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1656 Fork Bixby RdL DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003702 Tax PIN/EH #: 5779-17-2596 Billed To: Robert & M Subdivision Info: Reference Name: Stepha a Mathis Location/Address: Fork Bixby Road -27006 Proposed Facility Residence Property Size: 11.003 acres **NOT * ThIs�mpro4ement/Operation Permit DOES NOT authorize the construction of aseptic 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-F,�r Dishwasher: Garbage Disposal: 21'- Washing Machine: Z-- Basement w/Plumbing: Er-" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #P`e,�ople #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply !�6e�ign Wastewater Flow (GPD) Site: New 121 eo Repair ❑ System Specifications: Tank Size e -VA GAL. Pump Tank GAL. Trench WidthRock Depth Linear Ft Other: ) Required Site Modifications/Conditions: accepted Systems may also be used 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 1:3.ypm. on the day of installation. a ep one # is (336)751-8760.**** Environmental Health Specialist's Signature: DCHD 05/99 (Revised) f� d� Q�Ai-Wl 4V �✓ // Dater GB ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �( IMPROVEMENT/OPERATION PERMIT Account #: 990003702 Tax PIN/EH #: 5779-17-2596 Billed To: Robert &Mona Potts�s Subdivision Info: Reference Name: �/,� p//%� ,gyp,, Location/Address: Fork Bixby Road -27006 Proposed Facility Residence Property Size: 11.003 acres ATC Number: 4171 **NOTE** 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. 1 � / Residential Specification: Building Type _ #People #Bedrooms :!, ? #Baths -,-?,16 Dishwasher Garbage Disposal: 13Washing Machine Basement w/Plumbing Basement/No Plumbing: El Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply. /,&e�/ Design Wastewater Flow (GPD) �Gi7 Site: New Repair ❑ System Specifications: Tank Size/ AaWAL. Pump Tank GAL. Trench Width � Rock Depth _1,,2 Linear Ft.,�?600 Other: As stated in 15A NCAC 18A.1969(5 accepted Systems may Also ---- Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT., l A FINISHED GRADE. ****NOTICE: Contact a representative of system between 8:30 a.m. to 9:30 a.m.,or 1:00 p.m. to 1:30 p.m. on � e rj��W�-Ij Environmental Health Specialist's Signature: DCHD 05/99 (Revised) FI L fl r-4/- "00 S) IF 6," BELOW final inspection of this (336)751-8760. * * * e✓L�e Date: v DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003702 Tax PIN/EH #: 5779-17-2596 Billed To: Robert & Mona Potts Subdivision Info: Reference Name:.S 4-e..p �r��i s Location/Address: Fork Bixby Road -27006 Proposed Facility Residence Property Size: 11.003 acres ATC Number: 4171 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: ! /14 / / Date: 1e may 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. Q Septic System Installed By: V 0// (- fo i -IM /G�11" Environmental Health Specialist's Signature: A & Date: DCHD 05/99 (Revised) 7M.4 WE APPLICATION FOR SITE EVALUATION/I&IPROVEMENT PERMIT Davie County Health Department AUG Environmental Heaith Section 9 �aJ P.O. Box 848/210 Hospital Strout Mocksville, NC 27028 (336) 751-8760 D * A0,'Z'U'RIlRRM,I MAE COWIIY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOR14ATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. .---� 1 1 i AA -- A i // / 1. Name to be Billed -1\00e /'T Mailing Address 1DG13 r11e Contact Person �y ' /�� / nome Phone 52,1 •. %;37X- y -J G4 0 City/State/ZIP % �N�t/(i -nn% C/V V Business Phone 2. Name on Permit/ATC if Different than Above ' C-YliEi 6ul !l I Mailing Address /S�9o't �+r P�x6V /c C/ City/State/Zip 9% yl�Ctr�P% IV/� 074i'V, 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both 4. System to Service: 9 house ❑ Mobile Iiome ❑ Business ❑ Industry ❑ Other S. Type system requested: lam' Conventional ❑ conventional modified ❑ innovative Claccept:ed 6. If -Residence: Il People 3_ # Bedrooms # Bathrooms c�•-� Dishwasher ❑Garbage Disposal AWashing Machine 7. If Business/Industry /Other: verify type # Commodes tI Showers IF FOODSERVICE: It Seats -SBasement/Plumbing ❑Basement/No Plumbing # Urinals # People # Sinks 4 Plater Coolers Estimated Water Usage (gallons per day) I!. Type of water supply: ❑ •County/City 113 Well ❑ Community 9. Do you anticipate additions or expansions of the facility this systein is intended to serve?a Yes JgNo -A-0- If yes, what type? ***Il41P0RPAN7"°** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST IIB SUBMITTED by the client with TilIS APPLICATION. Property Dimensions: I e),03 Tax Office PIN: # -7771 / % ZYVA Properly Address: Road Name f 6��K � City/Zip AJA&yjK -Q7CDZ, If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (frons Mocluville) to PROPERTY:` 11 � 1.446J 4v��; k- �,X� y �d laerV PCS C�R-Of-� lea ' �'rOl�r�r�-�-1 �S T1C'jj�i ��' •. ar� �., P��, k 1� lC ,fid Date home corners flagged:Zfly . OLDS `Phis is to certify that the information provided is correct to the best of niy knowledge. I understand that any perniil(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or clianged. I, also, lulderstand that I nm responsible for all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie Co}}nit ' Health D�ep,/artment" to enter upon above described property located in Davie County and owned by ,DbE'r+ Let, ^? RQ - to to conduct all testing procedures as necessary to determiuc the site suitability. DATE 4-lun . cl , aotq-57- SIGNATURE THIS AREA AWAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05103 Site Revisit Charge Dalc(s): Client Notification Date: ' EIIS: Account No. v Z— Invoice No. .e DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 1. Soil/Site Evaluation AY'PLICANT INFORMATION Account #: 990003702 Billed To: Robert & Mona Potts Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5779-17-2596 Subdivision Info: Location/Address: Fork Bixby Road -2700 j Property Size: 11.003 acres Date Evaluated: ell- 6 S Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group C/— Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure A 6JZ Mineralogy HORIZON III DEPTH Texture grou2 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: !� 1 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 U/ : VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 33'et 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 lYoteS 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 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNEN MEMNON EmmonsG:::::::::::EMMONS ■■■■■■.�■■�!■■■■■■■■■■Ali■F�fl■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■/■11■■t ■■■■/■■�'fI■■1■11111■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■■/■■■■■■ ■■■■■■ll■■■�■■■■■Z//X11■■�,7■■/■■■■■■■■■■■■■■■■■■■■■/■■■■■/■■■■■■■■■■ ■■■■/■■■■■/■,■■[�■■�_�:�■■■■■■■■■%w■►iu■r,Awa+�►_/■■■■■■■■■■■■■■■■■w■■■■■ ■■■■■■■■._:�w■■r�■■■■■■■//■■■■■wwuouse�.lel.■ws■■■■■■■■■■■!/■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■