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292 Howardtown Rd t DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002893 Tax PIN/EH#: 5850-92-8463 Billed To: Zach Hartman Subdivision Info: Reference Name: Location/Address: 292 Howardtown Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3563 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 TRU T. VALID F RIOD OFF FI YEARS. Environmental Health Specialist's Signature: Da • < D 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. 3 ►331-x-V, r-110 !v3• (y oY 4 n N Septic System Installed By: Environmental Health Specialist's Signature: ate: 0 10D DCHD 05/99(Revised) ' DAVIE COUNTY HEALTH DEPARTMENT g -03 Environmental Health Section P.O.Boz 848/210 Hospital Street ' D 7 Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002893 Tax PIN/EH M 5850-92-8463 Billed To: Zach Hartman Subdivision Info: Reference Name: Location/Address: 292 Howardtown Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3563 **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 2 #13aths •2`? Dishwasher: Garbage Disposal: 13 Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: 13�� Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size G +�S Type Water Supply t-�—Design Wastewater Flow(GPD) Site: New❑ Repair System Specifications: Tank Size I 0Q AL. Pump Tank GAL. Trench Width'-5; Rock Depth 12 Linear Ft.Ljcc� ''JJbjSTQ$VT o,J c,�-:� . 1 N�TAt,I ,.� 5 `� o •C. v-,,, D . . Other: —1 l Required Site Modifications/Conditions: Oa1ALL.- Oa C—c7-3Teo!� Pao", )z . ��.�c�' 0 Ho.'•.% IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW. FINISHED GRADE. ****NOT Eontact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:3 or 1:00 p.m.to 1:30 pan.on the day of installation. Telephone#is(336)751-8760.**** -1-141 gyp' 9' 1STl►-�l� 40a'. 36 � a-12! pQoP LtJc= Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) f APPLICATION 17011 SITE EVALUATION/IMPIl0VEAIENT IlEfUlf Davie County Health Department Enlril-onmentaiHeaith Section A U u ? 2,903 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 EIJ (336)751-8760 .IROE OU HEALTy DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TIIE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person Mailing Address 2 92W4r1(6Wf% r c� t' Home Phone b 55-fJ 5 L) City/State/ZIP re�aG`LSuAkc C Zb 702 Business Phone 700— q 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation 11 Improvement Permit/ATC ❑ Both P 4. System to Service: g House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other — 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: It People ## Bedrooms 2 it Bathrooms ❑Dishwasher ❑Garbage Disposal ashing Machine ❑Basement/Plumbing ❑Basement-/No Plumbing 7. If Business/Industry /Other: verify type It People It Sinks _ # Commodes #t Showers # Urinals It Water Cooler[u IF FOODSERVICE: ## Seats Estimated /Water Usage (gallons per day) 8. Type of water supply: ❑ County/City U Well ❑ Community 9. Do you anticipate additions or expansions of the facility this syslenn is intended to serve? M ]'es ❑ No If yes,what type? —S6.T( c� !Erri'y 6u.te Na a &u\3\e, L.'P tel e ***IAfPORTANT***CLIENTSMUSTCOMPLETE THE REQUIRED PROPLICrY 1NI'ORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN dIUSTBESUIIit•IITTED by the client witli THIS APPLICATION. Property Dimensions: 5 t e- WRITE DIREC'T'IONS(rrom Aludisville)to PROPERTY: Tax Office PIN: # 50? � �j� 40r'r\ C4NN or\ ,OLM-1wn Property Address: Road Name Zg2 "aaMtACAw r& W- & ne k i- \e4 on Y�OworAtawe\ City/Zip M",.-X\G 27028 "isr, i5 enc A VroMG 44 \�'e If in a Subdivision provide information,as follows: }�,}��r.� o� �; oI\ Name: Section: Block: Lot: Date home corners flagged: 8/.z*0 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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 1 ant responsible for all charges insured fi•oln Misapplication. I,hereby,give consent to the Authorized Representative of the Davie County IIealth 1)el)artIII eul 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 �22/O 3 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inclu all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Client Notification Date: EIIS: Sign given �•Gr" Account No. 1�24 v Revised DCHD(05/03 S ITTvoice No. 3 2 6. r ro 2437---- M D .88 (2.39A) 2255 (287) n 1.07A) 2 2979 ----- (242) (242) A m1 w.. J (1183) o n 5N (7.73A) 2 W f 5609 Se B 0 i 1260 (448) (180) rn y (1.99A) rn YAAR MSC Q--- ------ 3g 46 46 31 q0 56 'T O n w (2.19A) ;' N 8265 I ss1 (136) 96 N N ...... ... (145) wo co 0 340 �N .. M � 3 0 354 M 1/ N M J 3! (1.37A) 3 (1258 3409 id Tl d ,d (2 39A)" f. " `� �• -2255 '`° L ?t { I I } E 107A) 25 2979, N (242) 5 ° � d 4 d l 5609 . ^? +, • V1/eB. : -M5c ;'(AQg( I # e (1,99A) x`SeB 8463 a ---- - -�r,-- ? � 40 �� ? __ ■Jy�■ _- - a (2A 9A) 8265 �S i u4. (136): 9t 501n \ J EnB 340 . (17,87A) � ? r 5724 y ,, lull)Aq (1,258) - ;. _ . :� 3409 m _r_ -) . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section OQ3 PO Box 848/210 Hospital Street O 2 Mocksville,NC 27028 PSG NtN Phone: (336)751-8760 ITE WASTEWATER CERTIFICATION FOR DWELLING c One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑ Name: Z a fx T Wta k Phone Number: (6 515 D S?Z- (Home) Mailing Address: a q oZ N yW A4 -I.un+ Ra (Work) Detailed Directions To Site: ) S'y - T. P- . N rwamll k K., Rce - T h A.. -1-• Lt r4- i r Fp a u--S (S 9 01" A• Property Address: S wg_ o.- ok w� Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: `? Type Of Dwelling: N Date System System Installed(Month/Day/Year): °l S 3 Number Of Bedrooms: Z Number Of People: i Is The Dwelling Currently Vacant? Yes❑ No P""'If Yes,For How Long? Any Known Problems?Yes❑ No P"o- If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: -b W Number Of Bedrooms: Number Of People: 000, Requested By: Date Requested: 2' 1 3 (S' ature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Comments: Environmental Health Specialist Date The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash❑ Check❑ Money Order❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002893 Tax PIN/EH#: 5850-92-8463 Billed To: Zach Hartman Subdivision Info: Reference Name: Location/Address: 292 Howardtown Road-27028 Proposed Facility: Residence Property Size: see map 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_ Sloe% 57-0 HORIZON I DEPTH D- O n - 2 D -. Texture group Consistence 6_ S Structure Lciz Mineralogy HORIZON II DEPTH Texture group Consistence Structure A L- Mineralo ` HORIZON III DEPTH Texture group C, M LYI Consistence �; S Structure C Mineralogy YnS HORIZON IV DEPTH -3 Texture group ,K Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: n n REMARKS: �' -2 D��Al(Z- RATE: xIST)►�(� 3t," 1Ra,,)C,14 � 1"I) 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) ■■NE■ 0 ONE 1,■■OENN■■ON■■■■ONE■E■■ ■■■■■■■■■■■N■E■E■N■.NNE■■��Ic1��:�■■�.■■■■■■■■■■■.■■■■■■..■■■■.■■■.■■ ■■.■■■■■■■■■■■■■■■■p��■■■■E■■OO■ ■■■■■■■■■■O11■■■E■■■■NEO■■■EE■O.■ ■.■..■■■■■■■■■■■■■Eli■■■�'!rr��'�N■■■ ■■■■■■■■■■■■■■.■■[1■■■■■■■..■■■■■ ■■■■■■■■■■■■■■■■■■■■INN■■r,T■�.:■.�■■■■E■■E■NE■E■E■■.�IE■.E■.s■E■■■■ ■■■.■■■■■■■■■■..■.■SINE■.■.E■i■v!n��NN■■■■■■■■■■■■■■.■■■i■S■■■.■■■■■■■ ■■■■■■■■■■■■■■■■■■■SIS■■■■■■■i■!►�.I■■■■NOON■■■e■■.■■■■■■■■■■■■■■■.■■■■ ■.■■■■■■■■.■■■■■■■■�i.E■ESN■■i■raE■■■■■■■■■■■.■■■■■■■■ES4�EE■ES■EE■■■■ uiiiiim MENiiiMonsonMEMBEREMMONSMEMEMEMENNIMM"EME ■■■..■■■■■■■■■■.■■■■■■is �r!1�1■■■111■■■■■.■■■.■■.■■■■■■■■■Il■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■ ■■■■■■■■■■■■■■Ori■■■■■■■■.■■■■■■a ■.■■■.■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■p■■.■■■■■■■■■NONE ■■■■■■■■■■■■■■■S■■■■■■■■■■■■■■■■NS■EE■■NE■■NE■■■►i■■■■E■E.EE■■EEE■■ ■■E■■E■E.E.ENE■E■■■■NNE■■■■E■■■■■■■■N■E■■E■■■■S■�S■■E■NSS■S■E■■■■■ ■■■NEE■.■■■■■■■■■■■■■■NOON■■SN■■E■■■■SN■■SSN■NSnES■■■■SSE■■■SEE■■■ ■■■■■■■■■■■■Ns■NS■■■SEES■■■■NS■■1�1■S■■■■ENE■N■E■N■NE■■E■■■EN■■■■E■ ■■■■■EON■■■E■S■■SE■■■■ESN■SE■■■■ ■.NNE■N■■E■■r■■ES■E■■■■S■S■E■■E■ ■■SENSE■NEE■SE■■■■■■■■■■■■■■S■■■■■■■■■NE■NE■E■►�N■■E■Ns.E■EEE■E■■■■ ■EE■.ENE■E■E■E■E■E■■■E■■E■E■N■E■■E■NEN■■ES.■S�■ES■■■■■■■SS■S■■■■■■ ■■■NNE■S■ESS■ES■■■N■■S■ENE■■■■■■■■■■■SNESNES■N■SE■■■■■SS■NS■■■■■■■ ■■SS■■■■NS■■S■■SS■■■■■■■■■■■■S■■■■■■S■■SES■■r�■EES■■S■s■ES■■NEE■■■■ ■■■ENS■■E■■■■■■■EN■■■■■■■■■■■■■■■■N■■■■■■■■Sr�N■■■N■■E■■S■■■SNE■■■■ ■■■■S■■■■■■■SS■■■■■■S■■S■■S■■■■■i�■S■■N■■E■■■■■■NON■■■■■■■■■■■S■■■ ■.■NEE■NNS■NS■■NESE■■■NSNENE■NNE■■S■■.ESN■S■1■■S■■■■SS■S■■NS■■S■■■■ ■■■ESS■■■■S■■■■■■■■■■■■■■S■■■■■■S■■■■■■■■■■tl■■■SN■■■■■■■■■■■■■■■■■ ■S■■N■■NS■■SS■NSE■■■■■■■■■■■■SN■■t■■■N■■■■■I1SS■■S.SE■S■E■■■■N■■SE■ ■S■NNS■SSN■■SES■■■■E■■■■■■■■■■■■■■■■■■■N■S■�■SS■SNSSN■■■S■■■ESNSE■ ■■■E■NE■N■NE■.■NEN■■NNE■■■■■N■E■■E■E■E■.■■�■■■N■■■■E■N■E■■■■.NEE■■ ■■■■■■■■■■■■NON■EOE■■■■■■ENNENN■y■OEO■■■O[I■OOOE■■■■■■NNNO■■EOE■■■ ■■■■■■■■■■■■ON■NON■■■NOE■■■■■■■■i�iO■■■■OON[IO■■■■■■■■■■■■■■■■■■■■■■ NOON■■■S■ESE■■■■■NN■■■■■N■■■SSE■N■■■■ESE■■r�■■■NE■E■N■NN■E�■■E■NE.■