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115 Hartman LnAccount #: 990001003 Billed To: John Hartman Reference Name: Ruth Hartman Proposed Facility: Residence ATC Number: 2339 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5842-39-9489 Subdivision Info:/16 fjAI&I rran zt"6 Location/Address: Farmington Road -27028 Property Size: 5 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: CER **NOTE** The issuance of this Certificate ofomplet n s: has been installed in compliance wit icle 1 Disposal Systems," but shall in NOW Y bet given period of time. �I 70 11b N A Ito ua indicl4e tk syst m described on Improvement/Operation Permit S. C pteV0 ,Section .1900 "Sewage Treatment and a gu tha the system will function satisfactorily for any Septic System Installed By:l/ll.��flsr- SIJ.CW41y- Environmental Health Specialist's Signature: Date:., �L.lo2 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001003 Tax PIN/EH #: 5842-39-9489 Billed To: John Hartman Subdivision Info: 116 yA1ztman 14 tv Reference Name: Ruth Hartman Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 5 Acres **N)�*iis �I11 n mprov3ein nt/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 Z!�z #People Z— #Bedrooms #Baths Dishwasher: Garbage Disposal: 0"- Washing Machine: 0 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Z�le Type Water Supply �� Design Wastewater Flow (GPD) � Site: New Repair ❑ System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width Z)Rock Depth � ,Linear Ft.�� A Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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. T6173U p.m. n -the. _y of installation. Telephone # is (336)751-8760.**** r A C-� Environmental Health Specialist's Signature: Date: Cq- 02U D6 DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT( ,� ''°•� Davie County Health Department �'Y'%ase complete ttie`liigtilighted area(s) and Envifnnmental Health Swdon Tetum.``' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 i (336) 751-8760 FEB 2 2 2000 ***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 TlS] P►� Contact Person Mailing Address -*7, 00 7 /Y� �y�. �J Home Phone City/State/ZIP , /ff r lam. /J �__,,_70,2' e � Business Phone 2. Name on Permit/ATC/ if Different than Above__ flee' C 6 i1(5Z4�J /• ` �� n .y Mailing Address 10 L City/state/Zip �41�►��fi ��, /N. („ ✓ �l/�i�' 3. Application For: *Site Evaluation ❑ Improvement Permit/ATC U/B'0 h 4. system to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People I- # Bedrooms 13 # Bathrooms W/Dishwasher N Garbage Disposal N'Washing Machine f] Basement/Plumbing [] 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: Cl"'County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VNo JU yea, What Type: ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. PropeDi erasions• _ s WRITE DIRECTIONSfrom'Mocksville to PROPERTY:. Tax Office PIN: # 15g4 -PL- 3q q 1PH (IYlrg-D) C S 000 60 DV - c Property Address: Road Name • �4_ � City/Zip1i'%e k -,d,%/, 27Q,Z If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged „Ld v 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 Authorized Representative of the Davie County Health Department to enter upon above described property located. in Davie COUnty and oo-nea by to conduct all testing procedures as necessary to determine the site suitability. DATE A — /S_ 2-d 6 d _ 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). Date(s): Client Notification Date: EHS- Revised DCHD (07/99) Account No. Invoice No. 1.2 e / MSC MSB IrB 1499Af MrB2 MSC 5296 f42.29A1 ,r L= Mr62 6 18 6 2192 AI IrB f6392AJ MrB2 9617 EnB ,N.}1 A/ 0270 ChA �M\ ms C m3c EnB MsC \ EnB This map is for PERC TEST - and BUILDING PERMIT purposes only. The Davie County ! Tax Administrator's Office r assumes no liability for any information contained on this ma MSC - En - w = _ EnB Mr - sC COUNTY -ID: C500000046 MsC (E B - February 22, 200010:38 AM E Parcel Identification Number w Msc 5842-39-9489 --- APPLICANT INFORMATION Account #: 990001003 Billed To: John Hartman Reference Name: Ruth Hartman Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size PROPERTY INFORMATION Tax PIN/EH #: 5842-39-9489 Subdivision Info: Location/Address: Farmington Road -27028 5 Acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1- 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ..i v 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:4,f VP liC. LONG-TERM ACCEPTANCE RATE: REMARKS: ice? N /%l N Y e-- d LEGEND Landscape Position EVALUATION BY: OTHER(S) PRESENT: 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)