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P2228 Miller RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000831 Tax PIN/EH #: 5745-60-9545 Billed To: Sheron Cromer Subdivision Info: Reference Name: Terry Dedmon Location/Address: Miller Road -27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 2228 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: , c g c Date: z/V7 /�! 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. r - Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: z�5-4T `,�o DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990000831 Tax PIN/EH #: 5745-60-9545 Billed To: Sheron Cromer Subdivision Info: Reference Name: Terry Dedmon Location/Address: Miller Road -27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 2228 **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 & #People f #Bedrooms _a2 #Baths `? Dishwasher: Garbage Disposal: ❑ Washing Machine: I21"� Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type /J #People #People/Shift #Seats Industrial Waste: ❑ Lot Size fJ9c Type Water Supply C a Design Wastewater Flow (GPD) _,p _� Site: New -Repair ❑ System Specifications: Tank Size/AW GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench WidthRock Depth/" Linear FtegZ IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature:W, Date: DCHD 05/99 (Revised) MIN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC c v�Y 124,oplo"Ll A Davie County Health Department Crpl b) m° u i Envlt>enmenfal Health Sedton w;1999 I( rh c? y e t B.O. Box 849/210 Hospital Street 6--A3-1 \/ Mockaville, NC 27028 �J (336) 751-8760 FNVIR NMENTAL HEALTH I* * HIS-RPPtICATION CRIOM BB PIW=SSD UNLRSS ALL TIM REQUIRM =NFOMWION IS PROtV'IDZDD. Refer to the INH'ORMATION BULLETIN for instructions. 1. Naas to be Billed /7 /1 fill) L , . C o In i5A Contact parson � g %/Ru Dr d /17d N (mailing Address a©&//-f>>l�VIF 11106i -RD , some phos. City/state/Lip Iii ac KSv i'llf N , C, 02 7b -LS Business phone SA /H/Z- 2. /:2. Mass on Perait/ATC it Different than Above (failing Address �- City/state/sip ]. Application ror: ❑ Sits Evaluation ❑ improvement Permit/]ITC Both 4. system to Service: X House 0 Mobile Home 0 Business 0 Industry 0 O er 3. If Residence: # People • Bedrooms _01_ IE Bathrooms ❑ Dishwasher ❑ Garbage Disposal )(Washiag machine ❑ Basement/Plumbing ❑ assamsnt/No rimbing 6. if Business/=ndastry/other: specify type — i people i auks i Commodes # showers r- + IIrinals r— • Water Coolers (' Ir >!'OODSERVICIZ: # Seats Estimated Water Usage (gallons per day) r 7. Type of water supply: County/City 0 Well (3 Community a. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes )No If yes, what type? !V ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Li LlL'1&tJ4 X 3 /o' W%OE Property Dimensions: S' Ac 2 t 5 4 - Tai Office PIN: # l (A 6 Property Address: Road Name fA 1 l ff,Q K o A 1) City/Zip /got kS v i 114 .9'7,62-F If in a Subdivision provide information, as follows: Name: WRITE DIRF.0 ONS (from Mockaville) to PROPERTY: 60 5, e .&�'V g � /,,,cR /f b. �itr oroA; L 61"T) RD 7-o t/r /P .41 // b Du �,r OUT 112WrAo Rd 3o 0 teo rg Section: Block: Lot: Date Property Flagged: This Is to certify that the Information provided Is correct to the best of my knowledge. 1 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 1, also, understand that I ant responsible for all charges Incurred from thb application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and by 5"Wt` R o 1V C.0 - to conduct all testing procedures as necessary to determine the site ty. DATE 0 O c% q q SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN (Include all of the following: Existing and proposed property lines and dimensions4 t"tare% setbacks, and septic locations). — - Site Revisit Charge i 11 K 0, I, 4ylc Revised (07/99) Q` 4 IDate(s): I Client Notification Date: LEHS: Account No. R31 Invoice No. / V (Y6 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000831 Billed To: Sheron Cromer Reference Name: Terry Dedmon Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5745-60-9545 Subdivision Info: Location/Address: Miller Road -27028 Property Size: 5 Acres Date Evaluated: %//V//fM Community Evaluation By: Auger Boring Pit Public ✓ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH - d Texture group Consistence Structure h K i Mineralogy/ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 711 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 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 - gal/day/ft2 DCHD 05/99 (Revised) ■ ■ ■ ■E■■■ MENEM ■E■■■ ■■■E■ ■E■■■ ■■■E■ ■■NO■ MENEM MENEM i14■■■ uPJNNE ■ ■■K■■ MENEM ■■uE■ SEMEN So 'LIEN ■■■N■ ■■■a■ ■■FA■■ MENEM ■E■■■ ■E■■ NONE OMEN OMEN MEMO ■■N■ MEMO OMEN OMEN MEMO ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MESONS ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■E■E■■■■E■E■■■■■EEE■■EE■■■■MEEE■■■■ MENNEN ■EMM■M■■■E■■■■■E■■N■■■E■■■■■■MEMS■■■■ ■■■NEE■■■■■■■■■■E■MEE■E■EEs■E■M■■MMM■ ■■■■■■ ■■■■M■■■■■■EEE■■■■■■■■■■■■■N■ ■■■E■■E■■E■■■EEE■■■EEE■E■■EE■■■■E■EE■ ■■■E■■■■EE■■■EEE■■■EME■E■■E■■■E■■■EE■ ■MEM■E■■EEE■■■E■■EE■a■■N■■N■■■■■■■E■■ ■EEE■■�■N■■■■E■■EE■E■■N■■E■■■■■■■E■■ ■■■■■■ ■EMM■■E■■N■■■■N■■■E■■■■■E■■N■ ■MME■■MESE■■■■E■■E■■■■■E■■E■■■EEE■■E■ ■■■■■■■E■■E■■■■EEE■■EE■t■■E■■■EEE■■■■ ■■EEE■■■EEE■E■■E■■■■■■■NE■■■■■EEEE■■■ ■■■■■E�E■■NEE■■EMM■■E■■E■■■■EENEENN■ ■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■NMSS■ ■■■■■E■■■■■■■■■■EEE■■■E■■■E■■■■■■■■■■ ■■■■M■■NEEM■■■N■■■■■■■■■■■E■■■■■■■■■■ ■■MEM■■■■■MME■■■■N■■■■■■■■E■■■■■■■■■■ ■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■wm!w.g■■■■■ ■■■■■■■■Sri■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ NONE ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■ NEON ■■■■■E■■■■■■■■ ■■■■■■■■■■■■E■ ■EEE■EE■■■■NE■ ■■■NEE■■■■■■■■ ■■■■■■■■■■■■E■ ■■■■■■■■■■■■■■ ■■■E■E■E■■■■E■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■E■■■■■■E■E■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■E■■■■ ■■■■■O■■■E■■■■ ■■■■■■■■■ENE■■ ■NN■NN■■■■■■E■ ■E■E■■■■E■■■E■