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544 Gun Club RdAccount #: 990002668 Billed To: John Poland Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Sectionpk P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 t/ (336)751-8760 ClL - % 7 3 / IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5871-04-2372JP Subdivision Info: Location/Address: Gun Club Rd -27006 Property Size: 10.57 acres ATC Number: 3404 **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- #People - #Bedrooms 3 #Baths Dishwasher: 0""' Garbage Disposal: 12"'- Washing Machine: Pill" Basement w/Plumbing: 13 Basement/No Plumbing: El Commercial Specification:: -Facility Type #People #People/Shift #Seats Industrial alrial Waste: Lot Size 10- 5 -7 �' Type Water Supply COONty Design Wastewater Flow (GPD) 3t�� Site: New [3` Repair System Specifications: Tank Size I OW GAL. Pump Tank GAL. Trench Width o Rock Depth Linear Ft. Other: 01STi-1 F-)QT10r l %.-i�-c-1cjT—�_ �+��5 �t � c • moi. 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.**** �k FGA L-jt.L5 1t,j OQ-C*. /'—\ -y NIX - vi:- l -Dd?r H 9-y Environmental Health Specialist's Signature: isedl 1 `r T1l CD3 Account #: 990002668 Billed To: John Poland Reference Name: Proposed Facility: Residence ATC Number: 3404 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5871-04-2372JP Subdivision Info: Location/Address: Gun Club Rd -27006 Property Size: 10.57 acres 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 U VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit +'L'V 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. ' I oos- y/. itc7 � r �o L so' Septic System Installed By: Environmental Health Specialist's Signature' DCHD 05/99 (Revised) FQACC � _. _._.__--___—____—__ ± ___�_—��—�. �.� .err•,..:.r�.:..s+.�m-�.��r-,T�,manru-�:�w--.. J � l l � SSD xA3 o 3a � � qs �z ll MAR 2 ENVIRONr`AENTAL HEALTH DAVIE COUNTY SIC e+ / 1.5 3 e 3 FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnvironmentaiHealth Section O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer tothe INFORMATION BULLETIN for instructions. �J p 1. Name to be Billed /n x. /�O /`t n rt% Contact Person T, �9d (� , J Mailing Address /3 3 L% �� ���?3 ��. Home Phone 3 3 6 -,7 V City/state/ZIP I � d�,� vi/lam /V L %� �5 Business Phone 331,--GT,7 - FM 2. Name on Permit/ATC if Different than Above 11 Mailing Address City/State/Zip V 3. Application For: 2 Site Evaluation ❑ Improvement Permit/ATCBoth 4. System to Service: 0/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 1 # Bedrooms 3 # Bathrooms o2 Ild'D/Garbage E1 Garbage Disposal R / Washing Machine L1 Basement/Plumbing 1-.1 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats — Estimated Water Usage (gallons per day) &I/ 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 eNo If yes, what type? 'IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or.SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: /b.S� AC WRITE DIRECTIONS (from Mocksville) to PROPERTY: b-71roq•a16ga Tax Office PIN: it ,-' 70 00001 �? 7 o Property Address: Road Name 6c'." ✓ b /�a Tc"" ' 1 i •��'j� ' City/Zip -- J v-.tn e? �% Dv ` ,%��,� r"A A, fy �A l Jywt--� / if in a Subdivision provide information, as follows: �lbne� S 7u 1'/i Name: �'2 Hgv�l �i '�,�f� �Eo• /-eVT 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, 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 ant responsible for all charges incurred from this application. 1, 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 suitability. DATE 3 v 3 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). Com- 3 1 rl �- Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. �. / T (67.95A) 9811 268 (1.13A) 1317 Oil-�18)- 9053 M53 2886 ao 5897 4833 (172) L96 283.31 E70000012701 (5.7A) 5282 (10.57A) 2372 rn co OPO/ e OD (3.31 A) co 5656 T. rn (37 (6.82A) 9508 297 (58) (114) 126 (95) (70) 99 ,'2 9225 T a 8203 0) A7 ry 128 222 o8160 0 8720 ?03-58 8539 CD m 265.50 0 5459 0 Mw A m 8438 C) ;u 265.50 200.72 W 8337 245.91 cD 7283 30 (8.34A) w Ln 1530 � 5 I INO I DEK111011 Ii: r. Z : I: rui .R FACTORS 1 Environmental Health Section 3 4 5 6 7 Soil/Site Evaluation APPLICANT INFORMATION 1- PROPERTY INFORMATION Account #: 990002668 Tax PIN/EH #: 5871-04-2372JP Billed To: John Poland Subdivision Info: HORIZON I DEPTH O - V- !o D - Reference Name: Texture group Location/Address: Gun Club Rd -270 Proposed Facility: Residence Property Size: 10.57 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut 0?1 L FACTORS 1 2 3 4 5 6 7 Landscape position L 1- I.. Slope % (op (Q - HORIZON I DEPTH O - V- !o D - Texture group C -L CL Cr C_ L. Consistence C4 - f 5f P-SS5v G SSS C Fvs� Structure 0?1 L Mineralogy HORIZON II DEPTH' 2 ta' - I 1p 10 - YO Texture group Consistence 1r: S G: P Structure Mineralogy HORIZON III DEPTH 44q SO -.3Z Texture group Consistence G: , Structure Mineralogy Wv t ; l; HORIZON IV DEPTH 3 Texture groupC Consistence Structure Mineralogy =SOIL WETNESS 2cA (O RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE D . Z? S. SITE CLASSIFICATION: PS �I��-�- EVALUATION BY: j& LONG-TERM ACCEPTANCE RATE. OTHER(S) PRESENT: W Ori 41G66�_ 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 16 1:1, 2:1, Mixed Note` - 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 ■ M ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■■■ ■■■■ ■■■■■ ■■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■■ ■■■ ■■■■ ■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NONE MENNEN EN■MiEME MEMNON MENEEMME ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■M■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ 0 ME MINE i� 1 3657 N1 3516 a 8649 w, 87 0791 96 122 190 61 6 8135 123 439 53 24 9531 0533 15: 6104 [,can 9 07 • 6023 56�N ! 60 d« 2 6 �97 ti 4833 r oaz z� int 77 i WM "SKr .. ,f APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL PROVIDED. Refer to the INFORMATION BULLETIN for THE REQUIRED instructions. /- 00 /.,,. 7O k, PD 4,f 1. Name to be Billed tJ p )K ' rt Contact Person �1 Mailing Address d 13 U /d /'.� ze ��• Home Phone ,3 31 --`%6 3 —4-7 3� City/State/ZIP //_3 I ." A"- '; /A /" G 2 Business Phone 33t,--M,1—?70J tel/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: /Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: O House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 12 # Bedrooms 3 # Bathrooms o2 /Dishwasher a / Garbage Disposal V/ Washing Machine U Basement/Plumbing 17 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats - Estimated Water Usage (gallons per day) / 7. Type of water supply: U County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes FJ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: /0,77/k SB -71.0 q -a-3qA Tax Office PIN: # 5 7o vooy j,2 7 o j Property Address: Road Name e—�' yn ��%✓� 'Ra City/Zip - 04 d v'.cnra r%dV if in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: l SS E -)-t -Pko.. AlPlAriJl. 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 suspens'ion 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 responsiblefor 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 to conduct all testing procedures as necessary to determine the site suiittability. \ f DATE 310 -3 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). --e (14-,e -- S° 3/y 103 lis � EHS: Cc�e'� '5�- / C . Account No. Revised DCHD (07/9 Invoice No. (3-% �% �/..s.a T Ali L,P_�/ J at �ijrlt'ftfrf/�I% h9 yye_J Z-eVT � Date Property Flagged: 0-3 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 suspens'ion 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 responsiblefor 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 to conduct all testing procedures as necessary to determine the site suiittability. \ f DATE 310 -3 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). --e (14-,e -- S° 3/y 103 lis � EHS: Cc�e'� '5�- / C . Account No. Revised DCHD (07/9 Invoice No. (3-% �%