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125 Griffith RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002212 Billed To: Brad Rogers Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5863-53-4919 Subdivision Info: Location/Address: Griffith Road -27006 Property Size: 2.75 acres **N 1 ffIslinprovement/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 VAOOSt✓ #People 2 #Bedrooms #Baths 2 Dishwasher: Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: 0" Basement w/Plumbing: U Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 2.?SAd-s Type Water Supply]' O T`1 Design Wastewater Flow (GPD) 31 gD Site: New d Repair ❑ System Specifications: Tank Size I DCOC'AL. Pump Tank GAL. Trench Width 3(o Rock Depth Linear Ft. -_X = Other: �L (715`0-1900TCJtJ 150Ke-S NS7ALL, L-Wi S Ol'o.C, �•� . Required Site Modifications/Conditions: 1l"r,-T,&L— Q,3 C6--'mOLIZ, Y-�iP erP IMPROVEMENT/OPERATION PERMIT LAYOUT APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a represeitative of the Davie County Health Department for final inspection of this arl-oopm to 1-31 12 -M -on he da of installation. Telephone # is (336)751-8760.**** _ 7 7 �• ,� � M 1 N t � gELD � Wil.-L�.� �Od r ��2 d"--�� Environmental Health Specialist's Signa e: Date: b 2— DCHD 05/99 (Revised) Account #: 990002212 Billed To: Brad Rogers Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5863-53-4919 Subdivision Info: Location/Address: Griffith Road -27006 Proposed Facility: Residence Property Size: 2.75 acres ATC Number. 3105 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 WASTEWATE NST S VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:L V ` 2 ate: ID 2 - CERTIFICATE CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Impr emen erati Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 " ewag reatme and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system 1 fun on satisf torily for any ' given period of time. i Septic System Installed By: �--� Environmental Health Specialist's Signature: DCHD 05/99 (Revised) l� TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � r Davie County Health Department LIAR J 2002 Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DAVIE col -IN -Ty IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �3 ra6 ��-�3"' �. o aens Contact Person C� �tpO t' � n �q Mailing Address C)"(acl KJ � p n J Q.l I 00A Home Phone City/State/ZIP A-dynoc o- N�FCi aCOLD Business Phone �33ta) 9oq- 037 2. mob i le - 2. e2. Name on Permit/ATC if Different than Above -S(,ZYY1 1 Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC KBp 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other N 5. If Residence: # People � # Bedrooms 3 #Bathrooms 2. 2. ` 1(Dishwasher ❑ Garbage Disposal Washing Machine Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes X No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERi'Y INFORMATION REQUESTED BELOW. Either a FLAT or SITE PIAN Al ST BE.Si.I8A117TED by the client with THIS APPLICATION. Property Dimensions: .4� K 'f D 9{- Ca•i 5 ac) WRITE DIRECTIONS (from Mocksville) to PROPERTY: , Tax Office PIN: #_ -1�1 (O 3Uj q I �a,ke, 15 R � -b g D I Property Address: Road Name Gr'l�-Fi Bi ' o cLcl 0 n g0 I I u ✓'n R i': ht D n '\(OL -A L Y) City/Zip 6 , 1 L'1 - 2700b UallQu-ict , Aypm . � rv►i 1e5 —1 If in a Subdivision provide information, as follows: -h qh1 on (rb9 h -Road, -it irn Name: L&i 0-'+- -G rSfi d ri / e.lAl 0, Section: Block: Lot: Date Property Flagged:���--- C This is to certify that the information provided is correct to the best of my knowledge. l 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 Authorized Representative of the Davie Couhty=Hcalth Department to enter upon above described property located in Davie County and owned by Brad( L4- . nay.rs e Robin C. TRooyeys to conduct all testing procedures as necessary to determine the site suitability. DATE 3' i:f 10 Z SIGNATURE 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). OLLa--Z � Site Revisit Charge Date(s): Client Notification Date: EHS: t Account No. Revised DCHD (07/99) Invoice No. �_ 1001 - ,,I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION Account #: 990002212 Billed To: Brad Rogers Reference Name: Proposed Facility: Residence _ Properly Size: PROPERTY INFORMATION Tax PIN/EH 5863-53-4919 Subdivision In`o: LocGtion/Address: Griffith Road -27006 2.75 acres Date E�4TiL. '-.,I: $ 0 OL Water Supply: On -Site Well Community :valuation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L, L Sloe % HORIZON I DEPTH 62_ / - ('� Texture group—'V, L GL— Consistence 5 Structure 614 ek Mineralo J; l , '- HORIZON II DEPTH p •- ? �gp d24 Texture group e_ C Consistence i 4:1:5 Structure 6614 ,. Mineralogy1 HORIZON III DEPTH'11 fle Texture group C -t S: -- Consistence ; Fr S5 Structure Mineralogy HORIZON IV DEPTH ' Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O• SITE CLASSIFICATION: �s EVALUATION BY: C 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■M■■ ■■■■■■ M■■■■■ ■ ■■■E■■■ME■■■■11E■■ ■■■■■■■■■■■■■II■■■ ■■■■■■■■E■■■■11■■■ NEEM■■■■■■■■■11■■■ ■■■■■■ ■■■■■11■■/ ■■E■M■■■EM■■■11■■m ■■EME■■M■■MEMII■■■ ■E■■M■■■■E■E■11■■■ ■E■■■E■E■M■MMUME■ ■■EMM■■MEM■■ ■NEEMENRIMM■■ ■■M■M■■RI■■M■ ■■■■■■■E■■■■ ■NENN■■■AM■■ ■M■■■ME■IIEM■ ■■■■■■■■11■■■ ■E■EM■■N11■N■ ■MNEE■■MIIM■■ N■■■EMEHI■■■ ■ ■■■■■■■■ ■EMM■■E■ ■■E■■MM■ ■ ■■■■■■EMEMEME■ ■■■■■■■■■■■■■■ ■■M■E■E■■MMEM■ ■■M■■MMMEMMEM■ ■EM■MEMME■■M■■ ■E■EMEMME■■EE■ ■ ■EMNON ■momod ■■■ME■ ■HE■■ ■■MMEOWD ■■M■E■SM ■■MEM■EM ■EM■■EM■ ■ no ME ■■■ENM■M■■■■ ■MNEE■■■■■■■ ■MMMMMMMNMM■ ■ME■EMN■EME■ ■■■■■■■■■■■■ ■E■■EM■■■EN■ ■■■EM■MEMME■ ■■EME■EMMEM■ ■N■■■E■■EM■■ SEEM■M■EMME■ ■ ■■■ME■■E■MEN■ ■■■■MMEMMENE■ ■■MEM■M■E■E■■ ■EM■■EMME■■■■ ■■■EM■ ■■■■■■ ■■E■N■MM■■E■S■ ■EMEM■MM■■MEE■ ■■■E■■■■■■■■■■ ■■E■■MNEME■■M■ ■■M■M■■M■M■■E■ MEMS■■■M■■ME■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■MEM■ ■E■■■ ■ENE■ ■ ■ENE■ ■ ■