tax Office PIN: # ,4-7&7 27 9 210 AER Oboly 1'2 4 Property Address: Road Name -Z -yc2h, P-- ��- city/zip 2V'94 If in a Subdivision provide information, as follows: X,P,CC,12oaG71- ,TDe Name: / .04Z 45 D /M17% Section: Block: Lot: Date Property Flagged: 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 application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie Comity -Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE .3 / OL SIGNATURE' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Revised DCHD (07/99) Account No. Invoice No. • w V w (261) N 3668• (200) • • (340) 7845 339 M • 7754 350 • 7644 LM-Dt3-A-t7-r-rTr%—z 150 r1173 9771 • • (4.96A) 8831 8597 aso 244 22, (2.66A) no.4c HAM_ 151115601105 weslM. 1 ' : 9,T10 ►M1 • , Environmental Health Section ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002198 Tax PIN/EH #: 5767-27-8210 Billed To: Linda Branon Subdivision Info: Refi)rence Name: Proposed Facility: Residence Location/Address: Everhart Rd -27028 Property Size: 1 acre Date Evaluated:�� Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 26 Texture group Consistence Structure Mineralogy_ 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 n , SITE CLASSIFICATION: 7 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 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 (Revised) ■ ■ ■E■ ■E■ SOMEONE monsoon ■E■■M■■ MONSOON ■■m■■m■ SOMEONE ■E■ME■■ ■E■■M■■ ■■E■EM■ ■EMEME■ ■E■MEM■ ■E■■M■■ ■MEMME■ SOMEONE SOMEONE ■■M■O■■ ME ■ SSSS■■■t■■■■■■■■■■■■■■■■■ SSSS■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■E■■■ ■ENE■ SOMME ■E■S■ MOSES SENSE ■■■E■ ■■■E■ ■■N■■ ■ ■ ■ ■ ■//SSSS■/■/■■■■■■■■■■/SSSS■■■ SSSS/■■/SSSS■■/SSSS/■//SSSS■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS/■■■■■■■■■/SSSS/■/SSSS■/■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■/SSSS■■ NOSES ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■M■■■■■■ ■■■■/■■■■■■E■■E■ ■■■■■■■■■■■■■■■■ ■■■■■■E■■s■■■■■■ ■■■■■■■■■■■■■■■■ ■E■■■■■O■■E■■EE■ ■■■■■■■■■■■■■■■■ an ■ ON ■ ON ire■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■