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613 Merrells Lake RdDAVIE COUNTY HEALTH DEPARTMENT PJ 51191 Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000721 Tax PIN/EH #: 5768-44-3269 Billed To: Traci Horne Subdivision Info: Reference Name: Traci Home Location/Address: Merrells Lake Road -27028 Proposed Facility: Residence Property Size: ATC Number: 2139 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 I! #People cO. #Bedrooms —f #Baths Dishwasher: zo,— Garbage Disposal: ❑ Washing Machine: 00" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size / ZI Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width ' Rock Depth Z;�_'lLinear Ft.l.'l—To / 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 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. Telep one # is (336)751-8760.**** vis��a Vk r n�ic Environmental Health Specialist's Si ature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000721 Tax PIN/EH #: 5768-44-3269 Billed To: Traci Home Subdivision Info: Reference Name: Traci Home Location/Address: Merrells Lake Road -27028 Proposed Facility: Residence Property Size: ATC Number: 2139 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 WASTEWATERGqNSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: S" / 2 -475;� 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. 11 Septic System Installed By: ,, d x-? k /? eAa Environmental Health Specialist's Signature :1&4,Z&Date: f� 2f --0 6 `✓ DCHD 05/99 (Revised) APPLICATION (;AOR SITE EVALUATION/IMPROVEMEiJf PERMIT &ATC n c� arc i Davie County Health Department jJ Envitnnmenta/Hea/td Swdon C31 319- P.O. Box 848/210 Hospital Street Mockaville, 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. flame to be Billed TSG �Qrne- Contact Person 5/�c * c Mailing Address ' Some Phone 8 - / L4 1 2. City/State/ZIP OCJC%V 111e_ , WC ala Z j � Name on Permit/ATC if Different than Above BusinesPhone tL19's I - Z(CIS / acs Gl7147C- Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC k%Both 4. system to Service: * House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People a 2 1 # Bedrooms J # Bathrooms I2� Dishwasher ❑ Garbage Disposal JV Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. if Business/industry/Other: Specify type # People # Sinks # Commodes # showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City 'HCl: Well a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Community ❑ Yes ZNo If yes, what type? _ ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESVBMITTED by the client with THIS APPLICATION. ' .r( i a000S • 2F Co�ne� 2 07� 11cl Z' o Property &ZIensions: Tax Office PIN: # JA)zt8 Boor ZIO p cl i �+ Property Address: Road Name M(re�l5 Lake. Kd City/Zip mxC syl&- -C O)103-8 ri g"t— rdxi mo �Iy WRITE DIRECTIONS (from MockrAlle) to PROPERTY: 10 q 2asf An 1 b Cree-L ", ekf-a6 Loke'?,d- s mh o If in a Subdivision provide information, as follows: Name: Section: Block: Lot: ---•- - - -r-. •.. - --ba— 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 am responsible for all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departme t to enter upon above described property located in Davie County and owned by�S . 'cx.VJ A -i�Q c' f n e— to conduct all testing procedures as necessary to determine the site sultab lity. DATE P� " 13 " 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). Date(s): EHS: Account No. %°2 Revised DCHD (07/99) Invoice No. E --00---Z i OP/13/99 09:20 DAVIE TAX ADM 3367512699 N0.164 D01 i i i X6+0 �s�e M E RRE LLS LAKE 194 »6 N 1.72A '3269 Ao2 (664) U our J Map r Parc e . = .99.0.9.0. 13,199910:47 AM . APPLIL'A]ION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A Davie County Health Department Jr Environmental Xeaft SmWon P.O. Box 848/210 Hospital Street FEC1998 h Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH ***IIWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. name to be Billed i P6 1 -ACA 44:2. )rZ-A A Ik Contact person %DRNfi-4 ,BL/3CCc�ltt 1lGl� Hailing Address 1 4/6 mar e f 2 Q . Some Phone City/State/ZIP /Y1 be i,111- r/1LL,�74141,C: L7Aa..P Business Phone 2. Mime on Permit/ATC if Different than Above Hailing Address City/state/Zip 3. Application For: Site Evaluation 0 Improvement Permit/ATC ❑ Both 4. system to service: ] House ❑ Mobile Home ❑ Business ❑ Industry 0 Other a. If Residence: # People 2 # Bedrooms . ? # Bathrooms R Dishwasher 11 Garbage Disposal F( Washing Machine JA Basement/Plumbing 0 Basement/Mo Plumbing 6. If Business/Industry/other: Specify type # people # sinks # Commodes # showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 0 County/City OL well ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes KNo If yes, what type' ***IlilPDRTANT*** CLIENTS IIIUST COMPLETE THE RPsQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMIT :ZD by the client with THIS APPLICATION. Property Dimensions: d • T GZCl = WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 5-7 M - y4 /317.2 doo"e� ew EAsT .c ----F7- OP 7W Properly Address: Road Name /11 P,Eh eu &,APE- Ag Nb e_p_ 116AL /A- Af City/Zip 41 pC-t//)LLt 426k If in a Subdivision provide information, as follows: Name: S/TE /S TJi41" C'e ill " _ e A NO CLEEk� 2_014A AM) JI �L �C1 R A) C q ZI, Section: Block: Lot: Date Property 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 ant responsiblefor all charges incrirred 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 k -W to conduct all testing procedures as necessary to determine the site suitability. DATE /1-21 ��� SIGNATURE? THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing And proposed property lines and dimensionsi structures, setbacks, and septic locations). � Noicftr 3aN,G 4 IJ���rC Account No. �3d Revised DCHD (07/98) Invviim No. v�– a w - , IiOr, Z4. V 61 I • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME l) //9G� &'10 I GD/ PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring 4// Pit SECTION LOT. DATE EVALUATED PROPERTY SIZE �iqG ROAD NAME %%�:�r� i� -67,4 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position / Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure 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 71, SITE CLASSIFICATION: D LONG-TERM ACCEPT E RATE: REMARKS: 6)/1 &_ C -P Sl /' 0 l t /X DCHD (01-90) LEGEND Landscane Position EVALUATION BY: o'LQ OTHER(S) PRESENT: SE 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 - gaVdaylft2 ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■ ■ m ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■BOOB■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENMONROEMEMO ■■■■■■■■■■■■■Ori■■■■■■■�■�■■�_ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■ ■ ■m._:a:mommom ■■■■■■■■■■N■■ ■■■o■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■E■■ mons■mmn■■mms ■■■■■■■■■■■E■ ■■■m■■m■■■■m■ ■■■m■■■m■■s■■ ■■■■■■■■■■■■■ ■■■■m■■■■■N■■ ■■■■■■■■■■/■■ ■■mmmonmmmmn■ ■■■■■■■■■■■■■■■■ ■■■m■■■■■■■■■o■■ ■■■■■■■■■■■■■■■■ ■n■■■Nom■ss■■■o■ ■m■■■■■■■■son■m■ ■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■///■■/BOOB/■////■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■!iii%■■■■■■■■■■■■ ■/■/BOOB■/■■/BOOB■■■ BONN MOON MEMO ■■M■ ■■m■ NONE MEMO ■E■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 January 20, 1999 Thomas Leslie Blackwelder, Jr. 561 No Creek Road Mocksville, NC 27028 Re: Site Evaluation Merrells Lake Road/3.4 Acres Tax Office PIN: #5768-44-1372 Dear Client(s): As requested, a representative from this office visited the aforementioned site on January 14, 1999 Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable on the back side for the installation of an on-site sewage system. A pump will be needed. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd Enclosure(s)