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967 Georgia RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002674 Tax PIN/EH #: 5811-27-8541 Billed To: Larry Tyndall Subdivision Info: 41 Reference Name: Location/Address: Georgia Road -27028 Proposed Facility: Residence Property Size: 5 acres ATC Number: 3400 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: Date: 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 16Cl `Z� • DAVIE COUNTY HEALTH DEPARTMENT Account #: 990002674 Billed To: Larry Tyndall Reference Name: Proposed Facility: Residence Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT /--c 7 - � —Oy Tax PIN/EH #: 5811-27-8541 Subdivision Info: Location/Address: Georgia Road -27028 Property Size: 5 acres **N OTE*i�isb Improvem0ent/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 _ #Baths Dishwasher: F", Garbage Disposal: ❑ 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 ;R'*' Repair ❑ System Specifications: Tank Size AR- GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width "Rock Depth ,�/ "Linear Ft. / d IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISIIED 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.**** Environmental Health Specialist's Signature:ld�?& Date: DCHD 05/99 (Revised) ovA 15 2003 Nom( IN 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 ***IMpOR HIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED LWFORFMTION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �. F. 'n I lL Contact Person Lo r r,/ (� . 7—Vhr)C% Mailing Address IS en r Cre e- I c Home Phone 3 3-6i_q q pL ` 5 /3 ga' City/State/ZIP MnA5 UI i co �C a_702-2 Business Phone M-'] — 7 S — Wil' % 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ")< Site Evaluation 4. System to Service: ❑ House Mobile Home City/State/Zip ❑ Improvement Permit/ATC Both ❑ Business ❑ Industry ❑ Other 5. If Residence: # People^ # Bedrooms_ # Bathrooms, 6. yDishwasherGarbage Disposal ` Washing Machine If Business/Industry/Other: Specify (type # Commodes # showers ❑ Basement/Plumbing ❑ Basement/No Plumbing # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes j No If yes, what type? / ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: YY�,Ctp';Zn qa'eS J Tax Office PIN: # moi $ + 1 q'5 �-I Property Address: Road Name YC , City/Zip c V 1 e If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: du r Lc4 �o U to rcn -i t,,'RG Le U 3<5 4;4t t4 Date Property Flagged: l �� 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 1 a►n responsihle for all charges incurred 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 Lar r'-1/ �C r�r\ lynd- / I I to conduct all testing procedures as necessary to determine the site suitabil' DATE U 3 S y �� SIGNATURE THIS AREA MAY BE USED FOR DRAWING Y PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacqs, ands ptic locations). 1 Revised DCHD (07/99) Client Notification Date: EHS: Account No. l Invoice No. � 3 J t p� J w - JIM F. STEELE D.B. 145 PC. 284 r�Eu IRON rt.: S 69.4 rjEu E I pOr: FIN -76.41' 49• S3 F N L. y Exl;Tlr:r, 203.76 i IFO"l alri N 76'4149' E_' 153.99 D. r-�j� � 9J• S �0 S AREA 9�J - _ 5.232 A CRSS f fi `9876 80rDTAL) .k N 83.12 2S• 4 ��oo ` U RY W ELLER 36.8 � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 1. • ' ' Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002674 Billed To: Larry Tyndall Reference Name: Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: ,5811-27-8541 Subdivision Info: Location/Address: Georgia Road -27028 Property Size: 5 acres Date Evaluated: Community Evaluation By: Auger Boring Pit Public 1--� Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group 5* e - Consistence Structure Mineralogy HORIZON Il DEPTH 1 y� Texture groupG' Consistence E'' 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: EVALUATION BY: �� LONG-TERM ACCEPTANCE RATE: _. _DTIIER(S) PRESENT: REMARKS: 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) ■ ■ ■/■NEEM■■■E■■■■■■M■ ■■EM■EEME■■N■■MMMM■ ■MEMEMEMEMMEEMEMEM■ ■EN■■N■MME■U■NMME■ ■■M■■■■NM■■ ■■NNE■ EMEN■ENNMEMM■■ENM■■ ■■■M■■■■■■■M■MMM■/■ ■E■N■■M■■N■M■■E■■E■ ■EMNMM■MMENNEE■■■M■ ■EN■EEMMME■■E■■NEE■ ■E■N■■EMM■MEN■■MM■■ ■MEMMEMMEMMUMEMME■ ■■MEMENEMM■ ■EN■E■ ■■M■N■E■M■EEM■ME■■ ■EN/MEMEMEMEMEMEM■ ■M■EN■■MME■■N■EMM■ ■■■MM■ENM■ENME■■E■ ■E■■M■M■MNEEMN■■E■ ■ ■ ■■MME■■MMM■NN■■ ■ ■ ■NNE■■■ ■E■ME■■ ■M■NEE■ ■■N■■■■ ■■/MMM■ ■NMENE■ ■M■MM■■ ■E■MMM■ ■EMMMM■ ■■■M■■■ ■■■■■M■ ■■■M■■■ ■M■MME■ ■NEMS■■ME■ ■■ ■MMMM■ ME MENNEN ■■N■ ■E■E■ ■■MM■ ■