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870 Fork Bixby RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 **NOTE"' Pgi�prb7 gent/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 /// #People #Bedrooms 3 #Baths Dishwasher: 12 Garbage Disposal: M Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Imo' Repair ❑ System Specifications: Tank Size /90 GAL. Pump Tank GAL. Trench Width �_ ''Rock Depth ,4.2" Linear Ft -;7,W Other: Required Site Modifications/Conditions: 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.**** i Environmental Health Specialist's Signature: 0,,5/ Date: � -, DCHD 05/99 (Revised) IMPROVEMENT/OPERATION PERMIT 970 f= v-ak-B %eb� Pd, Account #: 989900079 Tax PIN/EH #: 5778-38-0039.02 Billed To: Ronald Jones Subdivision Info: Reference Name: Ronald Jones Location/Address: Fork Bixby Road -27006 Proposed Facility: Residence Property Size: 30,000 sq. ft. **NOTE"' Pgi�prb7 gent/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 /// #People #Bedrooms 3 #Baths Dishwasher: 12 Garbage Disposal: M Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Imo' Repair ❑ System Specifications: Tank Size /90 GAL. Pump Tank GAL. Trench Width �_ ''Rock Depth ,4.2" Linear Ft -;7,W Other: Required Site Modifications/Conditions: 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.**** i Environmental Health Specialist's Signature: 0,,5/ Date: � -, DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900079 Tax PIN/EH #: 5778-38-0039.02 Billed To: Ronald Jones Subdivision Info: Reference Name: Ronald Jones Location/Address: Fork Bixby Road -27006 Proposed Facility: Residence Property Size: 30,000 sq. ft. ATC Number: 2277 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 ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: C c Date: �� a�'�� CERTIFICATE OF COMPL **NOTE** The issuance of this Certificate of Completion shall indicate has been installed in compliance with Article 11 of G.S. Ch Disposal Systems," but shall in NO WAY be taken as a gu given period of time. 0 Septic System Installed By: 6144 , Environmental Health Specialist's Signature: DCHD 05/99 (Revised) ON aescribed on Improvement/Operation Permit Section .1900 "Sewage Treatment and the system will function satisfactorily for any Date: ty - C-) / `'2b APPLICATION FOR SITE EVALUATION/IMPROVEMFM PERMR &ATC [E Q W IE . • , �q Davie County Health Department D Envtronmenfa/ Heath SkWon U P.O. Bos 848/210 Hospital Street NOV- 4 I Mockaville, NC 27028 1 9 (336) 751-8760 ***SMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. hams to be BilledContact Person Mailing Address Home phone 70? U City/Stats/zip a % Business phone — 1i '�3 2. Name on permit/ATC if Different than Above Mailing Address City/state/sip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: muse . ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms _3 # Bathrooms 'Dishwasher O Garbage Disposal washing Machine O Basement/Plusbing O Basement/No Plumbing 6. if Business/industry/Other: Specify type # people # Sinks # Commodes # showers # Urinals # Nater Coolers IF FOODSERVICE: , # Seats Estimated (Pater Usage (galls per fit) 7. Type of water supply: County/City ❑ Noll. ❑ Community 0. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ***IMPORTANT*** CLIENTS MAST COMPLETE THE REQAIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: .3 Ui O0y Tax Office PIN: # �7 %� - 3 � — D d 31(C 2) Property Address: Rose' Name City/Zip f u" e If in a Sabdfvision provide information, as follows: Name: WRITE DIRECTIONS (from MockrAlle) to PROPERTY: 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, Ifthe 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 lncamed 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 suitabWlly. DATE / l — `7' % � SIGNATURE r TIES AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: xfsting and proposed property lines and dimensions, structures, setbacks, and septic locations). C, Revised DCHD (07/99) DEC 1 7 1999 D Site Revisit Charge Date(s): Client Notification Date: ERS: Account No. O Invoice No. /���- .. ._ .._..._tom �•r E'�'i..r..._•,. T@ Lot 79 P/0 Tax, Lot 80 I Tor Moo I-7 \ Tyr yap I-7 Ronotd Bamay L'B 100 O PC 74J PK -Nor- Found I • \ PK -Nal Set it Aeprrott DriveI 1h1/1- UPTeta- L s 8r. 10.33-E 467.20' 1241' \ Tar Lot v0 T - \ Tar AW 1-7 a x :ISM6.-TE n/f ✓. lnode Jona 1 780.67 \ \ and Wife 0 \H 97 D. Jona* DB 97 O PC d38 ( PK-Nor7 Set S a9.1.'••J57C 175M* w/2' OR , 5 CL +/- SJL 1611 \ \ \ ; ^ 1 — . \\ \ 1x6.47^• \ N 17.39 X `•��� SJ �' „�, Prfo tral se �" - - 8_O8' 7etof S 8E•- ��•1-` 1R5 197.8 246-5a' Sa+r ne,w N 86.0x'0=--` J1.S0' ° i- EJP rn\ S 20.43.101E t IJ6.9a' t- DP o\ \` 79.19• Parcel 3 ; — N rax Lot 81.01 �= Paint 1.000 Acres +/- t Tax Moo t-7 11 \ n/f David Ronald Coning ^\ `, S 19114'70-E and Wife :16.8^ 'its :YN dmodro Ann J. Lanning \ ��� 6 95• tocol OB 104 O PC 684 \ ` 30.06' i5"E 25'•.0:. (0.87-1 Acres t/-) `�` N 7d� N 11 19P i- E1P Sp"re set in Pine Stump S 8E• x•'001M `-PK-Na Set � 198.07' � 198.09' I 5 86.40.33-M IRS 1- rip 518.70' N 8r48'J5"W \ a- ARSS PO.'Cel Z \ 0.1.19 ACM./- \ 19E.J9� N 18.03'_-"» \— S 21. E \` 110.66, Tie Rad (bent) Tax Lot 96 Tax Mao 1-7 1 +/- PK -Novi Set , n/f George Piazza /- SR 161 \ '� and I CL + IPS-Plaeaa r. Lina i9f Piazza J0.23, DB 285 O PC 361 S fa'08.10T 130.3.- l \ \ PK-Nca SR CL +,/ - S.R. 1611 i- E/P Found \ \ % I Tax, Lot 78 Ta: yop 0-7 n/f L.B. 8artrq DB 100 O PC 745 I 3/a- 13R S 87.71.40-L X39.14' Parcel 4 M246 ACtes r/- I1- E7P by Stone in Boss, of Oak Tree I I I 1 , ??e - m - 0 0-39 !ox Loc f Tax "Op I-0 I I t' DP S8714i•10"E 4iva• S OJ•0O.00-W 359.9J' Total .9 T-ir 01 Od 524.91• N 8M9'4C'"N $/8- EIR Tar Lot 99 } Tor Mao h7 ,If Budare Faster WW trfe Lola A. Faster DB 186 O PC IM I 311.30' N 02•59.10"E rre Line I I APPLICANT INFORMATION Account #: 989900079 Billed To: Ronald Jones Reference Name: Ronald Jones Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-38-0039.02 Subdivision Info: Location/Address: Fork Bixby Road -27006 Property Size: 30,000 sq. ft. Date Evaluated: J/ -/ % Community Evaluation By: Auger Boring >/r Pit Public 1/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position 4 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH G Texture groupG 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 S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 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 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) DAME COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 November 17, 1999 Mr. Ronald G. Jones 185 Livengood Road Advance, NC 27006 Re: Site Evaluations — 2 Sites Fork Bixby Road Tax Office PIN: #5778-38-0039 Dear Client(s): As requested, a representative from this office visited the aforementioned sites on November 17, 1999. Based upon the information provided on the Application(s) for Site Evaluation(s) and after evaluations were completed on the sites, both sites were found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked on each site. If you have any questions, please feel free to contact this office. Sincerely, p J&244 Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s)