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P2633 Fantasia LnS. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001487 Billed To: Carolyn Barnes Reference Name: Lynda Barnes Proposed Facility: Residence Tax PIN/EH #: 5788-86-4144 Subdivision Info: Location/Address: Fantasia Lane -27028 Property Size: 2 acres ** d4� *�Vffbgr. 2633 N is mprovement/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 A% rr #People #Bedrooms -,-? #Baths —�7_ Dishwasher: 701' Garbage Disposal: ❑ Washing Machine; Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size (i Type Water Supply &4Vdl Design Wastewater Flow (GPD)��� Site: New Zr Repair ❑ System Specifications: Tank Size// vv GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width M Rock Depth /:5 Linear Ft._,�2) IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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:14L�`t0 j Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001487 Tax PIN/EH #: 5788-86-4144 Billed To: Carolyn Barnes Subdivision Info: Reference Name: Lynda Barnes Location/Address: Fantasia Lane -27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 2633 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 WASTEWA R TRUCTION IS VA ID FOR A PERIOD OF FIVE YEARS. JU. Environmental Health Specialist's Signature: �� � Date: X, 06 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: DCHD 05/99 (Revised) Date: APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A N�V Davie County Health Department Environmental Health Sedian 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. what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: Se, # Property Address: Road Name �` nS t City/Zip If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 4779 (go Xd' YL Name: 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. 1, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County 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 \\ - _� _Z0 SIGNATURE * CGI1 "LM \ e 6 CU_/ � 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). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. O Invoice No. ✓ 1. Name to be Billed(eior6 Ur1h (/i Contact Person /L bAj a 5 w /'e �S 634) NT -S10,3 7 Mailing Address U (1� Home Phone /1 7U %_ Business Phone City/State/ZIP Ar UCi r1cp AJ. ` 2%U �r 2. % Name on Permit/ATC if Different than Above 1.ctYO �t� Mailing Address //•() . I� X 3 W. ity to/Zip Ad v ain L'll i N. c -2 is 0 (P 3. Application For: ❑ Site Evaluation Pe t/ATC ❑ Both 4. System to Service: ❑ House Mobile Hom(L41-Improvement ❑ Industry ❑ Other 5.If��Residence: # People # Bedrooms_ # Bathrooms IVDishwasher 1.1 Garbage Disposal ❑YWashing 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(gallons per day) 7. -Usaage Type of water supply: ❑ County/City i 5iell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 44-40 what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: Se, # Property Address: Road Name �` nS t City/Zip If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 4779 (go Xd' YL Name: 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. 1, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County 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 \\ - _� _Z0 SIGNATURE * CGI1 "LM \ e 6 CU_/ � 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). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. O Invoice No. ✓ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001487 Billed To: Carolyn Barnes Reference Name: Lynda Barnes Proposed Facility: Residence Water Supply: On -Site Well Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5788-86-4144 Subdivision Info: Location/Address: Fantasia Lane -27028 2 acres Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % 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 RA 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) 1. Application/Permit APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT Davie County Health Department f t Environmental Health Section U`� t P. O. Box 665 Mocksville, NC 27028 SSP q i C -C c, -------------- sted By, � Mailing Address �'' !' V `$'\\ V (A 1 1 l;"�— �.\l�-- Home Phone l�g —��� Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision ❑ General Evaluation Mobile Home ❑ Other No. of People No. of Bedrooms No. of Bathrooms i Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers M No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: ❑ Public XI Private 8. Property Dimensions aC�� `�L) I Sewage /Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? Xseptic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing PWashing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Yes IXNo ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property:`—L�> k-0 100C)��� O ��Oqs c This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incureo from is application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. -/-1 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized represente o the Davie ounty Healt Department to enter upon above described property located in Davie County and owned by �,, l� '- to conduct all testing procedures as necessary to determine s id site's suitability for a group absorption sewage treatment and di p sal sy tem. �� \v C O�A��-Q DATE SIGNATUR DCHD (12-90) • - t DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/Site Evaluation NAME ADDRESS /y� �/� PROPOSED FACIILTY �'"LI 4 DATE EVALUATED PROPERTY SIZE 1199 (!2- LOCATION !LOCATION OF SITES Water Supply: On -Site Well , / Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position •� Slope % C59— 2HORIZON HORIZONI DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH fi Texture group Consistence Structure Mineralogy Al / 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: O �� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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 (01-90) ■■■..■■■.■.■..■■■■■■■■■.■■■■....■.■NOON.■./■.■..■■■/■■■■■■■.■®�■./ ■../NOON../■../......■■■■..■■■■. ..■...■....................■...■ ■.....■■..■.■■.■■■■■■■..■..■.■■..■.■■.■■...■■.■......../BOOB/.■■.■ ■■■.■■■■■.■■■.■■..■■■■■■■■.■■■.■■../■■BONN/BOOB■/■■■■..■■■/■■■■■.■ .................................................................. ........................... ................... .................. ......................................... .... . ...... ...... .. ...............■.................■■......�■■■■ ■'mB■■■B■B■BB■■■�B�iiN■ .................................................................. ................................ .............................■■. ■...■■..■...■■■■.■■■■■■..■..... /■■..■..■..■.■.■■■/.■BONN■i■■■■■ iiiiiiiiiiiiiiiiiiiiiiiaiiiiiiiiii=iiiiiiiiiiiiiB■iii iiiiii■iiii�i'i ■...../■....../■....■.■..■..■■.■..■■...■..■.■►�B�.BBBB�iBB./eB./■ ■■■ ■..■./■/■■■■..■.��/BB■HBB■.BB■.■■■■.■..■.■■..■......�...../BONN mommomm .......................................................... 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Barnes: As requested, a representative from this office visited the aforementioned site on September 13, 1933. Based upon the infornntion provided on the application for a site evaluation and after an evaluation was completed, the cite was found to be provisionally suitable for the installation of an on-site sevage disposal system. if you have any questions, please feel free to contact this office. Sincerely, jQ'Ai. &Ie6�7* Robert B. Hall, Jr., R.S. Environmental Health Section Rei/?.ad Enclosure cc: Jesse toyce