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200 Lybrook Rdr DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900614 Tax PIN/EH #: 5871-78-1242 Billed To: John Penry Subdivision Info: Reference Name: John Penry Location/Address: Lybrook Road -27006 Proposed Facility: Residence Property Size: 186.34x231.19 ATC Number: 2085 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 Sew ge Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER rnNSTRUCT)ON IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's CERTIFICATE OF COMPLETION Date: **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 guaranteWtsyst will function satisfactorily for any given period of time.` 1 Z v FG Qc'T A. a t ic-, Septic/System Installed By: `�A. -) ate. 04r-) Environmental Health Specialist's DCHD 05/99 (Revised) Date: c1 / DAVIE COUNTY HEALTH DEPARTMENT _ Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900614 Tax PIN/EH M 5871-78-1242 Billed To: John Penry Subdivision Info: Reference Name: John Penry Location/Address: Lybrook Road 27006 Proposed Facility: Residence Property Size: 186.34X231.19 ATC Number. 2085 **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 SPIE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type E E #People 2 #Bedrooms . #Baths 2 - Dishwasher: Dishwasher: Garbage Disposal: ❑ Washing Machine: V Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size %t Z? Type Water Suppl} I.—V—I { Design Wastewater Flow (GPD)42 Site: New r3?Repair System Specifications: Tank Size I OCQ33AL. Pump Tank GAL. Trench Width 7Fi� Rock Depth 12. Linear Ft. Other: .3> Tmi2-+fw-noa�eX S Required Site Modifications/Conditions: ,Ce�oa -I yl-�, � 6 1ipas-z' IVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW [ED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 0 a,m. to 9:30 a.m. or 1. 0 p.m. to 1:30 p.m. on the day of installation. Telephone # is ( 36)751-8760.**** APWx.. tos' I -? Sol 1 0,J THIS eJb coF HoJ`. e, Environmental Health Specialist's Signature: PwP L.Itsir DCHD 05/99 (Revised) - PLO rb2 e.-rs 1--3 Q-S)r� P� FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC Dru f�(�-rwa Q Davie County Health Department Environmental Neaft SeWon S:)(e t� \9� Box 848/210 Hospital street /uk� !� �vN Mocksville, NC 27028 mac. �e�SN (336) 751-8760 ***II�QORTAMi��iI�NZs APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFO T^,7ON S PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed i b 1/\ \ e u Contact person Mailing Address U `(4r -o t Home phone i �.8�r� City/state/ZIP Pak1O -r \Q, � iG 2����i 8usiness Phone 1 2. Name on Permit/ATC if Different than Above Sf1Yn¢_ Mailing Address City/state/Zip 3. Application For: id Site Evaluation ❑ Improvement Permit/ATC B" Both 4. system to service: l9/House ❑ Mobile Home ❑ Business ❑ Industry ❑ other a. If Residence: # People # Bedrooms # Bathrooms �shwasher 0 garbage Disposal W washing Machine 0 Basement/Plumbing 0 easement/No Plumbing S. If Business/Industry/other: Specify type # Commodes # showers # People # sinks # Urinals # water Coolers IS FOODSERVICE: # Seats // Estimated Hater Usage (gallons per day) 7. Type of water supply: U'County/City ❑ Well 9. Do you anticipate additions or expansions of the facility this system Is Intended to serve? If yes, what type?. ❑ Community ❑ Yes 13'! leo ***IMPORTANT•**CLIENTSMUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: % eL, '5 4 V 3 / , /9 Tax Office PIN: #.5? 7/ -7 S - Property Address: Road Name L �g broo IC 'c 4 - City/zip 4 el vatic e , ?,"7 y0 b If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: / S-8 E'A-sT T v F0 / 5 o UT -/f t4PPR6X. mile, +q Lcr--T DN 4yaaepx e4_ Se_edfv✓ 1-0i i N 5eCDN0 73LoC/< Date Property Flagged: 4_//_77 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 ane responsible for all charges incurred from 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 �,�, h 102.4 r to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE es THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). k LA h'rock. 0 Lv a aodK. S 6TH Revised DCHD (07/98) Account No. �/y Invoice Na rp"'7 _ y01 � — N 8 °-59�-33E - •- -- ex�s=� soil rood N $40 f_ I point !' iron found _ - 3 CD ti New Right of Way as determined by J.598 Ac r S Rointree. Associates E N. C. Dept of, Trans /-(See D.8.112.-P.34)Total 534.08 N 850-14- 0 } point 0 1/2" iron fou7,0 186.34 �3 6�-�00 p I/2' ;iron in found '' N to 3 0 p A co - z i ! Z co - 2„ d 167.6 7",, •'' �' vb" S 85°- 13 -09 W found I C cm LL w LLL I 2' imn fount 1. pant cr .'•�'..=�i=-ae+rrr. ..h. 1 n .:. 2' Si' Ea' Q-' ` N23°-37'-42 ... -• . _. _ :..,?'�,m'�-'S.r!_.+._::.r .: -•i��.: 1� Chord 3F:Fi2 DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account* 989900614 Tax PIN/EH #: 5871-78-1242 Billed To: John Penry Subdivision Info: Reference Name: John Penry Location/Address: Lybrook Road -27006 Proposed Facility: Residence Property Size: 186.34x231.19 Date Evaluated: —7h 1% Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: V5 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �'`r 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 - 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 Structurg 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 I)CHD (Revised 05/99) Landscape position HORIZON I DEPTH Texture groupConsistence ��-_--- HORIZON 11 DEPTH Texture group Consistence Mineralogy HORIZON III DEPTH WAIMIN MAMMA M Texture group WA #4 Consistence WASIMM MUM . .11,781 Z I LTZ 6135 1 Consistence Mineralogy -SOIL WETNESS SAPROLITE CLASSIFICATION SITE CLASSIFICATION: V5 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �'`r 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 - 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 Structurg 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 I)CHD (Revised 05/99) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■m■■■■Ess■N■■■■■■■■■■a■■■■■■■■■■Wee■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■O■O■■■■■■u■OO■O■■011■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■Ott/■■/■■■■■■■■■■■■/■■■■/■■■■■■ i L ■■■■■IIO■■E■■■■■■■■■■■■OI■�!t•\■1111■■■�■�■■■■ MEMNONmommomi MEMEME liii'J■om ■■■■Eli■■■■■■■■■■■■■WE■NIIlR�■■■■■ SOMEONE ■O■■■lima■■■■■■■■■EE■EO■111■E/■T�1*�\E■■E■MWS■ ■■m■■li■■■■■■■■■■■/■■r. ■i��Iammm■■sue■■■■■■■■ ■■■■Eli■■■■■■■■■■■■■■■■■!■■■■■■■■ ■■■_as■■ ■■■■Eli■■■■■■■■■■■■■■■■■i■■■■■■■■■■■■■■■■■ ■E■MENNAMEENN■■ ■■■m■■■fromm■■■ ■M■■■OMILEYMENN■ ■■E■■E■■■■NEENNEN■ ■MEN ■EEMEMEMENEEM■ ■MOM■EMEMEMMEE■■M■ ■■mm■■■MMM■■m■■mm■ ■EMM■EMEMEMMEMMEM■ ■M■M■MENMEM■ ■NM■ mm:'_'O■■mm■■m�■NE■ ■■■E■■N■■M■ENEMEN■ ■Emmmmm■■■■n■mmmm■ ■ ■ ■uOmmu■ WEEN■■■ MONSOON ■■NOME■ i i ■■■EEEEWEEEEEEmm■11■EEE■■■ l�NOMINEE MENNiiiINEEMEM ■■■■■■■■■■■OWI'■■■■■■s ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ME