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417 Joe RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT' - Account #: 990003144 Billed To: Regina Draughn Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5767-25-8481 Subdivision Info: Location/Address: Joe Road -27028 Property Size: 1 acre * *NOTE *%Is 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 /; �11/ #People _ #Bedrooms. #Baths Dishwasher Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type �y #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply L� Design Wastewater Flow (GPD) �& Site: Newry Repair System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width S� Rock Depth `-r/Linear Ft�dl)�' 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.**** r - Environmental Health Specialist's Signature: DCHD 05/99 (Revised) I Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003144 Billed To: Regina Draughn Reference Name: ATC Number: 3738 Tax PIN/EH #: 5767-25-8481 Subdivision Info: Location/Address: Joe Road -27028 fA 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). TIES AUTHORIZATION FOR WASTEWATER CONSTRUCTI �yN IS7LID FOR A PERIODOFFI YEARS. Environmental Health Specialist's Signature: // Date: 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. Septic System Installed By: ON Environmental Health Specialist's Signature: ,5� yLz�/ Date: DCHD 05/99 (Revised) f APR 5 2004 I EfIMRONMENTAI HfA1,>N DAME COUN7Y CATION rOII SITE L'VALUATION/IhIPIIOVDIIINT PERMIT a Jl•1•C Davie County Health Department E/lviro1ll'110nta111.-,71111 Section t �% P.O. Box 848/21.0 Hospital Street Nocksville, NC 27028 (336)751-87,60 V * * *Il•IPORTANT* * * TIiIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for instructiolls. 1. Name to be Dilled e IA) Af t4 Contact PersonTor—�-;Clf 9,0 4 Mailing Address j 4 b Cvek h ft 7 00,4 , - 110111C! c Plione City/SL•ate/ZIP IDG/Ljy ti I le ly t �i 26 int} Dusincaa Phoac 2. Name on Permit/ATC if Different than Above Mailing Address City/SL'ate/ZiP _._.... a. Application For: ❑ Site Evaluation ❑ Improvement Pcimit/ATC ]loth 4. System to Service: ❑ House 1d01�ile Home ❑ BusinctD ❑ Industry ❑ Otlier 5. Type system requested :l Conventional ❑ conventional Modified ❑ innovative G. If Residence: it People ? ✓f Bedrooms L}_ 11 Bathroonw, 3. Dishwasher, NGarbage Disposal XWashing blachino ❑BascmenL•/Plumbing ❑banemont/11u Plumbing 7. IL• Dusincss/Industry /Other: verity type 0 People II Sinks _ ^ Commodos 0 Showers D Urinals 11 Water Cooleru IF FOODSERVICE: )) Seats Estimated Water Usage (gallono per day) s. Type of water supply: fiO County/City ❑ Well ❑ Conuaunity 9. Do you anticipate additions or expallsious or the facility this 53'StC111 is h1telide 1 LU Serve? ❑ Yes � No Irycs, wilat type? _-- I***IAlI'ORTy1JYTk** CLIENTS JVUST COh1P.L1;TL TILE 1ZLQUIRED PROPEK'i'Y INFORMATIONI(EQllliS'1'I:l) l BELONV. 21(licra PLAT orSITE PLAN r11USTBESURM17TED by the %lien( ivilll'1'lt[S APl'LICA'1'ION. Properly Dimensions: Tax Office PIN: # Property Address: Road Nalnc city/zip )'11 0 c k5 A) If in a Subdivision provide information, as follows: 1YRC1'L•' 1)IRLCTIONS (from Muct:sville) to 1'1(01'1;1%'1'1': fi wy d -is -r ��iT. 9 0 ���a x 3�� �•, 72) Na111c Section: Bloch: Lot: Date ho111c corucrs flagged: This is to certify that the information provided is correct to tllc best of illy l(notiv1• geunderstandIla ' peruut s) issued hereafter arc subject to suspension or revocation, if the site plans or fntcuded use chauge, or it the iufurination submitted iii this application is falsified or cllaugcd. I, also, undarstand that aur responsible for all charges iucur•r•c•rl fi•unr Ills upplicadou. I,1lcreby, give consent to the Authorized Rcpresclllalivc of t11e I):tvic County Ilcallll 1)cpartluc•ul to cuter upon above described property located in Davie County and utivllcd by to cuuduct all (.-sting procedures is necessary to determine 111.- site suitability. DATE JC Q �' SICNATI:JRI; yrzrtl , TRIS AREA MAY 13E USED FOR DRAWING YOUR SITE PLAN (Include all of the following:�'xisling and proposed property lines and dimensions, structures, setbacks, and septic locations). 1 I�� Site Revisit Charge LApq CI' �c ' v Sign given_� r,J �Q Datc(s): Client Notification Date: ERS: Account No. 3 t r 0451 (1.15A) 2307 3.581A 9 Q4 4360 j�df fll EfbE a 0 (73 1 Al ................... 821 0 47 197 —1-db 3 A 1170 9013 2.00A 14 4939 (9,25A) 0864 309 eE 362 (24,59A) 334----- -- 0543 34 ----- - (2,57A 2 (jr 3739E so 290 mi 23 1.25A 6187 8158 4,95 46 (4,24A) -- ------ -(2,85A) 9929 4 o 147 sso W7 -394 (2.24 26 1 47 3,157A (11.26 A) 5637 (4.96A) 4654 8503 (16.10A) 8481 A) 8 1390 750 75A) '755 -- --------------- 477 (35,48A) 4499 iib 506 (8.19A) 5088 1/0 014 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003144 Billed To: Regina Draughn Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5767-25-8481 Subdivision Info: Location/Address: Joe Road -27028 Property Size: 1 acre Date Evaluated: -` S, —d Water Supply: 1 2 3 4 5 6 7 Landscape position On -Site Well Community Public Evaluation By: Auger Boring Pit i ? Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % - HORIZON I DEPTH Texture group 4 Consistence Structure Mineralogy HORIZON II 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: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: 6L�Z 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 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) i ii i i i mom MEN ■ ■■■eM■■■E■■■■■■■■■■■■■ESM■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■e■■e■■■e■t■e■e■M■e■■eeeeeeeeee■■ee■■e■e■■ ■■■■■■■■■e■■e■�i■■EEee■■■ee■■eee■ee■■e■e■e■■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■/■■■■/■■■■■■■■■■/SSSS■■G■■■/■■■■■■■■■■■■■■■■ ■■■/■/■■■//■■■■■■■■■/■/■■■/SSSS■■/■■■/■■■■■■■■■■ ■■■e■■eee■■e■e■■ee■■■■■�::::::::::::::��■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ee■eee■e■■■e■e■■e■■ecce■■eee►�■■■e■■e■ee■■e■■eee■e■■■■■ee■Ee■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■SSSS■■e■■■■■■■■■■■■■■■■■■■■■■E■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■See■■■■■■■e■■■■■■■■■■■■■E■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ee■■M■■e■e■■■■■■■■eee■■■e■■■■■■■e■■■■■■■e■Ee■■ee■e■■■■See■ ■■■■■■■■■■■■■e■■e■e■■e■■■■■■■■■■eee■e■■■■■■■■■e■■M■■e■■e■■■■e■■■e■ ■ ■■■■■■ ■■■■■■ ■■■■■■ ■ MENS■ SEEMS ■■■■■ ■■