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180 Horseshoe TrailAccount #: 990000845 Billed To: Charles Lakey Reference Name: Charles Lakey Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT , /. 2 / //- Tax PIN/EH #: 5738-09-3164 Subdivision Info: Location/Address: Horseshoe Trail -27028 Property Size: 3 Acres ATC Number: 2245 **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 %'Tf a e #People #Bedrooms '-.-5 #Baths Dishwasher: a Garbage Disposal: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 2,tC` Type Water Supply Me// Design Wastewater Flow (GPD) --F�0 Site: New Repair ❑ System Specifications: Tank Size �AL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width,?,/ "'Rock Depth /0 Linear FLZID 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.**** H Environmental Health Specialist's Signature: 4-�"7' Date: 12177a DCHD 05/99 (Revised) Account #: 990000845 Billed To: Charles Lakey Reference Name: Charles Lakey Proposed Facility: Residence ATC Number: 2245 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5738-09-3164 Subdivision Info: Location/Address: Horseshoe Trail -27028 Property Size: 3 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 WASTEWATER CONSTRRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: •G� A9.-VDate: 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:rCGr/2111" Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: �-^ {L250 f z APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC 4 Davie County Health Department Envimnmenta/ Health Seddon ' P.O. Box 848/210 Hospital Street Mockiville, NC 27028 (336) 751-8760 ***XMP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATiON BULLETIN for instructions. 1, tame to be Billed C 6 L4 r le 4 , >J 14� eYContact Person �4!,,�Mailing Address ST/ Sam. Phos. cit3r/stat•/azP „ec�,�%_ ✓� ?n? su.in.., Phos. - -5-9o3 Z. Name on Persit/ATC if Different than !Above Mailing Address City/state/sip 3. Application For: ❑ Site Evaluation Wimprovement Permit/ATC it Both 4. system to services mouse . ❑ Mobile Home ❑ Business Industry ❑ Other 5. I! Residence: ;People ;Bedrooms _� f Bathrooms 2,d < "ishwasher 81 -garbage Disposal 8'irashing Machine 0-fasement/Pitmbing O 8asementMa Pl=bing 6. If suainses/Zndnatsy/Othe rs specify type # People # sinks # Commodes # showers # 'Urinals # Rater Coolers IF FOODSERVICE: # Seats Estimated stater Usage (gallons per fir) 7. Type of water supply: ❑ County/City 84011 ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes G -No H yes, wha! type? *"IMPORTANT' CLIENTS MAST COMPLETE THE REQI/IRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PW MUSTRES11WHTTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax 081ce PIN: # 5273 q -A 9 - Property _Property Address: Road Name uo r S& <A. n; City/Zip ///no% c I,: f�,Yi of. -2 902-d If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: //- / - ,2 9 i 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 Ifthe information submitted In this application is falsified or changed I, also, understand that 1 am responsible for all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of thea Co h' Healt Dep e• t to enter upon above described property located in Davie County and owned by , M,to conduct all testing procedures as necessary to determine the site suitability. DATE _ f -2 - p 9 SIGNATURE -�LL 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). R"td DCHD (07/99) Site Revisit Charge Date(s): Client Notilleation Date: I EHS. Account No. Invoice No. ` 'yam. ! �' � - � • - 8 S.78•4535"E 366.50' __ rie Line 888.87 N N 78045'35'W Part of Tax Lot 43.01 3.000 Acres t/— N 24029'43"E 368.50' 366.50' N 78045•'35"W 'TIe Line CL Proposed 22' Accessi Easement N 24.29'43"E .248.48' ///--- S 2402943"W 368.50' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION Account #: 990000845 Billed To: Charles Lakey Reference Name: Charles Lakey Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5738-09-3164 Subdivision Info: Location/Address: Horseshoe Trail -27028 Property Size: 3 Acres Date Evaluated: &/_& W. Water Supply: On -Site Well Community Public Evaluation By: Auger Boring___ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence , Structure i 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: L,S LONG-TERM ACCEPTANCE RATE: .13 REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 ois 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)