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229 Jamestowne DrDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 0� ' • P. O. Boz 848/210 Hospital Street L Mocksville, NC 27028 ,J� l (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001732 Tax PIN/EH M 5759-70-7676 Billed To: Paul Ketcham Reference Name: Proposed Facility: Residence Subdivision Info: Location/Address: Jamestown Road -27028 Property Size: see map **NOT)* iIss rov8ein nt/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 /72 AL#People #Bedrooms .3' #Baths 2. Dishwasher: Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: PTI*' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size (�-tA6 Type Water Supply Design Wastewater Flow (GPD)&6Z) 6Z) Site: New Repair ❑ System Specifications: Tank Size/0 (� GAL. Pump Tank GAL. Trench Widt� Rock Depth &?_ Linear Fkjj�L/ Cil,' -1�i 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 30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** r o(t Environmental Health Specialist's Signature: Date: 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 #: 990001732 Tax PIN/EH #: 5759-70-7676 Billed To: Paul Ketcham Subdivision Info: Reference Name: Location/Address: Jamestown Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2839 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 NS UCTION IS VALID FOR PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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 1 I 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. e .�f 4, �� ,ro Ad Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) • APPU&N FOR SITE EVAWATION/IMPROVEMENT POMIT &ATC • �• Davie County Health Department Envimamenb/Heaft Seaton Q P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760. ***nWCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALLI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for 1. Name to be Billed Mailing Address Contact Person c ,:eA(( ,e / Home Phone I fJ 7 -to t' city/state/Up S� i (./ Business Phone �� r0 &a 0 r. 2. Naga on Permit/ATC if sif!•rent than Above Mailing Address City/stat•/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both 4. System to servioe: ❑ House 6 Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People /# Bedrooms 3 # Bathrooms _ 11 Dishwasher 11@i Garbage Disposal washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing S. if Business/Industry/other: specify type # People # sinks # Co®modas # Showers # Urinals # water Coolers IS FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Nater supply: ❑ County/City a Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Wqo If yes, what type? ***IMPORTANT'*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMIT7ED by the client with THIS APPLICATION. Property Dimensiods:aQ W X IDX- 3� WRITE DIRECTIONS (from Mocksville) to PROPERTY: 1 Tax Office PIN: # �? 5 70' 7/&�fl f O( 1 '+4z> C'>�AtSy K -- Property Address: Road Name �rS�eF- ` L- - 0nJ City/Zip If in a Subdivision provide int Name: Section: Block: Lot: Date Property Flagged: J - 7-t) 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 ant responsible for all charges incurred from Misapplication. I, hereby, give consent to the Authorized Representative of the.�Dalis County Health Departme t to enter upon above described property located In Davie County and owned by to conduct all t Ing pybcedures as necessaryto determine the site suitability.. r DATE SIGNATURE ' lJ At,, 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 Date(s): Client Notification Date: EHS: Account No. Revised DCHD (07/99) Invoice No.�'/ oto f�{' y�1V � y: b ♦ 1 M H: � 1 Iv ! ♦ '� i. •4,i_i, e,�+, IkA, .rhe• ,M''' _ :t, •r - "'a ' - •3 ,�' �,� „Myr. . � OC 7 40 8 t� Yi 6 } 1 .'-i J04. 28 k 77 y 13. 5 0 Ac, 40.A c `lZ 20 10 Ac, Ak -' `,' J„ 6.50 :* 627 — 400 qp In ro ti M ' —- W yy�f�rt1 lS` O V O V O 01961 Ac 10.50Ac 6.85Ac N 2 : 7Ji0 O A cto n3A c 75rD ` 4 3' a F540Ac irk k, p ;±r 204 178 199 *, 74 50 7 A 627 1 t 404 j1 404.11 r 212 189 v" 16 2T... 8:'. 2.02' .5 w., 82 SAN 2.51 AGY �+� 0A c. c ..05 434:0 434 'P IP 4 err 82.()4 '��'-'`'�' _ `$2.0$ CD34 t5o e, 64 30F., 6.93Ac + + �ti'�` "R -v '`Na N c1. ii t� ..82.07 Q0, N 2.01A'c n, .92Ac -a I Ac '►, , , 8 ,,,� 35 r 31 a cv \ N60.5 5 x 82.06 ., T N e 4 19.38 Acs' t.''. 4 9. O A 4 /J1 fn 4, J I I APPLICANT INFORMATION Account #: 990001732 ; Billed To: Paul Ketcham Reference Name: Proposed Facility: Residence DAVIE COUNTY ]HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5759-70-7676 -Subdivision Info: Location/Address: Jamestown Road -27028 Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: "Auger Boring lz Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON 11 DEPTH Texture group 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 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: 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-Siltyclay , 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)