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134 Ford Trail (2) � . .. � �", DAVIE COUNTY HEALTH DEPARTMENT ,.o'� ' ` '' Environmental Heaith Section � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003510 Tax PIN/EH#: 5744-49-5512. MF Billed To: Mildred Ford Subdivision Info: Reference Name: Ronald Frost Location/Address: Lagle Lane-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4008 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 CONS IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Date: OJ CERTIFICATE OF COMPLETION � **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit ��C 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 guazantee that the system will function satisfactorily for any given period of time. r��� T • - __ __ _ -- S` — �' ��H , � �v , i l �J . .* '3Z, /Jp � . /Q ' i � ' /pTAC„ "� �Il� � ` k3c '' NL'• `�^a� �-r� l2-3 Septic System Installed By: �''��� � Environmental Health Specialist's Signature: ate: y Z/ , DCHD OS/99(Revised) .... . . • ' DAVIE COUNTY HEALTH DEPARTMENT �`'� Environmental Health Section .� � � P.O.Boa 848/210 Hospital Street /� � Mocksville,NC 27028 ��V � (336)75]-87G0 � IMPROVEMENT/OPERATION PERMIT Account #: 990003510 Tax PIN/EH#: 5744-49-5512. MF Billed To: Mildred Ford Subdivision Info: Reference Name: Ronald Frost Location/Address: Lagle Lane-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4008 **NOTE** This ImprovementJOperation 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 PERNIIT 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 ��)�.t-� #People � #Bedrooms � #Baths� . Dishwasher: C+7� Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑ . Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � �,CQ.t. Type Water Supply L��_1,L..Design Wastewater Flow(GPD) � Site: New�Repair❑ � „ � System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width �`Rock Depth l2- Linear Ft.y� Other: � 1��S`(�)��01� ��1�,"� Required Site Modifications/Conditions: ���� � C���,FL� �b� �� ���--'�S lL�-Z� ��O �'� 2�.(� INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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)`51-8760.**** �f� L-t tJL%S 1►� �'� (J�� I i' �K NIbX�2,�►J�l 1'�`�1 �l ���� _ I , ,� � , t �, ��-� , • . �-> —�r..,a. �o' � 1 � �Ir.�v�N *- � � �� ��� � �1' � ..,.ta,� _ I ' l2��i.11� � � � s„�,�,�Z,, /� 2�A I . � - �,- � Environmental Health Specialist's Signature: Date: c3 '� f�� v _,,.: DCHD OS/99(Revised) ' . - . _ � a � � � � CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC �i �� Davie County Health Department ' � � �005 Environmenta/Hea/th Section , FE� P.O. Box 848/210 Hospital Street , Mocksville, NC 27028 �NM�pLNEA� (336)751-8760 � COUN� *** ANT*** TFIIS APPLICATION. CANNOT BE PROCESSED,UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. .. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Silled ��f�r- ��(�� Contact Peraon Mailing Address �� ',)v� r� � � Home Phone ��(r, '�� Y ^a(�(p d City/State/ZIP ��/('�J71`e /U e y�� Buainess Phone 2. Name on Permit/ATC if Different than Above �nn� l �1 � h�Y'CJ� IJ Mailing Addresa �� ��-f City/State/Zip �Od �C'E�N .� /��,�� ���,1 �"� . 3. Application For�8ite Evaluation ��mprovement Permit/ATC ❑ Both 4. syatem to service: � House �Mobile Home ❑ Business ❑ Industry � Other 5. Type system requeated: � Conventional ❑ conventional modified ❑ innovative 6. �f Residence: # People �_ # Bedrooms .'� # Bathrooms Z �Diahwanher ❑(iarbage Diaposal �Washing Machine ❑Hasement/Plumbing ❑Basement/No Plumbing 7.. If Business/Induatry /Other: verify.type # People # Sinks # Commodea # Showera # Urinals # Water Coolers IF FOODSERVICE: # Seats Estiaiated Water Usage (gallona per day) 8. Type of water supply: ❑ County/City 1� Y�ell ❑ Community 9. no you anticipate additions or expansions of tlie facility this system is intended to scrvc? 0 Yes f�No If yes,what type? ***IMPORTANT''**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either�PLAT or SITE PLAN MUST BE SUI3MITTED 6y the client with THIS APPLICATION. Property Dintensions: � ��p�� WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Ofticc PIN: # �? � �t�Q .�� �2 ��� .Sl U j�� �fJ Property Address: Road Name �.Qq�e. � }t![� �:11e ]�•�(���e �a� �e�� �a �c�n�cyJ City/Zip �P . If in a Subdivision provide information,as follows: Namc: Section: Block: Lot: Date home corners flagged:____t2=,� � –D � Tliis is to certify tliat tlie information provided is correct to tl�e best of my kno�vledge. I understand that any permit(s) issued licrcafter are subject to suspension or revocation,if tlie site plans or intended usc cliange,or if the information submitted in tl�is application is falsi�ed or changed I,nlso, tutderstn�ld that I nni responsib/e for nl!cliarges ii�cttrred fron! t/ris applicatio�r. I,hcreby,givc consent to the Authorized Representative of the Davic County Hcalth 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 y � � SIGNATURE %��J�-�-�Q �Z-�4X.— "� THIS?�A MAY BE USED FOR DRAWING YOUIt SITE PLAN(Include all of tl�e following: �xisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Cl�arge Date(s): 'r' Clicnt Notifcation Date: �'�7�1� , EHS• Sign given e� Account No. � �/o Rcvised DCH (OS/03 Invoice No. ��00 � _ .--- g � � / `o- ;� \ : �.: �, i' � � '�-� � �,�aa>:� / � � / �� � `���, � ; s�so, � � � � \ t�,a�,�' / � � '(�'�5on '�. / � � � � '. . � � ���^�°� � � � j ..}'� .� � � J / � � �.. .�. ,y._, �.� ilt..3�v r t � . , a ���. � ' `� . . y � ` � b �� �� \ ,�. 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SA� � -�! \ C_o `a �� � -- , ��� � -%- - _- __ r -�'� ._'- _ �-1-"�.--- - �. � - �- �. � ,7L`C� " "��?j,t. � �� . �� , ' J _. 1� _ . � - , . • DAVI� COUNTY HEALTH DEI'ARTMCNT .- � • Environmenfal Heaith Section � Soil/Site Evaluation APPLiCANT INFORMATION ' PROPERTY INFORMATION ,, �,Account #: 990003510 . Tax PIN/EH#: 5744-49-5512. MF . Billed'T�:-. Mildred Ford � , �ubdivision Info: Reference Name: Ronald Frost ; Location/Address: Lagle Lane-27028� � . Proposed.Facility: Residence � Property Size: 1 acre Date Evalu�ted: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring `� Pit Cut FACTORS 1 2 3 4 5 6. 7 Landsca osition L !.._ C.�- Slo % HORIZON I DEPTH �—�� – � Texture rou �i.... SLI� Consistence SS ' Structure c2 Mineralo S.. HORIZON II DEPTH 1 –� Z �- � Texture rou LS 5�... Consistence - �• .�- S Swcture � < C�(L t� Mineralo HORIZON III DEPTH 22� ' Texmre rou C�k Consistence. ' ` Structure ' Mineralo ' � HORIZON IV DEPTH Texture rou Consistence - Structurc Mineralo SOIL WETNESS RESTRICTIVE HOKIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O. SITE CLASSIFICATION: u � EVALUATION BY: ���h� LONG-TERM ACCEPTANCE RATE: '�� OTHER(S)PRESENT: REMARKS: . LEGEND . andscape 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 xtur 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-Firnt VFI-Very firm EFI-Extrcmely firm � , NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky � NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ru t r , 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky -- SBK-Subangular blocky PL-Platy PR-Prismatic ' Mineraloav 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-ternt acceptance rate-gaUday/ft2 , . . . . � � � � . � . . � .: , - �.,��i� � �� . � . ,.. . . � . � . 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