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208 McDaniel Rd 1 DAVIE COUNTY HEALTH DEPARTMENT � .� �—� 2"' � • Environmental Health Section � . , . P.O.Boa 848/210 Hospital Street , . " , Mocksville,NC 27028 . - (336)75]-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002164 Tax PIN/EH#: 5870-13-13$8 .� �V Billed To: Robin Campbell Subdivision Info: � Reference Name: Location/Address: McD�niel Road-27006 Proposed Facility: Residence Property 8ize: 1 acr� ATC Number. 3077 **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 PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �T/ #People 7i #Bedrooms� #Baths o�- Dishwasher:f� Garbage Disposal: ❑ Washing Machine:.� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Faciliry Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size r�e Type Water SupplyC�6 Design Wastewater Flow(GPD) v�v Site: Ney� Repair� . System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width����Rock Depth,�� Linear Ftc���'� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.**** / ������� Environmental Health Specialist's Signature: �� Date: ` DCHD OS/99(Revised) � �.�• M ' DAVIE COUNTY HEALTH DEPARTMENT � •, ', Environmental Health Section ` P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002164 Tax PIN/EH#: 5870-1&1388 Billed To: Robin Campbell Subdivision Info: Reference Name: Location/Address: McDaniei Road-27006 Pro osed Facilit : Residence Property Size: 1 acre ATC Number: 3077 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � Date:�`���� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certifica of Completion shall indicate the system described on Improvement/Operation Permit has been installed in liance ' Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Syst "but sha ' NO Y be taken as a guarantee that the system will function satisfactorily for any -" given period of time. r. \r C� .M� ' _ dvr o L(� ...s _ �S L�..9� �„ � : a ,��,-� �r�s� � � �lo' : ►4r.��,. �4-� i _� �� �1 t t I �S �r— Septic System Installed By: �J �9"� l �41 Environmental Health SpecialisYs Signature: Date:� ! � `�� , DCI-ID OS/99(Revised) ' r +�J�b. �� , , . � � ,� oa � �� . , APPLICATION FOR SITE EVALUATION/IMPROVEMFNt PERMIT&A . -• ' � " Davie County Health Department • Environmenta/Hea/th Section F�6� � � ZOOZ P.O. Box 848/210 Hospital Street _ Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DAVIE COUN?Y ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED , INFORI�TION IS PROVIDED. Refer to the INFORL�iTION BULLETIN for i t ctions. 1. Name to be Billed ��{�I h l�(.��Y7GL' Contact Person ��p �YY1� c�i�' Mailing Address �!�. M �-�o�n,�e.i 2d Home Phone V1��5— / /I� City/State/ZIP ,Advar�Ce IU C ��00� Business Phone 2. Name on Pezmit/ATC iP Different than Above rtailing Adaress city/state/zip 3. Application For: GY Site Evaluation �Improvement Permit/ATC E�oth 4. System to senrice: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: � People �'l � Bedrooms �_ # Bathrooms � LY/Dishxasher O Garbage Disposal 6Y Washing Machine O Basement/Plumbing � Basement/No Plumbing 6. If Business/Industsy/Other: Specify type # People � Sinks # �ommodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Esti.mated Water Usage �gallons per aay) 7. Type of water supply: �County/City ❑ Well ❑ Community s, Do you anticipate additions or eapansions of the facility this system is inteaded to serve? ❑Yes �o If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client wit6 THYS APPLICATI�ON. �j 4 Property Dimensions:= � x �' 1 CLC/�- WRITE DIRECI'IONS(from Mocksvillc)to PROPGRTY: Tax Oftice PIN: � # ���d � 3 � 3�' �o"1 � � �eF� � �l��a-(1�Z.2-f� Kd'; Property Address: Road Name �c/JOt�'1 I Qi� KG( (1J F-�- C51� /(/j G ��� �'' . City/Zip�I r�van� AN���� 'QS�- I"1(3"US-� �{— `F'�12 lf ia a Subdivision provide information,as follows: 1� �P trt� ,�1,� . Name: Sectionc Block: Lot: Date Property Flagged: Z- Q O This is to certify that the information provided is correct to the best of my krtowledge. I understaad 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,a/so,understand that I am responsible for a[I charges iircr�rred from this application. I,hereby,give consent to the Authorized Representative of the}�avie County Health Department to enter upon above described property located in Davie County and owned by ICD�'Ji n+ K2( i n�tp�P,[I to conduct all testing procedures as necessary to determine the site suitability. DATE �/� ���Z SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed ' property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: � Account No. � � � Bevised DCHD(07/��) Invoice No. �� � � / � Z�.- �-� � \ � � i � O I I . . / ` " 7 -� . � �' Ir fou d e O `'�..- • �' .� I I . " i ,�'-cd � '�` I / ° � � � b�(\'�tS��t�0 \s '�Rs e�r I � - � � � Q,�' 9 lron pin !� I r fo nd e '• � �, T' 4 found 6� / Iron pipe � \� � /�found� pb�j►d�6� at 210.03' 3.6/ l 1/0.77' found _ . .� �� . �. � l�on pipe �—N 38°22'l2'W �� � \ � ���+'9�� ,�b�,�a,o� found 144.38' To►al s 'G�� � s �• � \ pk nai o � � � � � ��� � set 0� ie \ � ��`''a�o ��h ��;L � `� `� t� Q, . . .9 �• 'L ,. s ,l lron pipe y�,d y� v �. � 5 ... �"'� �G found �e9• I r found e� pk nail "'' i � j L- set �'�'`� ��9. � � �t,� �g, 1 ", _ ' %,`� �\ ��9 '� �f un�n � .� so 40 �• � � d : �s� � .�� � � . o� ,p�ti �,ti 1 � � �, b�j6 g"�• � ��"S„ lron pipe � � �, � � � found o�,, g � },., � � a � � • �.� . �,.� nail found at 1 ��: � benl pipe � � v . ,46.E�a9s.31' Totoi Iron pipe � 39 246,3�' found lron pipe found .1� �D� ,�9 1��• o�\ ' (� �� � �� � ,l o�' ��° � � �. Tra c t 2 � ��,4 ��.�� 27.488 Acres+- � 4, �', • � ���� �� ., . � . � � . DAVIE COUNTY HEALTFI DEPARTMENT , , Environmental Health Section - , ,._. Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002164 . ' Tax PIN/EH#: 5870-13-1388 Billed To: Robin Campbell Subdivision Info: Reference Name: Location/Address McDaniel Road-27006 Proposed Facility: Residence Property Size:� 1 acre Date Evaluated: �2s�D2- Water Supply: On-Site Well Community Public` Evaluation By: , Auger Boring /� Pit Cut FACTORS 1 2 3 . 4 5 6 7 Landsca e osition L Slo e% HORIZON I DEPTH ,• �� Texture rou SC�L S', Consistence Structure Mineralo HORIZON II DEPTH c3 °' '� Texture rou Consistence r- � Structure �� I j �� _ 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: �a EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � � i 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineraloav 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) ■���������■�■�■����■�����������■�o���■��■���■�■■■������■����E��s� 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