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397 Greenhill RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Sectionr v P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003143 Tax PIN/EH #: 5728-34-2854 Billed To: Rustin Harpe Subdivision Info: Reference Name: Location/Address: Green Hill Road -27028 Proposed Facility: Residence Property Size: 1 1/4 acre **NO+EG* 49prd1ALt/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 -4 Dishwasher:el!1 Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing12� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: Neve Repair ❑ System Specifications: Tank Sizp,-*' Pump Tank GAL. Trench Width- Rock Depth l� Linear Ft. t -z61 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.**** Environmental Health Specialist's Si DCHD 05/99 (Revised) Date:�� DAME COUNTY HEALTH DEPARTMENT 1k ' Environmental HealthS ection t� P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003143 Billed To: Rustin Harpe Reference Name: ATC Number: 3737 Tax PIN/EH #: 5728-34-2854 Subdivision Info: Location/Address: Green Hill Road -27028 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. to �z D► 'Tk i co --2-7 Septic System Installed By: A_�7� ►3 t k` Environmental Health Specialist's Signature: te: DCHD 05/99 (Revised) E E APS 5 2004 CATION FOli SITC LVALUATtON/Ihll'IigVC111LNT I'L11h11T �C Il'I'L' Davie County Health Department EnYi10nnlenta/Nea/i/1 Section EP1YIRpA IEf000NTY IAL `TH P.O. Box 848/210 Hospital Street Mocksville, ITC 27028 (33G) 751-8760 ***XKPORTANT*** TIiIS APPLICATION CANNOT BZ PROCESSED UNLESS ALL TILE REQUIRED- I INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for instruction 1. Name to be Billed Sti Q R Contact Person �eSt��_._ Mailing Address 3a C-'R.��N � i �� RD llou:c Phone Lf q 7 s'3 ZcP City/State/ZIP OL<<SV : 1� ' "—• �w'2 ° Business Phone _ ____._ �._..�..... ........ 2. Namo on Permit/ATC if Different than Above Mailing Address �,S.,,C1 V,,- 15., City/Stale/Zip �-X mr- 3. Application For: 'b—, ite Evaluation ❑ Improvement- Permit/ATC IIoLlI 4. system to Service: use Elllol�ile Home ❑ Businehs ❑ Industry ❑ Otller w. 5. Type system requested:leConventional ❑ conventional modified ❑ innovative G. If Residence: It People 11 Bedrooms II Ilathrooimi ishwasher ❑Garbage Disposal Shing Machino 7. If Business/Industry /Other: verify type # Commodes It Showers ❑Basement/Pliunbing ❑liacomcnt/no Plumbing It Pcoplc It Sin)= It Urinals 11 WaLcr Coolcru IF FOODSERVICE: t# Seats Estimated Water Usage (gallons per day) S. Type of water supply: lD� /City ❑ Well ❑ Conununit-y 9. Do you anticipate additions or expansioliS of file facility this system is illtellded t0 serve? ❑ Yes V No If yes, wliat type? ***IMIPORTi1NT'°** CLIENTS JVUST COAIPLL'TETHE 1U QU1KL"D PROPERTY INFORNIATION REQ111sS'1'ED BELOIV. Eitliera PLAT or SITE PLAN AfUSTBESURKITTED by the client witli'l'1IIS AI'P1,ICA'1'ION. Property Diinciisions; f ,l� tic t Tax o dice PIN: fl Property Address:' Road Nallic ; (L / /4�jt� (� City/Zip 'V`bjat1(it 1--X, x-1028 If in a Subdivision provide infornlation, as follows: Nano: Section: Block: Lot. WRITE DIRECTIONS (from Muclovillc) tt; I'ROPE'ltTY: M Date home corucrs !lagged: S �% This is to certify that We information provided is correct to the best of lily knowledge. I understand that any perlltii(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use cll:ulgc, or if the information subiiiitted in (Itis application is falsified or changed. I, also, understand that I aul responsible for all charges hicurred./i•oin This application. I, hereby, give consent to file Authorized Representative of IIIc Davie Cuuuty llealtti DC11:u•tuicut to cuter upou above described property located in Davie County and owned by to conduct :Ill testing procedures as necessary to determine file site s ' ab ity. i \ DA'I'i: �t ' 5 SIGNATURE THIS AREA MAYBE 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 DCHD (05103 Site Revisit Charge Date(s): Client Notification, Datc: EIIS: AccountNo. Invoice NO. t ✓ 4595 a rn rn (12.25A) a 9284 5102- (30.85 A) 0 9046 �9l 2------ 8� 1� 751 T : ----------------(� lA, 3 3 �-- ------------------ 05k----------- N 15.062A `'7- ----^ 349(1'464.. 9A) = 7431 0:307 (7,21 A) 4249 :S _ 48733 1065.90 (4 ----------- 394----- 65.15A 0586 (1.09A} 2360 (2.38A)' � 0251 7771 CCS _1 a 5 : 'a (6.65 A) 8548 �4.55A) (18.35 A) 3382 9350 8208 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003143 Billed To: Rustin Harpe Reference Name: Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5728-34-2854 Subdivision Info: Location/Address: Green Hill Road -27028 Property Size: 1 1/4 acre Date Evaluated: Community Evaluation By: Auger Boring Pit Public 1l--**' Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r� Texture group G 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 t SITE CLASSIFICATION: _ i ) EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(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) ■ ■E■■MM■NEEM■■■ ■ENE■M■■E■■ME■ ■EEMMENMEEMEM■ ■EM■■E■ENE■M■■ ■E■EM■■E■EMEN■ ■ ■ ■ ■ ■ ■ ■ ■ ■■■/■■/■/■■/■//■■/■■/■■/■//■■/■■/■NEEM■■NEEM ■■■f\Il■■NEEM■ ■■■■■■■■■■■■■■■■/■■NEEM■■■//■ ■/■■■■■■■/■//■//■/■■/■//■//■//■//■//■/■/NEEM ■/■■■■■/■/■■/■■/■■/■■//■NEEM/■■/■/NEEM//■//■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■//■■/■/■■/■ ■■NEEM/■■/■■NEEMNEEM■■■/■■/■■ ■■■//■/■■/■■■�/■■NEEM■■■/NEEM■/■■/■■NEEM■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■/■■■■■■■■■■■/■■/■■/NEEM■■/■■■■■■■NEEM■ ■■■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■■■■■■■NEEM■■ ■■■■■■■■■■/■■■/■NEEM■■■/■■//■■/■//■//■/■■//■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■