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867 Howell Rd, Lot 1 DAVIE COUNTY HEALTH DEPARTMENT l 7,-,7 9 ` Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900205 Tax PIN/EH#: 5823-61-8970 Billed To: RMF Construction Subdivision Info: �a��/ `�'o) ie`t' Reference Name: Rudi Faak Location/Address: Howell Road-27028 Proposed Facility: Residence Property Size: I Acre ATC Number: 2081 **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 TRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type t�t D066 ' #People #Bedrooms 3 #Baths 2— Dishwasher: Dishwasher: 19 000' Garbage Disposal: ❑ Washing Machine: 2r Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Typenn #People #People/Shift #Seatts^s Industrial Waste: ❑ Lot Size Cl0 Type Water SupplyC. Design Wastewater Flow(GPD) Site: New Repair❑ n System Specifications: Tank Size IDQIIAL. Pump Tank GAL. Trench Width 2i� Rock Depth 12" Linear Ft.&(�t Other: �i5"f�l P�?TIO� LtS Required Site Modifications/Conditions: 14S>TAU� 0"I C&J-pgj X Vd D� V1d•We,�='��4 o� 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.**** lzj'z' F--�gtO.G• v ' Environmental Health Specialist's Signature: Date: lqq DCHD 05/99(Revised) 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900205 Tax PIN/EH#: 5823-61-8970 Billed To: RMF Construction Subdivision Info: Reference Name: Rudi Faak Location/Address: Howell Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2081 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 Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CO ON IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: / M, 01 V0 CERTIFICATE OF COMPLETION **NOTE**The issuance of this Certificate of Completion shall in"e the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G. .7 apter OA Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken a grant th the system will function satisfactorily for any given period of time. �,12l j2 �1� 110 e. Septic System Installed By: Environmental Health Specialist's Signature: f'/Y��& Date: 110' r7 GC/ DCHD 05/99(Revised) ' APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT nn 1� Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Z 9 19Z Mocksville, NC 27028 (336)751-8760 ENVIR0 ENTq�H DAVIE KITH ***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 u D' �}il Contact Person Wit tY, Mailing Address f�^�C?�6 M V {)� ulc /n '//J�/j Rome Phone 9'9g 3 11� City/State/ZIP �D/', iIi,r,� /K- Business Phone 7S-1 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: d House ❑ Mobile Home ❑ Business ��11❑ Industry ❑ Other S. If Residence: # People # Bedrooms 6 # Bathrooms 1-21 R( Dishwasher ❑ Garbage Disposal © ".skiing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People AIA-t- # Sinks 1 11 # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats = --- Estimated Water Usage (gallons per day) 7. Type of pater supply: U /County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑Yes ©No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: / �6� �ffic1� WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 70 (0 1 Property Address: Road Name T/b�►(�l�_ !fit 11i2 n;141 3E6 &1C. City/Zip `{YAy'n (�•�' M i fe 0 / If in a Subdivision provide information,as follows: n Name: (v 4Wooal' QFC Section: Block: Lot: Date Property Flagged: G7 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 owned by to conduct a testing procedures as necessary to determine the site suitabili . DATE r- SIGNATURE THIS Y E USED FOR D WING YOUR SITE PLAN(Include all of the following: Existing and proposed prop i h' i es a dimensions, q ures, setbacks, and septic locations). I Date(s): Site Revisit Charge 0 Client Notification Date: 1�\2� 33. EHS: Flo f p� Account No. ZD� Revised DCHD(07/99) ' IFE Invoice No. �v �t5 0 , 05 ` E 'poi* A marked 15" ELM co v 0- 0z - 2 1 rw j N7 oZ pan ,roe found ?3 64 38- 45 65l 59 S 21°13 - 45 E 187. 51 � — x int at S 29°-22 - 45 E 220.00, 0o O�f !� x po t wo t �+ U S 28°-30'-30 E s 250.94 0) J rI 249.42 placed 208.35 r' 'asp haltn ' I S 88°- 34 W g W 15" tree870-20 -45"W 4 — S . I i PARCEL 124 I I PLAT FOR RUDI FAAK SCALE: I = IO O APPROVED BY DRAWN BY DATE: 09-07-93 PARCEL 124.01, DAV I E COUNTY TAX MAP C -3 SEE DEED BOOK III-PAGE 212, LCLARKSVILLE TOWNSHIP, DAVIE COUNTY , NORTH CAROLINA C . RAY CATES Telephone 704 /634-373 DRAWING NUMBER II .� DEPOT STREET 3198 M<,CK VI LC I NORTH CA RQLINA 7028 i APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By_ Rudi Faak Mailing Address Rete g Box 267, Moaksval a Home Phone aasa8__29()g 3 Business Phone 2. Name on Permit if Different than Above 1 3. Application for: E General Evaluation a Septic Tank Installation Permit 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # I ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public private ❑ Community 8. Property Dimensions ,11!9& Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: Parcel 124. 01 West side of Howell Rd. SR 1419 This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. Segt:emberzaT 93- DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ONBA OVE DESCRIBED PROPERTY MUST CHECK ONE: , ❑ 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 said site's suitability for a ground absorption sewage treatment and disposal system. 9- 2-1 93, zlz4 DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME /6", �� DATE EVALUATED ADDRESS PROPERTY SIZE �1ilre PROPOSED FACIILTY Alrr SC LOCATION OF SITE ,�� Water Supply: On-Site Well t/ Community,-, Public Evaluation By: Auger Boring ✓ Pit Y Cut FACTORS 1 2 3 4 Landscape position A- C- Slo e Z a HORIZON I DEPTH Texture group S'4- Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence Structure b/ /C Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE f/ SITE CLASSIFICATION: �,� EVALUATED BY: 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-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(01-901 ■/■!■.....■./■!■..■/!■..//.MEMO/.//■■■//.MEMO//.■■../.■.!■ ../MEMO ........................... ...................................... ........................................■�.....■�...■........■'MINE .■ iiiiiiii■iiii'■iiiiiiiiiii�i■iiii�iiiiiiiiii�iiiiiii''■iiiiiiiiii=iii ■.■■..■■■■■■■■■■■■.■.■■..■....■.■....■■....■.■■■..■■■.■■■■ ■■.MEMO ■.......■■..■■..■■....■..■....■..■■.■■■.■■.■.■■■■■■■.■■■.■�■■■■■■■ ■..■■.■.■....■....■.■..■...■■..■■.....■■..■■■...■..■ MEMO .■.MEMO .iiii�iii�.ii�iii'.iii�iiiiiiii ' iiiiii�iii�■i i'iii'rMEMONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■�■■ONE■■ !a■■l...!■■...■■ ■.■..■..■■...■N■■.M■■■..■...■■.■.■■■■ ■ ■■E■■' MMI■IMMUM■■■■■ ■■■ � ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■ H !. ■ O. 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