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170 Mocks Church Rd . • �� • �' � DAVIE COUNTY HEALTH DEPARTMENT � Environmentai Heaith Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 990001798 Tax PIN/EH#: 5870-87-2275 Billed To: Amanda Miller Subdivision Info: I'r� Reference Name: Location/Address: Mocks Church Road-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 2880 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: (� <U ��/ (� uis�eC� 1� Z�f o► 3�Bealr-o�ms CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate of Completion 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 gu antee that the system will function satisfactorily for any given period of time. a�� � _ � � � r � ae�►1 r Septic System Installed By: �l'i'� Environmental Health Specialist's Signatwe: Date:�� ✓ DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' , ' Environmental Health Section �� �'���l . '� � ' P.O.Boz 848/210 Hospital Street � � Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001798 Tax PIN/EH#: 5870-87-2275 Billed To: Amanda Miller Subdivision Info: Reference Name: Location/Address: Mocks Church Road-270� Proposed Facility: Residence Property Size: 2 acres **NOTEC* T'hi b�mprov8em�nt/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHOWZATION 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 I 1 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 STALLING SYSTEM. •raw'�e�. Residential Specification: Building Type #People� #Bedrooms ��#Baths—� Dishwasher:� Garbage Disposal:�Washing Machine:�� Basement w/Plumbing:� BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �/9 Type Water Supply� Design Wastewater Flow(GPD)� Site: New�Repair❑ / ii � System Specifications: Tank Sizg��GAL. Pump Tank GAL. Trench Widtlt��r �� Rock Depth� Linear Ft. �G� Other: Required Site Modifications/Conditions: Il�'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW FINISHED GRADE. ****NOTICE: Contact a r res lt Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1: .m.to • . i��ephone#is(33G)751-87G0.**** �l� � 1\ �� 0 � �� l� �� �J �� � ti � � �o' � � � � C� ` ' �v Environmental Health Specialist's Signature: Date: �� DCHD OS/99(Revised) , v . �+�.�....� • ' ' � , APPLICATION FOR SITE EVALUATION/IMPROVEMENi PEfi 1� �CJI� � � � � �1 q� Davie County Health Department � "'�'�""'"�"""� (� , Environmenta/Hea/th Section � f � �j� P.O. Box 848/210 Hospital Street � ,!��` JUN — � 2�0� � Mocksville, NC 27028 (336)751-8760 E[lVftiOi;I„�fiT�,L hEE�LTH DAViE CQLI,dTY ***IMPORTANT*** 'TIiIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI�,TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. � 1. Name to be Billed ���/��'(� M I U/��IL. Contact Person �1�n�-�.,r M r w�rL Mailing Address �I� I�1�Lv✓� 1�0� Home Phone L g'1 ' Z� � � � �n �V � r (� �l �1t3` ( 1 8(0 ���`�`�-2 City/State/ZIP i�l�(h-�V�LVG i N C ����CJ Business Phon� Z.�.r(�.�, 2. Name on Pezmit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: � Site Evaluation ❑ Improvement Permit/ATC �Both a. system to service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People �_ # Bedrooms �_ # Bathrooms Z� S � Dishxasher � Garbage Disposal �Washing Machine �Basement/Plumbing II Basement/No Plumbing 6. If Business/Zndustry/Other: Specify type # People # Sinks If Commodes # Shoxers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �qallons per day) 7. Z�pe of water supply: � County/City ❑ Well ❑ Community 8, Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑ Ycs �No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. d � Property Dimensions: � f1�� S WRITE DIRECCIONS(from Mocicsviilc)to PROPLR7'Y: Tax Office PIN: # 5�6 -1� ` Q-1- 2215 H Wy 15�j`E R - }lW\/ $D l' S �—� Property Address: Road Name MUGK.S C(�1.l-P-C(� IZI� �' � MUG�S Gff7.(���� ��- City/Zip }��V�C,� �i7U�10 ��� lf in a Subdivision provide information,as follows: ��)� M�CKS �I.���" '�D� �D�� Name: '�l!btS(�(�. � �V/1�t,tilTj o�l TD BE ��Nr�J p . Section: Block: Lot: Date Property Flagged: �- ��'� � � T6is is to certify that the information provided is correct to the best of my knowledge. I uodcrstand 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,understaird t/:at I ant responsible for a/1 c/rarges i�rcurred jron: 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 owncd by to conduct all testing procedures as necessary to determine the site suit ility. DATE lO� � �D� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(lnclude all of thc following: Existing and pro�osed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Chargc � Datc(s): - Clicnt Notificat�on Date: �HS: CS'��—� ' Account No. � � a Revised DCHD(07/99) Invoice No. �� l �1/ 1� C :D------sarsa—f •------Sa�� ! � I I I 1 1 I 9� t , � � �h10CKCMURCHROAQ � � an � a�a i yron ; °i°° � � . ' � o..� i � .�,�oa.�.�oa � �,. � � � � � � � E � � � W / ... � .�.eoo�ym�: `� .coa�xm n .�,�ow..�om ' .�.Eow.mm .oueno�.�d . � . F8000000 '� ` .�o�,�� �—�_ an C� � ��-� � �. , .�o�,�w . �� . - � � ___ --_ -_- , — _ � P� � � � a.. , � . �.. � g� i - a , � f � f � a a. R u9, � �'.,` • � �• { eemix ' \ �—- . t A� � / �• � � � DAVIE COUNTY HEALTH DEPARTMENT - _ . , . ' � ' • Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �v/�� / rr DATE EVALUATED__ ��lS'"�� PROPOSED FACILITY PROPERTY SIZE Q/�� SUBDIVISION ROAD NAME Water Supply: On-Site Well Community Public v Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 ' 4 5 6 7 Landsca e osition ,[__ Slo e% HORIZON I DEPTH �• /�3 Texture rou Consistence Structure Mineralo HORIZON II DEPTH �!J'' ,�i Texture rou Consistence � Structure 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:�/� EVALUATION BY: �� LONG-TERM ACCEPTANCE RATE: .v OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Lineaz 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 VFT-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 Mineraloev 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(sui[able),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD(01-90) ■���■����■���■�■■�■�■��■�■■���■��■■���■��■■�■�■■■�■����■�■��O��i■■ ■■����■■�■■��■■�■��■������■��■�■��■��■■■����■■�����■���������■■��■ 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