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1814 Junction RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street MockvAlle, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900149 Billed To: Home Improvement Services Reference Name: Proposed Facility: Residence 0j-S.'j-o -L // 0v Tax PIN/EH #: 5735-56-0548 Subdivision Info: Location/Address: 1814 Junction Road -27028 Property Size: see map ATC Number: 3214 **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 114 #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type El #People #People/Shift #Seatts Industrial Waste: Lot Size Type Water Supply a Design Wastewater Flow (GPD) Qll�U Site: New;2r000'Repair ❑ System Specifications: Tank Size%0GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Dept �� Linear 170%02 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 K 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.**** Environmental Health Specialist's Signature: - ' Date: DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900149 Tax PIN/EH #: 5735-56-0548 Billed To: Home Improvement Services Subdivision Info: Reference Name: Location/Address: 1814 Junction Road -27028 ATC Number: 3214 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 WAST=N;ST UCTION IS VALID FOR A PERIOD OF FIVE 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: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 6:�� /:z L� JUL 1 5 2".) I ENVIRONMENTAL HEALTH nAXIM Cnl[MTy CATION FOR SITE EVALUATION/IIIIPROVEAIENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be BilledHo Contact Person (� ('i Y1/J cCjC OS'� Mailing Address v Home Phone City/State/ZIP iic St)j (lT XC X707$' Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 4. System to Service: 0 Site Evaluation VHouse 0 Mobile Home 5. If Residence: # People //-- I Dishwasher LI Garbage Disposal Nr Washing Ma 6. If Business/Industry/Other: Specify type II Commodes # Showers 0 Improvement Permit/ATC Both 0 Business 0 Industry 0 Other # Bedrooms 3 # Bathrooms Z. hi.ne II Basement/Plumbing II Basement/Ho Plumbing # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: it Seats Estimated Water Usage (gallons per day) 11.1 7. Typo of water supply: f County/City 0 Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes WK10 If yes, what type? **IAIPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED 11 ,I,OW. Either n PLAT or SITE PLAN Il1U.ST flESU8Af17TF.D by the client witli THIS APPLICATION. Properly Dimensions: Y A Tax Office l'IN: dJ �73�' rJ6 f75� Properly Address: Road Name TuAICAW Civ d -, " " City/zip. 1pocksv,' f le AAA. If in a Subdivision provide information, as follows: Name: A nst section: Block: Lot: WRITE DIRECTIONS (from Mocicsville) to PROPERTY: 60/-S -to 6 faA'foeye Kel-Tkc Vii, sLeue ' o- AI/o!le- j, j rg ' OL _Alalle,�1 ut�G7?oi✓ Pel L/ f 2 n1, )-e acv - Cln j kuSC A aoa Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submit(ed in (his application is falsified or changed. 1, also, understand that I cin responsible fur all charges incurred frollf this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described properly located in Davie County and owned by to conduct all testing, prq�Eedures is necessary to determine the site suitability,--, DATE, !--- SIGNATURE TIIIS ARCA MAY (1E USED FOR DRAWING YOUR SITE PLAN ncl c • of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locatio Site Revisit Charge Date(s): Client Notification Date: EI -IS: Revised DCI4D (07/99) Account No. l 9>% � 601q Invoice No. c Y �;ij � �'�✓�// iii/ � i///i' s.�'�a�%�, / d / N� y t O i r� 0548 cr 0477 N 0 O O 1308 $3 Co A� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900149 Billed To: Home Improvement Services Reference Name: Proposed Facility: Residence Property Size Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5735-56-0548 Subdivision Info: Location/Address: 1814 Junction Road -27028 see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 2 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence / Structure !C 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 : c SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: c REMARKS: EVALUATION BY: !/ 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) ■ ■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■MEMO■ ■■■E■■■■■■ ■■■■■■■■■■ ■■■■■M■■N■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■EM■■■■ ■■■■■M■■■■ ■■■MEMO■■■ ■■N■■■■■■■ ■■MM■■■MN■ ■■■■■■■■■■ ■EM■N■ ■■MONS ■■EME■ ■ME■E■ ■M■ME■ ■■■M■■ ■■■■N■■■■■■■■ ■MEM■M■■EME■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■M■■■■■ ■■■■MM■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■M■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■M■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■N■■■M■■■ ■■■■■■■■■■■■■ ■■■■■■■M■■■M■ ■M■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■M■■■M■■E■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■E■■■■■■■ ■■■■■■■■■■■■■ ■■■■■M■■M■■■■ ■■■■■■E■■■■E■ ■N■■■■■■■■■M■■ ■M■■M■NM■M■■M■ ■■M■MM■■■■■M■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■M■■■■■■■M■■ ■■MM■■■■■■■■■■ ■■M■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■N■ ■N■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■M■■■■■■■ ■M■■■N■■■■■■■■■ ■■■■■■■M■■■■N■■ ■■■■M■■■■■■■■■■ ■M■■■■MNM■M■M■■ ■■■■■■■■■■■■■■■ ■MMM■■■■■■■■M■■ ■■■■■M■■■■■■■■■ ■■MEMNMMN■NMM■■ ■■■■■■■■■■■■■■■ ■N■■■■■■■■■■■■■ ■■■■■■■■■■■■■E■