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942 Farmington Rd (2)I Account #: 990002675 Billed To: Larry Michael Reference Name: Proposed Fa ility: Farm bldg ATC Number: 3406 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 4 -L - Tax PIN/EH #: 5841-75-3686.02 Subdivision Info: Location/Address: Farmington Rd -27028 Property Size: see map 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: 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 'll fun ion satisfactorily for any given period of time. �o I W' 1L Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Get 1tJ <o Tle-, Date: 1 A DAVIE COUNTY HEALTH DEPARTMENT p Environmental Health Section / Ct P. O. Boz 848/210 Hospital Street / Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT � � 4-17 Account #: 990002675 Tax PIN/EH #: 5841-75-3686.02 Billed To: Larry UUcJaael Subdivision Info: Reference Nam. Location/Address: Farmington Rd -27028 Proposed Facili :=bldg Property Size: see map ATC Nypb?r: 3406 **NOTE** 'Ihis mprovement/Operation Permit DOES NOT authorize the construction of 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 _ Z&A A A #People �_ #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Commercial Specification: Facility Type #People Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People/Shift #Seats Industrial Waste: ❑ Lot Size -14r Type Water Supply Design Wastewater Flow (GPD)1,21} Site: New 21"�Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth L_ Linear Ft;2& 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: ^ e r DCHD 05/99 (Revised) PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmenta/Health Section ._ 03 P.O. Box 848/210 Hospital Street 1rNi/;r�N�F Mocksville, NC 27028 �I/ •"•"�� • " (336) 751-8760 ;,%L'�c 'sn ---***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Ryjefer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed L��/J/i�� Contact Person Mailing Address,9/ Home Phone City/State/ZIP Lz2,z,�t/, Yl—e— Y,22e-U3 Business Phoneme 2. Name on Permit/ATC if Different than Above Mailing Address/)7 E City/State/Zip S,.3ifJ 3. Application For:Site Evaluation r❑ Improvement Permit/ATC Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ IndustryI Otherv'� / 5. If Residence: # People # Bedrooms 3 # Bathrooms .MtE� Dishwasher ❑ Garbage Disposal f.IrWashing Machine E1 Basement/Plumbing II 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 ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLCTETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with TIi1S APPLICATION. Property Dimensions: -R "4:11V Tax / Tax Office PIN: # y I - -7 Property Address: Road Name City/Zip,t� If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from 1%1ocksville) to PROPERTY: 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 Hcath Depart it to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the sitcsi itability. 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). P;1P1i+ 2 20"03 ' Revised DCHD (07/99) 0'5R0NME1,:TAL HEALTH DAVIE t 001Y Z'-1) C.'C' 6z L/= - Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 7 -7 429 Invoice No. ! I ,Fv i - -7 6 - 3 ar, DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002675 Billed To: Larry Michael Reference Name: Proposed Facility: Farm bldg Water Supply: On -Site Well Property Size PROPERTY INFORMATION Tax PIN/EH #: 5841-75-3686.02 Subdivision Info: Location/Address: Farmington Rd -27028 see map 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 RATE: REMARKS: LEGEND Landscape Position EVALUATION BY: OTHER(S) PRESENT: 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)