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134 Idlewild Rd Lot 6 ti DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003354 Tax PIN/EH#: 5862-34-9883.06 Billed To: H&V Construction Subdivision Info: Idlewild Lot#06 Reference Name: Eddie Hubbard Location/Address: Idlewild Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 4448 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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,190 T!LI�DOR and Disposal Systems). THIS AUTHORIZATION FOR WASTE CO IR S A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign tures Date: Cx, 5' CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall ' dicat the ystem described on Improvement/Operation Permit has been installed in compliance with Articl 11 of pt 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAYS taken a an ee that the system will function satisfactorily for any given period of time. ,k O i1 1 2Q 1� i Septic System Installed By: � Environmental Health Specialist's Signature: Date: DCI-1D 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT 9•' � ' Environmental Health Section • P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 D 1 IMPROVEMENT/OPERATION PERMIT t� Account #: 990003354 Tax PIN/EH#: 5862-34-9883.06 0 Billed To: H&V Construction Subdivision Info: Idlewild Lot#06 Reference Name: Eddie Hubbard Location/Address: Idlewild Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 4448 **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�� '� .� E #People #Bedrooms #Bathsr 2•S Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type //,�,� #People #People/Shift #Seats Industrial Waste: 13Lot Size 0.735 Type Water Supply (20L/1WDesign Wastewater Flow(GPD) OZoO Site: New 2f—Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft. �`(ti0 ae stated v 15A NCAC 18Aalso be used Other; t� aecepted Systems may also be used Required Site Modifications/Conditions: ��� ��t�2. Kms'�t g0X&; LQ Log4 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 s tem between 8:3 a.m.to .m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Ra) t4 ibpl "1 Environmental Health Specialist's Signature: Dat : 7 q DCHD 05/99(Revised) �1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street -� Mocksville,NC 270 8 (336)751-8760/Fax (3 751-8786 Application For: ❑ Site Evaluation/Improvement Permit Zhorization To Construct(ATC) ❑ Both ***IMPORTANT***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 1+4-V G9v.5-11-u,c TI p-►1 GD Contact Person Ob bA(15- �L4�vfx-)— Billing Address -2 1 10 G! tldn an&- AVE Home Phone City/State/ZIP W1 wS f,-m- 5/1-/,�e vim. .::�-: Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) Street Address 2 b er&Ald City Acte Tax PIN# 69'11e7--3-5202q Subdivision Name 'T DCC Wt LD Section/Lot# Lot Size 2a7 K /V6 x?—'Wo Directions To Site: ��Q,�,q,tib � f ( 0o &� r`- O1.0 tje V 1)1-- Le2!YO N Date House/Facility Corners Flagged e O 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? Dyes UNO Does the site contain jurisdictional wetlands? Dyes ©filo Are there any easements or right-of-ways on the site? ❑Yes OK Is the site subject to approval by another public agency? Dyes P10 Will wastewater-other than domestic sewage be generated? Dyes Rio IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms .-3 #Bathrooms Garden Tub/Whirlpool VIYes ❑No Basement: ❑Yes No Basement Plumbing: ❑Yes o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: V'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes vNo If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(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 compliance with applicable laws and rules on the above described property located in Davie County and owned by 1 Site Revisit Charge Property owner's or owner's gal representative signature Date(s): 7 I0 Q� Client Notification Date: Date EHS: Sign given Dyes ❑No Account# 3� Revised 2/06 Invoice# �� Mr 0s 04 103434 awT•aaunar onvDs�ltn 370 M SM hz • j i . y.�u�ry M9YftlMC I.C.mX wta ffos 1 1 Itz"t IDcbVuh,IC 21021 _. p2g1S1.11S0 M16tP5:C1110I CUW MM 1"EXI SID MM90 AM mCMMItSOM tt Pmmo. Molar to ttt IMIDO ?tw 1offiASM toe talbll:iidi1w, L w.,„hS ru.1,�� LaustRucrfvN Co. Q"t tQ,. 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I I • 1 t0'J £T£ttZt9££ w + + ASN WU 9C:10 "'o-6,1-das w • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003354 Tax PIN/EH#: 5862-34-9883.06 Billed To: H&V Construction Subdivision Info: Idlewild Lot#06 Reference Name: Location/Address: Gordon Drive-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: 2— 8 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ! Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence Structure ' Mineralogyt. HORIZON II DEPTH Texture group Consistence Structure Mineralo 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 X SITE CLASSIFICATION: f . EVALUATION BY: Nrr &bLUA._Sj 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 05/99(Revised) 23 I 450 ` ' IS 6 03 l g 48' 6, i Tf • Q cz � Q/V VolO cs 0, <Z) V ru OJIfSEE . - d � � A o L 3 Li g� --, cu 0iu i ,f( 1 PwT\C Q45, Duk }� ly Q 5s�z 35�'oaq tv -Z 3 P l3 reLLFW SLAS D1Y(SIoN �) to �C.oVEQDRI.�- A,Vts- . lux— 19 S4/- tot4.D