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626 Howardtown Circle (2)
. / � , � .. � . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • .�' P.O.Boz 848/210 Hospital Street _ Mocksville,NC 27028 (336)751-8760 Account #: 990004102 Tax PIN/EH#: 5860-09-6631 Billed To: David Purkey Subdivision Info: Reference Name: Location/Address: Howardtown Circle-27028 Proposed Facility: Residence Property Size: 9.5 acres ATC Number: 4505 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater Systecn 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 CONSTRU TION I VALID FOR A PERIOD OF FI YEARS. Environmental Health SpecialisYs Signature: Date: i �� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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 guazantee that the system will function satisfactorily for any given period of time. �o" T.�, G �d� o�, k y � <c ��.c.�( �,�,�-�•�o.+,-�i -.---,._. . . _._. _ . ____.������ (�dd � � � l ---� � � � �� �� � . ` � � o � � � ��. ���.4s Y � t � C _� � /- �h ��, , �( r � ,, 1`�N. � � 3g , � t.. 1 '� , , , '� / / � � ��� — (c _,�,- � —� Septic System nstal�By: . 1.<✓ 4 5oK 1 � • �— —�.... 7 c�c..e !w Environmental Health Specialist's Signature: L ,C%f �J���^— Date: �G—1 7 `d� DCHD OS/99(Revised) S,wrn� �� ,� � .�' DAVIE COUNTY HEALTH DEPARTMENT � _ f . . Environmental Heaith Section � � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 � � , (336)751-87G0 � IMPROVEMENT/OPERATION PERMIT Account #: 990004102 Tax PIN/EH #: 5860-09-6631 Billed To: David Purkey SubdiVision Info: Reference Name: Location/Address: Howardtown Circle-27028 Proposed Faciliry: Residence Property Size: 9.5 acres ATC Number: 4505 **NOTE**This ImprovemendOperation 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). T'HIS PERMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type /J #People� #Bedrooms��� #Baths�_ Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: �� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply'�����Design Wastewater Flow(GPD)��� Site: New�Repair❑ ii System Specifications: Tank Siz��_GAL. Pump Tank GAL. Trench Width-�" Rock Depth/.1 Linear Ft.� Other: Required Site Modifications/Conditions: 11�1PROVEh'IENT/OPERATION PERMIT LAYOUT- APPROVED EFELUENT FILTER RISER(S)IF 6`°BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis 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(33C►)751-8760.**** ?s � � r/ . . �"� � Envir mm �al Health S ecialist's Si ature: Date: �/� �� o e t p gn DCHD OS/99(Revised) � •r� ..__...y n . � � ♦. � - ...i' ♦ li � . � .�P APPLIC ,7� .__ . R'SITE EVALUATION/IMPROVEMEN ��T� x �_ � � -->---� ��. � 1 Davie County Health Department � � � �_�.----�---�-- , ��� ��`�' ' � Environmental Health Section SEP - , `+;: :Y _ '��� � 2006 � ` �� 0 b ��'.,'r ' P•O. B o x 8 4 8/2 1 0 Hospi ta l S tree t �F +, � - , - - � `• Mocksville,NC 27028 �V�RGNMENTAC y � ` :------� (336)751-8760/Fax(33�751-8786 �AVfECOUNTy��TH S �' ���r�i�;� � "��;,��.�, � *�.,.��1�%1�,�� � . � pplication Fo��`��_ it a a►on/Improvement Pemut ❑ Authorization To Construct(ATC) C�{-Soth .,�---�-- __..-�-- -'' -� ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION �� Name to be Billed �R'✓�� �1� ��''k�� -Sr. Contact Person SA-m� Billing Address O /YI;!/i I��. Home Phone 8'-5 — �''�' S- 3) City/State/ZIP �YI o`Ksvi//� � Business Phone�'�'�S- ��(3 / , �k2 b Name on Permit/ATC if Different than Above cSA-n'J� �y� �— Mailing Address City/State/Zip PROPERTY INFORMATION �'�" � NOTE: A survey�plat or site plan must accompany this application. S! (Permit is valid for months with site p�n,no expiration with complete plat.) Street Address �ooZ G ���i'�fdc�/�t/C--/�i"G�t— City /Y�dckSc/,�/le, Tax PIN#�$j„009(0(031 Subdivision Name Section/Lot# Lot Size S.S ����- Directions To Site: /.h S F �o w,9�d f-o�n Ci rr •� , ar ti! /`iq ti¢ 2�/2 r,-�i/�5 0-,�. r,�h�- - Date House/Facility Corners.,Flagged 9 0 If the answer to any of the following questions is"yes",supporting documentation must be attached. . Are there any existing wastewater systems on the site? ❑Yes�10 ` Does the site contain jurisdictional wetlands? ❑Yes �o Are there any easements or right-of-ways on the site? G1Yes Cl�io Is the site subject to approval by another public agency? ❑Yes f�10 . Will wastewater othet than domestic sewage be generated? ❑Yes fi}'�10 IF RESIDENCE FILL OUT THE BOX BELOW #People �_ #Bedrooms � #Bathrooms_�� Garden Tub/Whirlpool es �No _ Basement: FX�es ❑No Basement Plumbing: �es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBnsiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Ed'�onventional �A'ccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water �1ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�Io If yes,what type? This is to certify that the information provided on this application is true and conect to the best of my knowledge. I understand that any pemut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine�c�npliance with applicable laws and rules on the above described property located in Davie County and owned by %� �Gt.r� i � � � Property owner's or owner's legal represe ive signature Site Revisit Charge � Date(s): � p� Client Notification Date: Date � EHS: Sign given ❑Yes ❑No • Account# [dZ- Revised 2/06 Invoice# �.- . � �� � ,.> .- 6 q a :`•:P 7 9 � I 1�" Edc �����4r: ) . i m � �" i � ` " � I ' .,.� _..._.�:�::.t _ . ,'. � �. �"s . . � ___ 1025_36_— --� .. _— i__ \ y9g30 � --�-- � (9.33A) ,,, ---. -/ --- 0349 `� N / m — � I / / / '---.. � � ��g23� � (7654) �I '_'_ , -_ (8.60A) s - - � 7157 9 L, --�L6961 � ` N - �N I ' .- � N � (9.35A) ..(7sq6� - -- - 98� 598 o-----= - ChA j i ,a�� — — / � MsD EnB EnB ___ _ __ 6�� � ; EnB MsC � (9.35A) .-"� yQk 6631 MsC EnB --� MsD �, ._ .. MsD EnB EnB �y � EnB �s�s ; � . . . . . . 1232 .. _ . .._... . . -� _.___. __,._. (563) t , � /. o ;•' / 0 0 o y � � � {3.64A) ��l � 8266 � ..� . _ ___ W N 4� �z8„ 658 ` v o rz4s, — � zsa.. � N 3089 — --_zsa o (2.03A) � ��. � 8004 � m "'. (1.94A) . 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' • Environmental Health Section . • Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004102 Tax PIN/EH#: 5860-09-6631 Billed To: David Purkey Subdivision Info: Reference Name: Location/Address: Howardtown Circle-27028 Proposed Facility: Residence Property Size: 9.5 acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slope% HORIZON I DEPTH Texture grou Consistence Structure Mineralo ° HORIZON II DEPTH Texture mu Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEP'TH Texture rou Consistence '� Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE . CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: ; REMARKS: _ LEGEND T, n s pe Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope T�sturs . _ 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 .ON4I4T�,NC , II'I9iSL VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �g , �SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky � SBK-Subangular blocky PL-Platy PR-Prismatic ' Mineralo�v 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-gaUday/ft2 DCHD OS/OS(Revised) . . ; ' ' ,� a , . . �{' G //� ... . , . - . .. � � •�• j� � . . ,` . .. . . . . . w . � � //' � . . � . - . � . . � .�. � � .� .. . � . . . a , �� - �P T N FOR SI7E CVALUATION/IMPIiUVEhf , NGih11T S t17'C � � �(/q�� ' Davie County Health Department S 3 � ZQ � Envi�onmenta/Hea/th Section �. . h �`� � '�P.O. Box 848/210 Hospital Straet �n �G � �yY� �R,�„ ' Mocksville, NC 27028 �fv �� ��` �/ . �3i1£���N�� , � (336)751-8760 v y� � lY // : ***IMPORTANT*** APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE R�QUIRLD � INFORMATION IS PROVIDED. Rafer to the INFORMATION BULL�TTN for ins�ruction�. 1. Nazne to be Billed ���-�'✓� L�/ � v��s Contact Per�on _ ._, ___ ___ / �� �,,,p �/ � � � O � Mailing Address � lQ � ���'�J Z�2-""' • Home Phone City/State/ZIP Y�-� G<� S v L L L � su�ines� Phone 2. Namo on Permit/ATC if Different than Above __ Mailing Address City/State/Zip � 3. Application For:�Site Evaluation ❑ Improvement Permit/ATC ❑ BoLh . � a. Syatem"to'Service: iUfl House ❑ riobile Home ❑ Busine�s ❑ Industry 0 Other 1 5. 1�pe system reque3ted: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ` 1} Bedrooms � 4F Bathrooms 2- (XJDishwasher ❑Garbage Disposal shing Machine ❑Basement/Pluml�ing ❑Dasement/No P1umUing 7. If IIu3iaess/Industry /Other: verify type 1t People IE Sink� # Commodes 1F Showers � Urinals 1! Wal-er Coolera IF FOODSERVICE: # SeaL-s � Estimated Water Usage (qallona per aay) , 8. Type of water suppiy: 1� County/City ❑ Well ❑ CommuniL'y 9. Do you anticipate additions or espansioiis of thc facility tliis systcm is iutc��dcd lo scrvc? ❑ Ycs : E3-Pv� • � Ir)'CS�}Vll�t f)'�C� � , ***lA1PORT.4NT'"°**CL1�N'CS tYfUST COAIPLETETHC RL•QUIIZEU PKOPLK'CY 1N�OKMA'1'iON KI:QULS'1'�D , 6GLOW. Gitlier a PLAT or SITE PLAN dIUSTITCSUI3Ml77'L•D by tl�c clicnt �+•itl�7'ItIS APPLICA7'ION. I'ropert)'Dimcnsions: � ��S �� WR1TL D1It[;C7'IONS(Cruw 11•lucks��illc)to PKOPEK'I'1': Tax OfGcc PIN: {� s�t a - D f �� �p .� � W a—��/�- Property Address: Road Namc �'J r.✓-v�.�C ��. ( �^"�-- . City/Zip � I� If iii a Subdivisio�i providc information,as folloivs: Namc: Scction: Blocic: Lot: Datc homccoriicrsllagbcd: � � �'�� � Tliis is to ccrtify that tl�c informatiou provided is corrcct to tlic bcst of my Icno�vlcdbc. I uudcrstaud tl�al any peru�il(s) . issucd l�creaftcr are subjcct to suspcusion or revocation,if tlic sitc plans or intendcd usc cl��i�bc,or if thc informatia� submilted in this application is falsiGed or clianged. I,also,r�ndersfand tlrat I ui�i re�7�onsiGle jur al[chrub�es iucnrre�!fi•om ' d�is applicalion. I,l�ereby,gi��c cousent to the Authorized Representative of ttie Davie Couuty IIcalth lleparU»cul ' to c�itcr upon abovc dcscribed pi•opci•ty locatcd in Davic County and o�vncd by ___ to conduct all testing proccdures�s nccessary to dctcrminc the sitc suitability. , . DATE SIGNATUR� �- THIS AREA MAY BE US�D TOR DRA�YING YOUR SITE PLAN(Includc all of tIic follo�ving: Laistin�;aud proposcd property lines and dimensions, structures, setbacks, and septic locations). � I Sitc Rcvisit Cl�argc � � �r �� �� Datc(s): � � � � � � �� Clicnt Notilicatiou llatc: E�IS: Sign givcn � � Account Na �2' Z-_ Revised DCF (OS/03 ' Invoicc No. �a I - _ (9bZ) 'I j ! � �18Z) I N � N O O -- -- - 96 Ebb � � 99Z8 � 9z£5 0� ' (dv9�E) o � �b'68' 4) �o��' � � Z 0 � ZZ Lb£ �E99) I l69 — - 6 �6L zEz� � � � ,'�� � ���w�,���� ����� . �£99 �� �d5E�6) � � � - � � � �� � z090 �000009� � ;� - � � � '� .�°' �- __�£bL / - -- , � — � - _ I�.�� 6c�O �Qs, �.,!� - �5�f O � (£g�) _ , _ (9bgl) �b�5i;�6� 69 � � � � Cu�/ ..._ cN,' , �ti� - i ' i ' _ � ����- _----.. �� �'- _ � N�I � N � ' �9� � 9��� � _ L5 �L �b09�8) _ - - � � `� (tiS9�� . . , . . , . . . (�z8�I , . , _ .. ,.� . . . • • ' " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002822 Tax PIN/EH#: 5860-09-6631 Billed To: Clement Jones Subdivision Info: Reference Name: Location/Address: Howardtown Circle-27028 � Pro�osed Facility: Residence Property Size: 9.35 acres Date Evaluated: _� �3 ' � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � -. Slo e% HORIZON I DEPTH << y Texture rou Consistence Stnicture Mineralo ' HORIZON II DEPTH �� � �� Texture rou G Consistence � � Swcture / Mineralo � ; HORIZON III DEPTH `, _; � : . � _ _ ` Texture rou � Consistence Structure . Mineralo � HORIZON N DEPTH � Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , 2 SITE CLASSIFICATION: EVALUATION BY:Ti�l// 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-Tenace 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-Silry 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 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-gaUday/ft2 , DCHD OS/99(Revised) ,; ■���������������■��������■�/�■�■��■����■■����■���������������■��■■ ■�■��■����■��■��■��■�\■��������■���■�����■���■������■��������■■�■■ ■■����■���■0����■���■����■■��������■■�0���■������■��■������i�0��■ ■\���■����■����■����■��■■������■ ■����■����������■��������������■ ■�������■��■������■����■■����■���■�����■�����e��■\������■��■�■■�■■ ■�������■■���������■����■■�������■■��■��■e������■��■����■����■��■■ ■����������������������������������������������������������������■ ■■����■��0��■���■O��■�e■��■��������■■����■���■■���■�■����������■�■ 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■■����■������■�����t■��������■■��■��a��■���������■�■■■�o���e���■■■ ■■��������■��■����■�■��■����■�■■��■����■��■���■��■��■��■���■�■��■■ ■■�■���■��■�■�������■��■������■■���■�■�■■�����■■����■���■■■��■■��■ ■��■������■���■�■�■■�■■����■�■�■����■�■■������■��■�■■�■■■■��■■■�■ ■�■���■��■�■■�■�■■��■�■�■■�■■■�■ ■■■■■■■�����s�■����■����■■�■�■■■ ■�■��■�■���■�����■����■��■����■��■��■�������■��■■�■■�■�����■���■■■ . 3 � , � •� � � . .-. « � .. � - .. . .. _ . . . i , Il�i��F� CO[�1t�TY�I��T�i ���'�.f��i l�i� " ��': ��� .,-.<, �, .�F..., �..__...._.,_ �a m. .... _ . _ .._..�. ._,.. ... _a..t..... . .. . � . . , _ ... ..a �. . . h.�:z � ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 �,�.. __.�_.._._��__._..e. .v�.��._�u ._. :Phone_#� .y(336)751 w8760;.. ,_. .�_ ,._..._,,.�,.._., "...�,��..��w� July 10,2003 ` Clement D. Jones 964 Cornatzer Road Mocksville,NC 27028 Re: Site Evaluation/ Howardtown Road ' - Tax Office PIN: #5860-09-6631 Dear Client(s): � As requested, a representative from this office visited the aforementioned site on July 8, 2003. . Based on information provided on the Applications for Site Evaluations and after the evaluation was completed this site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Authorization(s) to Construct can be issued the appropriate application(s)must be filled out and the house/mobile home location staked on each site. If you have any questions,please feel free to contact this office. Sincerely, /�o2►'�t���,/��• Robert B. Hall,Jr.,R.S. Environmental Health Specialist RH/df . Enclosure(s) _ ; ` ` - - .'�' � . , , � AI'1'LICATlON f01i 511�C CVALUATIUN/Ih1PItUVUiClVT I'LIih111'S A�TC ' � Davie County Health Department , � Envi�onmenta/Hea/tfi Section , P.O. Box 848/210 Hospital Strae� Mocksville, NC 27028 (336)751-8760 � ***ItSPORTt1NT*** THIS APPLICATION CANNOT B� PROC�SSLD UNLLS5 ALL TIIL R�QUIRL:D_—� I INFORMATZON IS PROVIDED. Retor to �ho INFORMATION IIULL�TIN �or instructionJ. • l. Namo to be Dilled �,�►^�-+'✓ � � � V��� Contact Person ._ , „__._ C7 �— co � c o 2dailing Address � la � � � r �Z�2-"'"' • 2tome Phone _.__ i City/State/ZIP y� �Q C-<� S � (, LI � IIuaine�� Phone _ _ 2. Namo on Permit/ATC if DiEferent than Above ___.^__.__ Mailing Address City/State/Zip __. 3. Application For:�Site Evaluation ❑ Improvement Permit/ATC ❑ IIoLli ' .�/ � . r � 4. syatem to servica: 1� Houae ❑ Ziobile Home ❑ Busine�� ❑ IndusL-ry ❑ Othcr ► 5. Type uystem reque�ted: ❑ Conventional ❑ canventional modified ❑ innovaLive 6. If Residence: � People � Bedrooms � 4k Bathrooms rf [.f�Diuhwasher ❑Garbaga Dispo�al shing bSachine ❑Ba�ement/Plumbing ❑Uasement/No l�lunil�ing 7. Zf Du�iness/Industry /Other: verify type IF People If �inlc� _ � Commodea 1f Showers 8 Urinala �t P7aL•er Cooler� IF FOODSERVICE: � SeaL's ' Estimated Water Usage (gaiiona per aay) e. 2ype of water 3upply: 'kT County/City ❑ Well ❑ CommuniL-y 9. Do you anticipate addition3 or expansious of tlic facility tLis s�'S1C1111S 111IG1dC(1 lU SCl'VC� ❑�'CS �l� • I�)'CS�IY�IAf f)'jlC? � ° . ***lAiPORTANT�**CLILN'CS�YIUST COAIPLCTGTHC I�lQUI1tE1I 1'ROi'LK1'Y 1NFOIiMA'1'ION 1LI:QULS'I'l:ll I3GLO�V. �itlicr a PLAT or SIT�PLAN dIUST13ESUllilfl7TL•D by thc clicnt �ti•itli'1711S APPLICA'I'IO1V. I'roperly Ditttcctsio�ls: _ / .�S �--�� tiv,zi'CL ll11tLCl'IONS(fru�u 11•lucl.svillc) lu PIt01'CIZ'I'1': Tax Officc I'IN: # -��� a - a`� � � � 1 � ,�-- ��' Property Address: . Road Nauic ry < /3'"'�— . ry"� ��-/��. City/Zip __,�(�`- /!-C_� �-' � If iii a Subdivisioii providc information,as follotivs: Nat»c: Scction: Blocic: Lot: Datc honic corucrs llagbcd:��� �� � Tl�is is to ccrtify that tlic informatiou providcd is corrcct to tlic bcst of uiy luio`i•Icdbc. !undcrslaud tl►:►t:uiy permil(s) . issucd licrcaftcr are subjcct to suspcusion or rcvocation,if thc sitc plans or iutcndcd usc cl�anbc,or if lhc iufa•mation suUmitted in tl�is applicatioii is falsired or changed. I,also,undcrstanrl lliat I unr re�1�ui�siLlc fa•all chn�b�es i�rcru•red fi•ou� ' rlris applicario�r. I,l�creby,gi��c couscnt to ttie Authorizcd Rcpresentativc of llic Davic Counly IIcalth llcparlu�cut to culcr upon abovc dcscribcd property locatcd iii Davic Cout�ty and o�vucd by _____.____. to conduct all testing pi•occdures as iicccssary to dctcriuinc tl�c sitc suitabilit��. DATE SIGNATUI� '�- ,o,� THIS AREA MAY B�US�D rOR DRAtiYING YOUR SIT�PLAN(Includc all of thc 1'ollotiving: Lxistiub a��Q proposcd property lincs and dimcnsions, structures, sctbacks, and scptic locations). Sitc ltc��isit Cli:irbc /�� �� ��_ O� — , ll:itc(s): ! �sr � � �(� � �� Clicnt Nolilicatiai llalc: t�` . �IIS: Sign givcn � � Accouiit No. Reviscd DCf (OS103 ' Iiivaicc No. , ' r �..._�._.�_���..�.:..�� ���kii\l�Sd1Y 1 1 �1�L'lEa�17a��1 ��e1»YlYY� .�...y Oi�T� � �' ,.-_5.»s��^. � � � ENVIRONMENTAL HEALTH SECTION� �� � P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 �._.,,--_ _. __ . ---.- �„� _�- _.__ .�,�.. .,� � Phone`#: �33�751-8760 , � .� .....��.,.._.�. .._ �__ �. � ...,�W.,.��..u.,�..�.,�.�,.,���.�„�m�.�..m_�.�.���,n��..�.,a,�,...�; July 10, 2003 Clement D. Jones 964 Cornatzer Road Mocksville,NC 27028 Re: Site Evaluation/ Howardtown Road Tax Office PIN: #5860-09-6631 Dear Client(s): As requested, a representative from this office visited the aforementioned site on July 8,2003. . Based on information provided on the Applications for Site Evaluations and after the evaluation was completed this site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Authorization(s) to Construct can be issued the appropriate application(s)must be filled out and the house/mobile home location staked on each site. If you have any questions,please feel free to contact this office. Sincerely, - �a�'�����• Robert B. Hall,Jr.,R.S. Environmental Health Specialist RH/df Enclosure(s) _ . - . . : , .� . - : � - . ..- . . " . . _, . ., ,,;,,, ,; , ,, ,, ., .