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590 Fred Lanier RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000725 Billed To: Frances Farmer Reference Name: Frances Farmer Proposed Facility: Residence ATC Number: 2146 Tax PIN/EH #: 5719-284847 Subdivision Info: Location/Address: 590 Fred Lanier Road -27028 Property Size: 3/4 Acre **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. Residential Specification: Building Type 1'w / #People #Bedrooms �,7 #Baths —2 - Dishwasher: E!f�- Garbage Disposal: ❑ Washing Machine: 12'- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type �! #People #People/Shift #Seats Industrial Waste: ❑ tv Lot Size/'r/ C Type Water Supply C Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size%W GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.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 e y of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: J/ 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 #: 990000725 Tax PIN/EH #: 5719-28-4847 Billed To: Frances Farmer Subdivision Info: Reference Name: Frances Farmer Location/Address: 590 Fred Lanier Road -27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2146 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 WASTEWATfR CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 2��1-�� 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 guaran hat the system will function satisfactorily for any given period of time. Q Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) 9F --c Date: �Z//-- I- 41:e r APPLICATION FOR EVALUATION/IMPROVEMENT nt PERMIT & AlDavie County Health Department D Enilivnmental Health Section P.O. Box 848/210 Hospital Street 10171999 Mockaville, NC 27028 (336) 751-8760 �.„,,,,.,.., .,_......._.. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to/ttth�/e1 INFORMATION BULLETIN for instructions. 1. Name to be Billed ,+ter A.Al 0 C S P / iY LM G cont --t Person gAAw- FG/Lti"'� Mailing Address E 9 b Eh e j L A /V i e- r Home Phone 1 Z s to 4t0 city/state/ZIP /� I�5 V l 1 I e'.T me— C. ,1'7Da g Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: 9 Site Evaluation )a improvement Permit/ATC Both Aakbi�_ w;de 4. System to Service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms -_ # Bathrooms^ Dishwasher ❑ Garbage Disposal Bashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of .rater supply: County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes I�No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Pronerty Dimensions: _ Tax Office PIN: Property Address: Road Name,S'QD Ft -r-- J P k I eH k City/Zip /y?,oGks lil LIE /V, C . If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: ON �J l� mG5 CFI .7'n kl�° A L 2 �fJD%X, A1 mi LIP Date Property Flagged: Z, 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. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Aathorized Representative of the D vie County Health Department to enter upon above described property located in Davie County and owned r y2nn a� to conduct all testing procedures as necessary to determine the site suitability. DATE 9�/ � r ! / SIGNATURE 'T�� 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). ' QJ se DC (07/99) i Site Revisit Charge Date(s): Client Notification Date: ERS: Account No. QInvoice No. 1 R APPLICANT INFORMATION Account #: Billed To: Reference Name: Proposed Facility: Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation 990000725 Frances Farmer Frances Farmer Residence PROPERTY INFORMATION Tax PIN/EH #: 5719-28-4847 Subdivision Info: Location/Address: 590 Fred Lanier Road -27028 Property Size: 3/4 Acre Date Evaluated: , On -Site Well Community Auger Boringy Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L 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: P--( LONG-TERM ACCEPTANCE RATE: 0 / REMARKS: EVALUATION BY: ZZ�l/ 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) ■ ■ ■ i J iii ■■M■■E■■ ME■■M■N■ ■M■■■■■■ NEEM■■■■ ■■E■E■■■ ■■MEM■■■ ■M■■■■■■ ■■MME■■■ ■■■■■M■■ ■■■■■■■■ ■E■■■■E■ ■M■■■■E■E■E■ ■MENS■■E■EM■ ■■MME■■E■■M■ ■■MEM■M■■M■■ ■E■E■■■MEN■■ ■M■M■■■■E■E■ ■■M■■M■■M■E■ ■E■■ME■■■MM■ ■■M■■MME■ME■ ■E■E■■■MNE■■ ■■NN■■■MME■■ ■■■■M■■EN■■■ ■■E■E■■M■■■■ ■EN■■M■MEM■■ ■■MENMENN■■■ ■■M■■ ■E■E■ ■■■■■"■■ME■ ■■MENNE■MME■ ■E■M■■E■EME■ ■M■E■■M■■ME■ ■E■M■■MM■■E■ ■E■■M■NM■■■■ ■■■■M■■MEN■■ ■■■■ SEEN OMEN ■EM■ ■ ■ ■ so on ■M■M■E■M■■E■ ■MME■E■M■■E■ ■■■M■ENNE■■■ ■■■E■■M■■■M■ ■■M■ENE■■■M■ ■MEM■■M■■ME■ ■■■ENEMMOM■■ ■E■E■E■M■M■■ ■M■■■M■MEME■ ■MEMEM■■■■M■ i ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■NMN■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEN ENMESH MEMN■NMEM■■■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■�■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■E■ ■OE■ MEMO ■■E■ ■■E■ ■■E■ ■E■E■■M■M■■ ■E■■M■■EM■■ ■E■■■■■MEM■ ■EM■■■■MEM■ ■■M■■E■■MM■ ■■M■■ENEME■ ■■ME■ENM■■■ ■■M■■E■■EM■ ■■MME■■■■■■ ■MEMS■E■■■■ ■E■ME■EMME■ ■EMMEMMEME■ ■■M■MOMMEM■ ■MNOMMME■■■ ■E■■■M■EM■■ ■ME■■E■MEM■ ■■■EMM■MM■■ ■■■■■■M■■■■ on ■