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1476 Main Church Rd � � . � . DAVIE COUNTY HEALTH DEPARTMENT �d -- Environmental Health Section �� I � I p/ r.o.Bog sasnio x�P;t��s��t � Mocksville,NC 27028 r (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001675 Tax PIN/EH#: 5872-73-7385 Billed To: Carl Smith Subdivision Info: Reference Name: Location/Address: 1476 Main Church Road-27028 Proposed Facility: Residence Property Size: 200 x 500 **NOTE**Tiii b�mproveninent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system: An AiJTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF STTE 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: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � Type Water Supply�_ Design Wastewater Flow(GPD)�s�� Site: New la Repair❑ ,. �D17. System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���Rock Depth� Linear Ft�` �� , Other: . ;" Required Site Modifications/Conditions: ' IMPROVEMENT/OPERATION PERMIT 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(336)751-87G0.**** � r,ve F • ✓ Environmental Health Specialist's Signature: � . Date: '�l�d� DCHD OS/99(Revised) � ' �� DAVIE COUNTY HEALTH DEPARTMENT ` � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001675 Tax PIN/EH#: 5872-73-7385 Billed To: Ca�l Smith Subdivision Info: Reference Name: Location/Address: 1476 Main Church Road-27028 Proposed Facility: Residence Property Size: 200 x 500 ATC Number: 2774 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section priar 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 WASTEWATE ON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � � , Date: ��'(�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 guazantee that the system will function satisfactorily for any given period of time. � �, � zoxsX�ti„ 7dX� ' � Septic System Installed By: Environmental Health Specialist's Signature: Date: '�'""f�--o / ✓ DCHD OS/99(Revised) . - ....�___..n_--n-n---- �� � �� � u L'/ � PUCATIOiI FOH SITE fVALUATION/I�dPROVEMEM PERMIT&ATC , Davie County Health Department �� � 3 � Environmenta/Hea/Gh Sec�ion r r.�• B�x 848/210 Hospital Street . . Mocksville, NC 27028 ENVI DAVIE COUNTIf LTH (336)751-8760 ***IMPORTANT*** TIiIS AEPI,ICATION CANNOT HE PROCESSED 'UNLESS ALL THE REQUIRED INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. , / �� �rj-� '1 � ' 1. Name to be Dilled ��]Y s � Contact Person /h Mailinq Mldreas ��U �;h [�. j'��_ Home Phone _�GC (9_�b f City/State/ZIP ��('�(�S�"li�� ����Buainesa Phone %/��— �(p �� _ 2. Name on Permit/ATC iE Ditferent than Above Mailing addreas City/State/Zip 3. Application For: 0 Site Evaluation 0 Improvement Permit/ATC � oth a. syetem to service: ❑ House H Mobile Home � Business � Industry 0 Other s. If Residence: N People �_ � Bedrooms _.�_ A Bathrooms _� ❑ Diahxasher ❑ Ga.=bage Disposal i7 Wsshing Machine ❑ Basament/Plumbing ❑ Sasement/No Plumbing 6. If Buainesa/Industry/Other: Specify type � People �1 3inka # Commodes # Showera # Urinals #{ Water Coolers IF FOODSEBVICE: # Seats Estimated Water Usage (gallona per a8y� �. Type of water supply: � County/City ❑ Well ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to servc? �Yes �'No If ycs,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUES'I'GD BELOW. Eit6er a PLAT or SITE PLAN h1UST BESUBMI7TED by t6e clicat with THIS APPLICATION. Property Dimensions: �� � �6� WRITE DIRECTIONS(from Mocicsville)to PROPGRTY: Tax Office PIN: #`��f?Z ' 7� - � ��_� �(LI ��`l/ � / � (l�/? PropertyAddress: RoadName ��f7� maj}� ��� f�Q,�/�l (�'1, ��LX �'Jr�d /N.` ��ty,Z�p�na�ss�:�r� � � � � G,r� If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Fiagged: T�3 rJ ! This is to certify that the information provided is correct to the best of my knowledge. I understand that s►ny permit(s) issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsi6ed or changed I,also,understand that I am responsible for al!charges incurred fro�ri rhis application. I,hereby,give consent to the Authorized Representative of the Duvie County Healtt�Department lo enter upon above described property located in Davie Couuty and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE `� - � — � ! SIGNATURE + --�- 'I'�IIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, set6acks, and septic locations). � Site Revisit Chargc � Date(s): �- 7 � Client Notification Datc: ��, �-- 1-� -� � EHS: � � �� � Account No. _ � � ✓ Revised DCHD(07/99) �✓ Invoice No. � ? ��_� . . .• 4 ' � ' � . y . . - (1421) �... � � "� -� . . � f .: _ � . .' . � . 500 -� % ��.---- _-__ -\ G4080A0034 .__-----._ _. ._ . , 587z��3-� 735� j N _ (2.28A) � 0 � 7385 : � � _ �� : : ��� _ _ 500 230 100 100 100 G4080A0028 G4080A002701 G4080A0029 G4080A0027 14 4 N o �� .04A) •N � 446 � � � 54 � 0116 � 7155 �146 6154 . � , . 200 100 100 ------ 100 ' --- _._____- � - _L._-----....__.....__.._--._.._ .._._. _----___ __._ -----_._- j_ L ._.__._� -'._""`�__._- I ZOO j 100 150 � 1 �. 5 5 � , � � � � �, �a� � � 9975 � � , DAVIE COUNTY HEALTH DEPARTMENT � � � N Environmental Health Section . � � • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001675 Tax PIN/EH#: 5872-73-7385 Billed To: Carl Smith Subdivision Info: Reference Name: Location/Address: 1�t76 Main Church Road-27028 Proposed Facility: Residence Property Size: 200 x 500 Date Evaluated: `�`6�QT Water Su 1 On-Site Well Community Public v PP Y� Evaluation By: Auger Boring /�_ �Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition L Slo e% �--- HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEP'TH <l ``� '��'`' Textwe rou Consistence J Structure f _ Mineralo ' HORIZON III DEPTH Texture rou Consistence Structure Mineralo ' HORIZON N DEPTH � Texture ou Consistence Structure Mineralo 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-Silty clay C-Clay CONSISTENCE ois 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 ture SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic MineralogX 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-gaUday/ft2 DCHD OS/99(Revised) ■������■■�������■��■�■■�■■�■������■�e����■�■�■�■��■���■��■■!lSS�■■ 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