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472 Fred Bahnson DrDAVIE COUNTY DEALTH DEPARTMENT Environmental Health Section Account ##: 990001430 Billed To: Beauchamp & Assoc. Reference Name: Bleeker Strand riVVw�u i-dUfflLy. rMV-1111tel ATC Number: 2598 P. O. Bog 848/210 Hospital Street Moeksville, NC 27028 (336)751-8760 Tax PIN/BH #: 5873-64.2476 Subdivision Info: 47t rr4� bk. Location/Address: _524 Fred Bahns on Drive -27028 r1vN;M:2iy .mice. uC� 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 CONSTRUCITON IS VALID FOR A PERIOD OF FIVE YEARS. —11 Environmental Health Specialist's Signature: - Date: – 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 I 1 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. lo, Septic System Installed BA� Environmental Health Specialist's Signature: �'/_Date: U DCHD 05/99 (Revised) 17 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section / P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001430 Billed To: Beauchamp & Assoc. Reference Name: Bleeker Strand Proposed Facility: Kennel Tax PIN/EH #: 5873-W2475 Subdivision Info: Location/Address: 524 Fred Bahnson Drive -27028 Property Size: see map ATC Numb r: 2598 **NOTE** This mprovement/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 #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type4AdAL #People % #People/Shift #Seats jQ ndustrial Waste: ❑ Lot Size Zio96 Type Water Supply A ell Design Wastewater Plow (GPD) Site: New er Repair ❑ f System Specifications: Tank Size/" GAL. Pump Tank GAL. Trench Width, ZgCRock Depth � `a d Linear FkE 191P Required Site Modifications/Conditions: 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.**** Environmental Health Specialist's Signature: Date: `' `Z� DCHD 05/99 (Revised) y✓ APPLICATION FOR SlIE EVALUATION/IMPROVEMENT PERMR & ATC �( `� L J Davie County Health Departinent V Environmental h/ee/tfi Section OCT - 2 P.O. Boa 848/210 Hospital street U Moaksville NC 27028 (` (336) 751-8760 ***ZWORTANZ'*** THIS APPLICATION CANNOT EE pp4CESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORHATION BULLETIN for instructions. 1. Name to be Billed tdGAss " GC 4� contact person CL , (c= Cs� Mailing Address SZ 7 Home Phone kl-o ! city/state/sxa `/ �Z Business Phone %jB-`j 2�5 2. Name on Pezmit/ATC if Different th," Above L s Mailias4 address5291 E9 [S,�iLIi�S��, City/state/Zip 3. Application For: mite Evaluation ❑ Improvement Permit/ATC Both 4. system to Service: O House ❑ Mobile Home 9-1§usiness ❑ Industry ❑ 0th s. If Residence: # People — # Bedrooms Bathrooms 0 Dishwasher E7 Garbage Disposal D Washing Machine 0 Basement/Plumbing fl Hasemant/No Plumbing 6. If Business/Industry/Other: Specify type �y " # People # Sinks # Commodes gy # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Rater Usage (gallons per day) 7. Type of water supply: ❑ County/City . U/Rell ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Cho If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAIT or SITE PLAN MUST BESUBMITTBD by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS (from Mockwille) to PROPERTY: Tax Office PIN: # C> -2 v Property Address: Road Name City/Zip r dG �� If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: IC)- 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 all testing procedures as necessary to determine the site saitab' DATE 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). Revised DCHD (07199) Site Revisit Charge Dates)' Client Notification Date: EHS: Account No. ) -(3 d Invoice No. 1�1111=0 DAVE COUNTY HEALTH DEPARTMEN'.0 Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001430 Tax PIN/EH #: 5873-60-2476 Billed To: Beauchamp & Assoc. Subdivision Info: Reference Name: Bleeker Strand Location/Address: 524 Fred Bahnson Drive -27028 Proposed Facility: Kennel Property Size: see map Date Evaluated: le_ � * 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 grTT Consistence Structure Mineralogyt HORIZON II DEPTH Texture group s✓/211 Consistence 'r Structure t �7 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture EM Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLTTE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: /' 1 LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: //f f 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 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)