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430 Jack Booe RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000788 Tax PIN/EH #: 5812-69-7551 Billed To: Michael Ball Subdivision Info: Reference Name: Michael Ball Location/Address: Jack Booe Road -27028 Proposed Facility: Bam Property Size: 200 x 200 ATC Number: 2205 **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 #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type Ar/L #People / #People/Shift _L #Seats Industrial Waste: ❑ Lot Size AM c Type Water Supply Design Wastewater Flow (GPD) Site: New ❑ Repair ❑ d r � System Specifications: Tank Size f�LZ GAL. Pump Tank GAL. Trench Width,; � Rock Depth Linear F&5? X�- 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.**** �T Jr Qw� 0 (jfahw4�t Environmental Health Specialist's Signature: o''�/ Date: l? � DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000788 Tax PIN/EH #: 5812-69-7551 Billed To: Michael Ball Subdivision Info: Reference Name: Michael Ball Location/Address: Jack Booe Road 27028 Proposed Facility: Bam Property Size: 200 x 200 ATC Number: 2205 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 WASTEWATE ONSTRUCTION IS VALID FOR A P OD OF FIVE YEARS. Environmental Health Specialist's Signature: 9, ate. 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. r �s S7a,� s Septic System Installed By: C461b TIRD1 PSo� 600tJ 92(- ' 003 Environmental Health Specialist's Signa Date: ID DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMfM PERMIT & ATCr ��✓AJ Dave County Health Department Envlronmenfol Hes/tfi Section <P.O. Box 848/210 Hospital Street SEP 2 4 Mockaville, NC 27028 - (336)751-8760 ***sem TANT*** THIS APPLICATION C.UMT BN PROGSMW UNLE88 ALL TRS REQUIRED INFORMATION IS PROVIDED//. Refer to the INFORMATIOtN BULLETIN for instructions. 1. Mass to be Billed -4 Gh d Q I � Contact Person � Nn Q Mailing Address Ll an ct C., (c c - n 7 g--' Ross rhon. �1 Z - Z 3o City/state/ssP _iia c_ IL S. V'% 11Q V\ _C- r business Phone 3 (4 -S7 - 4 LI (-1 $ 2. Hass on Permit/ATC if Different than Above Mailing Address City/State/sip 3. Application For: 49 ite Evaluation 0 Improvement Permit/ATC oth 4. eyston to service: O Rouse C Mobile Bone O Business O Industry �er _(2rxc V-% 3. Xf Residence: # People # Bedrooms • Bathrooms D Dishwasher 0 Garbage Disposal O lashing Machine O Rassssnt/Plmabing D nasemsnt/AMo Plumbing 6. St ftsiness/Industry/Othsri specify type # People # sinks # Commodes # showers # Urinals # hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (galiona Per day) 7. Type of MauQ' r supply: 0 County/City Nell D Community 0. Do you anticipate additions or expansions of the facility this system is Intended to serve? D Yes 94L 0 If yes, what type? I***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN,MUST BESVBMIZ7'BD by the client with THIS APPLICATION. Property Dimensions: GGX'2� 3041 Tax Office PIN: # S $ 7 /(� Property Address: Road Name .Ja-e� City/Zip�oc!/i/le /-//C- If in a Subdivision provide information, as follows: Name: Section: Block: Let: WRITE DIRECTIONS (from Mocl aville) to PROPERTY: (e0-1- n0r-rA IL e 2dr D A t -g- TT , Y Z M, IQ 6 eQa `e r �DC'0- o n Date Property Flagged: cT— -7 C! ':�S 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. 1, also, understand that I am responsible for all charges Incurred froth 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 ail testing procedures as necessary to determine the site suitability. DATE J-7-9-99 SIGNATURE L2 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Imes and dbpensions, structures, setbacks, and septic locations). Oct Revised DCHD (07/99) 1 1 i Site Revisit Charge IDate(s): Client Notification Date: ERS: Account No. 0 0 Invoice No. AleI APPLICANT INFORMATION Account #: 990000788 Billed To: Michael Ball Reference Name: Michael Ball Proposed Facility: Bam DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5812-69-7551 Subdivision Info: Location/Address: Jack Booe Road -27028 200 x 200 Date Evaluated: ,Zellr Property Size: Water Supply: On -Site Well !/ - Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position J, Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 41 0 + Texture group or Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 793 LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: •X Cid / EVALUATION BY: OTHER(S) PRESENT: Z17 ✓1V 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) ME ■ MEMO ■E■■ MEMO ■E■■ ■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■e■1�1■■■■■■■■■■■■■■■■■■■M■■■■■Mee■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■MEN ■■■■■■■■■■■M■■■NOON ■■■■lr■■■■■■■■■■■■■■■■■MEMO ■ ■■■■■■■■Mee■■■■■■■■■e.:■iia■■■■■■■■■M■■■■e■■■■■■■■■■■■■■■■ INEMEME EMMONS MEMNON 11MEMEM MEMiiiEMSEEMMEMEME ■■e■■■■■■■■■■■■■■■e■■■■■eel■■■■■■■■■■■■■■■■■■■■■■■■■■Ee■■■ ■■■■■■■■■■■■■■■■�I■■■■■■■■11■■iil�■■■■■■■■■■■■■■■■■■■■Mee■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■