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200 Iron Horse LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003550 Tax PIN/EH #: 5746-29-8459 Billed To: Paul Hinkle Subdivision Info: Reference Name: Location/Address: 200 Iron Horse Lane -27028 Proposed Facility Residence Property Size: 5.113 acres ATC Number: 4086 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 10, S&I CERTIFICATE OF COMPLETION lit te-, *IN,OTE** 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 0 Septic System Installe y: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) SNE -P Si -1 L-'�nn A.J lj Unir.1 DAVIE COUNTY HEALTH DEPARTMENT • .+ _ Environmental Health Section 6 • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003550 Tax PIN/EH #: 5746-29-8459 Billed To: Paul Hinkle Subdivision Info: Reference Name: Location/Address: 200 Iron Horse Lane -27028 Proposed Facility Residence Property Size: 5.113 acres ATC Number: 4086 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 �J Dishwasher: e 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 ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth L inear Ft Other: L12ii Required Site IMPROVEMENT/OPERATION PE" FINISHED GRADE. ****NOTICE: Cc system between 8:30 a.m. to 9:30 a.m. or 1 0,. OUT - APPROVED EFF T FILTER RISER(S) IF G "BELOW epresentative of the Imo` \�� ealth Department for final inspection of this on the�`�V m al i Telephone # is (336)751-8760.**** 301: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) )pD a :� N Lr-. APPLICATION FOR SITE EVALUATION/MPROVE41ENT PERMIT Davit: County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 MAR 2 S 2005 i ENVIRONMMT." , ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE -7Q INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. llama to be Billed k-�AULL CN1tS 1/Nk6f Contact Person Mailing Address 7/0¢ ArSc-drY CxuXf Home Phone 76 -3 q�/T) e1 9� City/State/ZIP y'&LALIT' cd yA 22 X Irj Business Phone !Q-3 e10 J.z6, 2. llama on Permit/ATC if Different than Above Mailing Address City/SSt�ate/Zi 3. Application For: Site Evaluation l Improvement Permit/ATC ❑ Both 4. System to Service: 14 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: X Conventional 13 conventional modified ❑ innovative 6. if Residence: # People 'S'`' # Bedrooms tt Bathrooms 3 gDishwasher 4roarbage Disposal h(Washing Machine ❑Basement/Plumbing ❑Basement/llo Plumbing 7. If Business/Industry /Other: verify type # People tl Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ 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? ***1/11P0RTANP** CLIENTS MUST COMPLETE TILE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBd11TTED by the client with TIIIS APPLICATION. Property Dimensions: �. / ( 3 a-� Tax once PIN: # S74 2 98 45-9 1VRITE D ECTIONS (from Mocksville) to PROPERTY: ,J r e. Property Address: Road Name 200 :0�0 A/1164 city/zipAlKictsylcct IVC 207—F 1y `v!—S o cf�-- If in a Subdivision provide information, as follows: d 'f'J 4-1 Name: Section: Block: Lot: Date home corners [lagged: 6 3 0/ O "3 This is to certify that the information provided is correct to the best of my knowledge. I understand that any perinit(s) issued hereafter arc subject to suspension or revocation, If the site plans or intended use change, or if the Information subnliltcd 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 Represcutative of the Davie County I-Icaltli Dcpartlllcllt to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine.the site su' ility. DATE �� /" `2 O SIGNATURE TIiIS AIZEA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed nronerly lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCHD 5/03 C- 44 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. �7 t2 V� K50000010204 CD 7S 5746298459 5.113A 8459 (100) PSI h r � DAME COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account ##: 990003550 Tax PIN/EH #: 5746-29-8459 Billed To:- Paul Hinkle Subdivision Info: Reference Name; Location/Address: 200 Iron Horse Lane -27028 Proposed Facility: Residence Property Size: 5.113 acres Date Evaluated: Water Supply: Evaluation By: On -Site Well Community Auger Borin I Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % -� s HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH R Texture group Consistence - Structure /J / Mineralogy HORIZON III DEPTH C Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: f EVALUATION BY: Y&Zz OTHER(S) PRESENT: r REMARKS: LEGEND • Landscgpc 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 Textur 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 of 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 MineralogX 1:1, 2:1, Mixed • Notes :a 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 nrtin mmo (Reviged) ■■■■■/■■.■■■■■■/■■■■■■■■r■MMM■■■No■■■■■■■■//.■■rN■■■/■■■■.■■■■■■/■ .......■.................................................... ■ ■ ....................■.........■M.■...N........■■nn■n......H.g ■■■ ■.s■■..■■■■NN.■■..■ern.■ee.rr..e=gre■e.r....rreeWEeN■gg■g■■■ g ■ ................................ ■.................. . won no on ...............................■EEErerEE■r...■Eerr■Eerr■■■■■ Eg ■■ ■■■■..■■.Mm■■■■■■■■■.M/Mn■■■■■N.■■■n■■■■■NNt.u■r.■/■■■nn.oE.■ ■ ■ ..............■................. ......................... . no ■■/Nns.■....M■■e■Nr....■tercet■■■■■■■Err.■eer..rr...e■rrre■ ■ ■■■ ■.■■■.N...■■■■■■■.......M■.■N■■....r■■■■/M/■.........MM■■ogeg g■. ■■■■■.■■■.■■■./■■■...■.....■■■■....r....r■eeear■.rrrrr■re■ g on ■.M■■■e.s.■..M■■■err...■...W■■■e...r...MH.■Nee.Sf'...r..E■■■■ g ■■■ ■■■■■■.■■...■/.■■■.....■....■■■■.■....l...Cl1f[�■.fA■........■■■ r.■ Monson :::::::::::C . : Ion ......■.......................7m■�■�11�/��t1/��m�■■■.■■■■■■OEM ■■■r.■g■■........MM■■■■...■■c����■■�No.........i�E/.aor...■ Mg.■■IN ■■■■■■ ■■■■■■■.M.■■.■■■■■■■■■r;■■■.�■■■■�,rrr�w■ri�■■■■■.■orr■ ■ ■■N■■ ■■■■■■..■.■■■r/.rrr■■■■..■�!r■■■ ■/■■vWr■■r■■I■■■■■■■■■■■■.■■e■ ■■ ■■■■■■■■■■■■■■■■■.■■■■■■■►r■■rr. 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Hinkle 7104 Kelsey Court Springfield, Va 22153 Re: Site Evaluation/ Iron Horse Lane Tax Office PIN: #5746-29-8459 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, Apri15,2005. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s) •� . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑ Mailing L Detailed Directions To Property &GJ Phone Number: 3[s� 7 (Home) �P 3 citet� X0.27 (Work) A 5o Please Fill In The Following Information About The Existing Dwelling: 1 �. Name System Installed Under: Pa (�t � �`J ( ' -1 /ei ' Type Dwelling: a u s r / Date System Installed(Month/Day/Year): t9 Number Of Bedrooms: Number Of People: Is The Dwelling Currently Vacant? Yes ❑ No .B'If Yes, For How Long? Any Known Problems? Yes ❑ NoT If Yes, Explain: Please Fill In The Following Information �tboit The New Dwelling: a .� Type Of Requested By: ipX�l v For Environmental Health Office Use Only Approved I'' Disapproved ❑ Comments: ber Of People: Requested: Environmental Health Specialist r` %'✓ �'�'�`'e=-. Date *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a euarantee(extended or limited) that the on-site wastewater system will function vronerly for anv eiven period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: Paid By: Received By: Account #: Invoice #: