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611 Jack Booe RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003237 Tax PIN/EH #: 5812-57-0099 Billed To: Chris Ends Subdivision Info: Reference Name: Location/Address: Jack Booe Road -27028 rroposea r-acurty Kesiaence ATC Number: 3809 �i•T•1�� ���l�tfZ�i� 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 O ION IS VA ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ,r,- - 1 tell'/ �q V7 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit -fie has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and uv 10 Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. 0 ti �l-8t✓.i �-�6v 'TA- V- DATA (o -ZZ- Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 11 DAVIE COUNTY HEALTH DEPARTMENT � • Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksviille, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003237 Tax PIN/EH #: 5812-57-0099 Billed To: Chris Ends Subdivision Info: Reference Name: Location/Address: Jack Booe Road -27028 Proposed Facility Residence Property Size: 5.008 acres ATC Number: 3809 **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 VJW Se #People 14 #Bedrooms #Baths Dishwasher: u Garbage Disposal: L'- Washing Machine: Er Basement w/Plumbing: C?"" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 54-AL'R�S Type Water Supply dDesign Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size )CWGAL. Pump Tank GAL. Trench Widthl'�eto Rock Depth 17-" Linear Ft.'0-- Other:Q 'nUy�ps Required Site O{ Modifications/Conditions: 1 L �� K}!� r �S (r�?, Kix1' �O� i'`"`, 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.**** LA v lob. ioo , v t5 r P f � Environmental Health S eciali A-rls-)ignature: Date:l? <7 VLL'*AP�l Al DCHD 05/99 (Revised) N' ` v CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D- Davie County Health Department g 20n Environmental Health Section Q� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 RQNMENTAIHEA� (336)751-8760 uNn *** ANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS P/►ROVIDED. Refer to the INFORMATION BULLETIN for instructions. L--*,'. Name to be Billed _L.t1 ►r(�� 5 E nG#J Contact Person aDrl I C1( `1 61 so c/ Mailing Address 1� p �`^'('� �1 n _ Home Phone -/d- —(y -b. -03V City/State/ZIP M©( I� �C- a-7Qa8 Business Phone A13 —343-7 -2. Name on Permit/ATC if Different than Above `Mailing Address City/State/Zip 3. Application For: �Lr�/Site Evaluation ImpYovement Permit/ATC ❑ Both �4. System to Service: LH hiou/se ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ✓5. Type system requested: Conventional ❑ conventional modified ❑ innovative 14. If Residence: # People # Bedrooms 3 # Bathrooms I? `j L1Dishwasher 53/Garbage Disposal LYWashing Machine LJBasement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: #��Seeats Estimated Water Usage (gallons per day) _,8. Type of water supply: lid' County/City ❑Well ❑ Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes I"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: v 0 &LIX RITE DIRECTIONS (from Mocksvillc) to PROPERTY: Tax Office PIN: # Sb �a5-10091 ✓Property Address: Road Name lL -__)ULi�lD petS� < S i ni's t-1tJl1 i' WC1h Ac+ r, City/Zip MocICSV Ile rlC h kk nn 3a 'Pmt- Rd. If in a Subdivision provide information as follows: n _ - y p ows: ArPDYO X Nil I�.S C7 rl llL�I & f- F - IU Name: L 41 - Section: Block: Lot: Date home corners flagged: Y-1 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 fi•oln 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 suitability. % ATE U SIGNATUREf 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). Site Revisit Charge .✓ Jo °` Date(s): Client Notification Date: ERS: Sign given/HD � - � - ' Account No. 3 a:��-7 ---------- Revised D(05/03 Invoice No. / m/a om a s saon»n� •av sao•s v =v3av d 'aul Vl.ldd 30VO1W0Yi ria ON Cl J - CONT y� O2 '+ m CD a o nom v DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003237 Tax PIN/EH #: 5812-57-0099 Billed To: Chris Ends Subdivision Info: Reference Name Location/Address: Jack Booe Road -27028 Proposed Facility Residence Property Size: 5.008 acres Date Evaluated: Z Water Supply: On -Site Well Community Public i Evaluation By: Auger Boring Pit ! . Cut SITE CLASSIFICATION: > LONG-TERM ACCEPTANCE RATE:y REMARKS: EVALUATION 14 ' 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic CONSISTENCE FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S - Sticky VS - Very Sticky 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) Landscape position Texture group Consistence MAN= Mineralogy HORIZON 11 DEPTH Texture group Consistence INUMMM ' M 0"17 m ""!a HORIZON III DEPTTexture group Consiste nce Consistence Mineralogy SOIL • -®����® SAPROLITE SITE CLASSIFICATION: > LONG-TERM ACCEPTANCE RATE:y REMARKS: EVALUATION 14 ' 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic CONSISTENCE FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S - Sticky VS - Very Sticky 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) ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■a■■ems■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMNONMEN EENONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■Iii■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■s■■■■■■■■■■■ren■ �■■■■■■■ ■■�■■■■e■■■■■■■■■illi■ �■■■■■■■ ■■■■■■■■■■■■eau■ Z�■■■1 I■■■■■■■ ■■■�■■■■■■■■■■■■■■■■11111■■■■■■ ■■■ ■■■■■■■■■■■■■■■■11111■■■■■■ ■■■■■■e■■■■■■■■■■■■■■II lel■■■■■■ ■■■■■■■■■■■■■■■■■■■■■111■I■■■■e■ ■■NNU■■IIGiVIUMM■MNI■IU11IYNNNEINEU ■■■■■■■11■r■■■■■■■■■■■111■■■■■■'� ■■■■■■■11■■■■■■■■■■■■■111■■■■■■■ ■■■■■ell■■■■■■■■■■■■■111■■■■■■�■ 1■■■■■■.�',■■■■■■■■■■■■■111■■■■■/1■ I■■■■■■IA■■■■■■POW,■■■■■NI■■■e■11\ ■■■■■■■■■11■■■Ilii■■■■■►\■■■■ ■■■■■■■■all■■■■■■■■■■■■■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 PhonefI, (336)751-8760 / Fax: (336)751-8786 May 21, 2004 Chris Ends 178 Dakota Lane Mocksville, NC 27028 Re: Site Evaluation - 5.008 Acre Tract/Jack Booe Rd Tax PIN#: 5812-57-0099 Dear Client(s): As requested, a representative from this office visited the above site May 20, 2004 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally, please have the new parcel surveyed prior to making this request. If you have any questions, feel free to contact this office at 751-8760. Sincerel4eauchamp, Jeff. R S. Environmental Health Section Enc(s)