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��" • DAVIE COUNTY HEALTH DEPARTMENT �— �''J' �—� 1-- '��-'�>~� � Environmental Health Section ,� �� . • «, �y�. P.O.Bog 848/210 Hospital Street � Mocksville,NC 27028 (336)751-87(►0 IMPROVEMENT/OPERATION PERMIT Account #: 990002424 Tax PIN/EH#: 5860-17-8420 Billed To: John Marshall Subdivision Info: Reference Name: Location/Address: Lear Lane-27028 Proposed Facility: Residence Property Size: see map - **NOTEC* Thmb�mprovement/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 PERNIIT BEFORE INSTALLING SYSTEM. � Residential Specification: Building Type #People_� #Bedrooms � #Baths�_ Dishwasher� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size •�J �� Type Water Supply�N�/ ' Design Wastewater Flow(GPD)� Site: New�Repair❑ S stem S ecifications: Tank Size �l � y p ���GAL. Pump Tank GAL. Trench Widtl�� Rock Depth� Linear Ft.l�� 1 �.. Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMtT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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(33G)751-87G0.**** �r� �'� ; � /� P`' ,��a� r,� �� `� . �qs�� ,{_n� �e � �W wW" . �� ti� P��U � �� �e � , ��'��-- Environmental Health Specialist's Signature: ,, Date: DCHD OS/99(Revised) •� ' �C/�_.... . �r '�� � .. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002424 Tax PIN/EH#: 5860-17-8420 Billed To: John Marshall Subdivision Info: Reference Name: Location/Address: Lear Lane-27028 ATC Number: 3266 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLJED 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 ST U IS VALID A ERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �Date: � `��� CERTII�ICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 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 � Septic System Installed By: -�� .� � � j Environmental Health Specialist's Signature:�,���i/ Date:�,�.��� DC�ID OS/99(Revised) � •:. ; .' , S%• •, � . � �� ` APPLICATION FUR SITE EI/ALUATiON%Ih1PROVEM1tENT PCRM1itT l� � ,.� Davie County Health Department CJ � � Environmenta/Hea/th Sec[�ion Q � P.O. Box 84B/210 Hospital Street ; ? �'S Mocksville, NC 27028 A(/G� (336)751-8760 � r ?00� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS T INFORMATION IS PROVIDED. Refer to the INFORI�TION BULLETIN for i A �. 1. Name to bQ Billed _ e�� (Nf.�Y S �G [( Contact Person Mailinq l�ddress 3 ��s G �f�j� I S� xome Phone py5� �,� ��� 3����`� --r�� � City/State/ZIP �J�(J,�S �j �1Q {�.��, �,Z� Business Phone s a 2. Name on Permi.t/ATC if Different than llbove ��1� {1}�1T(� y� 1'1(1 �� Mailing Address `�. City/State/Zip 3. Application For:�'�Site Evaluation �Improvement Permi.t/ATC [I Both . a. system to service: L'T House f_1 Mobile Home CI Business (_l Industry ❑ Other . 5. I£ Rasidence: # People _ �� q Bedrooms �_ # Bathrooms �_ I�shxasher 1:1 Garbage Disposal li'W shing Machine �sement/Plumbinq IJ Basement/No Plumbing 6. If BusinQss/Industxy/Other: Specify typo # People # Sinks � Commodes $ Showers A Urinals 8 water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gaiions per day) 7. Type of water supply: ❑ County/City C�-'P9e�11 ❑ Community a. Do you anticipatc adclitions or cxp�nsions of thc facility tl�is systcm is intendcd to scrve? ❑ Ycs W-A�S Ifycs,wL:it typc? ***IAIPORTANT*** CLIENTS MUSTCOMPLETCTHE REQUIRED PRQPERTY INFOItMA'fiON REQUCS'1'GU I [31?LOW. Githcr a PLAT or SITG PLAN MUST BESUBMITTED by thc clicnt witli TFIIS APPLICATION. 1'roperty Uimensions: c�7 ee- �'""`� �VRIT�DIRGCCIONS(from Mocicsvilie)to 1'RO('['sR'i'1': .x Officc P(Ns #" � �d./ S�oZ /��l��d,� {� � _ 7i� -.�--_..`� Property A�ress: Road Namc,.z�o_G ,� �.�rQf,. �-�� ��_ City/Zip�l a c � `�Q c1�i�� [f in a Subdivision providc information,as follo�vs: Namc: Scctian: I31ock: Lot: Datc Property rlaggcd: v a y /� 2 'Tliis is t��ccrtify tl�at thc information provided is corrcct to thc bcst of my Icnowlcdgc. 1 undcrstand that any permit(s) issucd hcrcaftcr are subjcct to suspcnsion or rcvocatim�, if thc sitc plans or intcndcd usc cLangc,or if tl�c infor�ualiun submitted in tl�is application is falsiGed or cl�anged. l,a1.so,rutdersla��d t/iu/I am respausiGle for rrll clrarge.s iircurred jroin. , 1/�is applicalinu. I,I�cre6y,givc conscnt to thc Autt�oriud Rcpresentativc of thc Davic County Ilcalth Departmcnt to cntcr upon abovc dcscribcd property locatcd in Davic County and owncd by __�__ lo conduct sll tcsting proccdures as ncccss�ry to detcrminc tl►c sitc suitability. DATE � • `� / .I> r� SIGNATURC THIS AI2CA MAY B�USCD rOR DRAW[NG YOUR SIT�PLAN(Includc all of tl�c follo�ving: Cxisting and proposcd property lines and dimensions, structures, setbacks, And septic locutions). Sitc Revisit Cl�ar�;c � Datc(s): Clicnt Notificatiun Datc: CHS: o'�..-� � ��.��� ' �� � � c� �! 0 2-- Account No. � . � / � `f ` _ 1 � . `I � Reviscd DCHD(07/99) '�-�j — '�� °"' �� [nvoicc No. � ( 7' <�LJ� .. , � � �_ _�_.,3...._.�� ,__ � , -� , .��,� � ---- ��- a �' _`� � v � � � , �___ - � �. g � _���� ��� �� � � i � _ :. :• �: �....: � W`'�� . .. �..� � ����t�, �. - . _,::,.:.m�..<.= . _.,...,,.., �� . �. y.. � : .::. 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' • � ' DAVIE COUNTY HEALTH DEPARTMENT �►'' � � �� • � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002424 Tax PIN/EH#: 5860-17-8420 Billed To: John Marshall Subdivision Info: Reference Name: Location/Address: Lear Lane-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: ��.�Q�� Water Supply: On-Site Well ✓ Community Public " Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 ,..�,4_�.. ..-�5 6 7 Landsca e osition Slo e% HORIZON I DEPTH - l� �- ✓ Texture rou ,L Consistence Structure Mineralo HORIZON II DEPTH /' > Texture rou G � Consistence . Structure �%1 Mineralo � �- HORIZON III DEPTH Texture rou Consistence ` Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure � � Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: �� EVALUATION BY: G LONG-TERM ACCEPTANCE RATE: ' � OTHER(S)PRESENT: REMARKS: 4�u '�C�G� � I�� �P LEG D 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 day loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Mois 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangular blocky PL-Platy 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