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765 Fork Bixby RdDAME COUNTY HEALTH DEPARTMENT Environmental Health Section ,o P. O. Boz 848/210 Hospital Street -` .3 Ili b Mocksville, NC 27028 (336)751-8760 Account #: 990003902 Tax PIN/EH #: 5778-26-2833 Billed To: Richard Williams Jr. Subdivision Info: Reference Name: Location/Address: 765 Fork Bixby Road -27006 ATC Number: 4346 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 CONST UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ' Date: S. CERTIFICATE OF COMPLETION **NOTE** The issuance of ertificate of Corm-1 has been in a liance with A Dispo ms," but shal NO WA' given period of time. Septic System i shall indicate le system described on Improvement/Operation Permit 11 of P.S. Chapter 130A, Section .1900 "Sewage Treatment and Rkegos a guara tee that the system will function satisfactorily for any Environmental Health Specialist's Signature: lf /� Date: DCI -ID 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT + Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 3 Account M 990003902 Billed To: Richard Williams Jr. Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5778-26-2831. Subdivision Info: Location/Address: 765 Fork Bixby Road -27006 Property Size: 7 acres **NOTE * Th�46 Is improvement/Operation t/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. 1 Residential Specification: Building Type # #People �z #Bedrooms _ #Baths 2� Dishwasher Garbage Disposals Washing Machine: ;!r Basement w/Plumbing: ❑ Basement/No Plumbing Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply (�10 Design Wastewater Flow (GPD) -?CO Site: New Repair ❑ System Specifications: Tank Size/MP GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width( Z Rock Depth �f Linear Ft.� 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.**** L - Environmental Health Specialist's Signature: ALa Date: DCHD 05/99 (Revised) >t � ``V �= Annlication For: SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 \� (336)751-8760/ Fax (336)751-8786 X30 Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) oth ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed R. J,,,,,) tJ, Contact Person Billing Address 3,,;t,) Home Phone S 7 b - Y9 2� -a 3 -2--7 City/State/ZIP fn o e 1-s v,'l l o V c- 0,t Business Phone 7yt/ - 6 3,V- 6 11 / Name on Permit/ATC if Different than Above Address "I PROPERTY INFORMATION City/State/Zip NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with gomplete plat.) t"7 ? Z�- Z �3 Street Address 765 �OrK -�; x6�� City :�► ,� Tax PIN# -' Subdivision Name Section/Lot# Lot Size Directions To Site: 4; z/ L } 4A Za '/0 (1 /r- � I k �e �--6i .,Xb L- uc)s -1 � v�+. W b& . '4'e. .9`1 l�fillc� C,, -A - Lo -4 J,,4 -e' & IJ 11 I Date House/Facility Corners Flagged If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes 2�qo Does the site contain jurisdictional wetlands? ❑Yes 2110 Are there any easements or right-of-ways on the site? ❑Yes (moo Is the site subject to approval by another public agency? ❑Yes Udo Will wastewater other than domestic sewage be generated? ❑Yes QNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms ;?- # Bathrooms -2 Garden Tub/Whirlpool)d-Yes ❑No Basement: J27Yes ❑No Basement Plumbing: ❑Yes Flo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested4Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other 1 Water Supply Type: [County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? b Yes A�`No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to��et�rrtpe co p lance with applicable laws and rules on the above described property located in r,-4. r ,,,"�.. —A .,.,,.,owl V- '-PO SIL 1/ i c Site Revisit Charge Property owner's or owner' lega re Date(s): 3 - -�� Client Notification Date: Date ` � EHS: Sign givenes ❑No Account # 3102, Revised 2/06 Invoice # oil , • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990003902 Billed To: Richard Williams Jr. Reference Name: Proposed Facility: Residence Water Supply: On -Site Well Evaluation By: Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5778-26-2831.002R Subdivision Info: Location/Address: 765 Fork Bixby Ropd 270 6 Property Size: 7 acres Date Evaluated: /A6 � Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 77 Sloe % Qo HORIZON I DEPTH 'Y" y /e Texture group e -L cLl Consistence Structure C/- C� Mineralogy 4 " HORIZON II DEPTH 3g�� Texture group S C Consistence 'i Y5i Structure ,�. S 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 i )�. SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: /&/ OTHER(S) PRESENT: 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 rk"Jilm VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Ka 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 suitabl (unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■!!��■■■■■■■■■■■■■■■■■■■■■ ■f.SLS■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■11■/■■■■■■■■■■■■I■■■■■■■■■■■■■/■■■■Ili■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■11■■I��■[tri■■■■■'�■■■■■■A!/��i■\■■■�I■■■■■■11■�■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■1\1■I■■■■■■■■�!..pit■■■■■■■■J■■■■r■■■■■11■lal■■■■■■■■■■■■■■■■■■■■■ ■■///■■//■■/■■■////\'//■/■//■■//■�■■/■■viii/■■■■////■///■//■■/■//■■ ■/■■■11�/■■■■■ ■%■■■■ ■■■/■■ ■■■■■■■■■■■■■■■■■/■■■■/■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■