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493 Mr Henry Rd ,i�' � DAVIE COUNTY HEALTH DEPARTMENT ��" � � Environmental Health Section P.O.Boz 848/210 Hospital Street Z��" `T s Mocksville,NC 27028 (336)751-87C0 Account #: 990003465 Tax PIN/EH#: 5717-60-1525 Billed To: Deboarh Branch Subdivision Info: Reference Name: Location/Address: 493 Mr. Henry Road-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 3976 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �� CERTIITCATE 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 ar tee that the system will function satisfactorily for any given period of time. � f� sb � lG � �� Yv� � �' � � , Septic System Installed By: C.�i;�,) � / � Environmental Health Specialist's Signature: ��G Date: /�~ S� DCHD OS/99(Revised) � DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section ' P.O.Box 848/210 Hospital Street � y �/—d`� , • ' Mocksville,NC 27028 � (33G)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990003465 Tax PIN/EH#: 5717-60-1525 Billed To: Deboarh Branch Subdivision Info: Reference Name: Location/Address: 493 Mr. Henry Road-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 3976 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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_�l/� #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) �6(� Site: New�Repair❑ System Specifications: Tank Size�j�GAL. Pump Tank GAL. Trench Width� `� Rock Depth��{,inear Ft,�� Other: Required Site Modifications/Conditions: Ih1PROVEMENT/OPERAT[ON PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G "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(33G)75�-87G0.**** '� � � . Environmental Health SpecialisYs Signature: Date: �� DCHD OS/99(Revised) ,, , � �� J �� ly C � _ . .�. __.. A��L � FOR SITE EVALUATlON/IhiPROVEh1ENT PERhfI ��`' G ' � Davie County Health Department �' �� JAN 1 9 2005 � �.�.. �� ` � - - Envi�onmenta/Hea/th Section `�� ,� -� , 4 ` J P O. Box 848/210 Hospital Streat � � �i�ENVIRGNiNENTAL HEALTN Mocksville, NC 27028 Eiy�,��- , " �' , . `r;��' 0,N (336)751—s76o �a�;F��r��"`•� -``./ ***IMPORTIlNT'*** TH ICATION C1lNNOT 13E PROCESS�D UNLESS ALL THE REQ D INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Namo to bo IIillod _��Q�f� T�y1Z�tjl�fG� Contact Peraon Mailing Addresa �/�/G/�li' _ � Home Phone 3��--7 Qa'73� City/State/ZIP /�p�,C'SI�L(.L� (� Buaine�s Phone �L�/,r� /f�S /��d"l/� 2. Nama on Permit/ATC if Different than Above Mailing Addresa City/State/Zip 3. Applica�ion For: '�Site Evaluation J�J Improvement Permi.t/ATC �oth �� l � 4. syatem to servicu: ❑ House �" Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type syatem requestod: ❑ Conventional ❑ convontional modifiad ❑ innovativa 6. If Residence: # People / # Bedrooms .3 � Bathrooma �� l�dbiahwaaher ❑Oarbage Disposal ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If IIuainesa/Industry /Othor: verify type �F Poople # Sink� # Commodes # Showers # Urinala 1f Water Coolors IF FOODSERVICE: #� Seata Eatimated Watar Usage (gallona par day) e. aypa of water suppiy: O County/City Ltil Well ❑ Community �, 9. no You anticipate addition� or cxpansions of tlic facility tl�is systcm is intcndcd to scrvc?O 1'cs .[�o �'` If �cs �vliat t c? (� 3 � YP , , ***Id1PG�P.Ti1NT"`**CLIENTS�1lUSTCOA1f'LCTLTIIG ltEQUIRED PROP�RTY INrORMATION R�QULSTCD - BELO�V. �itl�cr a PLAT or SITG PLrW MUST 6ESUBhIITTED by tl�c clicnt tivitl�TIIIS AI'PLICATION. Properly Dimensious: � 7 �� 1VI2iT�DIRGCTIONS(froni Nlodtsvillc)tu I'ROI'CRTI': TaX orr��rirr: �f 5 7/76 o i�'�� ler,�� ,�c� �v �Q�%e .4��„�,� Property Address: Road Namc �F3 /Y1 r.�,�,-5/ ,�,� '�e � ,-,�P„J,.�.,/ 1�� r-„1 �.�� O.c( City/Zip_/�pG/�S e/i��/+� �70�� f'Yl r. f��nlr��1'. �A?;�e 7�0 `�J'' ICin a SubJivision providc ii�forniation,as folio�vs: � ��2,��/ iS n,rl f,e� _�;o% Namc: ' r�� S Section: Block: Lot: Date liotnc coriicrs Ilagged:� vu Tliis is to ccrtily tl�at tl�e inforu�ation providcd is correct to tlie best of tny IuioivIcdge. I undcrstaud that any permit(s) issucd l�crcaftcr are subjcct to suspcnsion or revocation,if tl�c sitc plaus or intcndcd usc changc,or if tl�c inforcnation submitted in this applicatiou is falsired or cl�anged. I,also,rurderstand tlrnt I a»t responsiLle for nll char�es iuciirred fruni llris applicalio�r. I,t�ereby,give cottseut to the Autl�orized Representative of tl�e Davie County IIcalth Dep�rtnient to cntcr upon abovc describcd proper[}�locatcd in Davic Couiity and otiv�icd by ��3p/1.t��1 i"iPi,�T�ohl L32�tNG'� Iu ca�duct�1l tcsting proccdures as ucccssarJ•to dctcrmiuc tl�c sitc suitability. DATE /�/S�D� SIGNATUI2� ,/1/�%��Li , i'�;d_�c� b'1F�Gt.�-G.J JT � TIIIS AItEA MAY B�US�D FOR DRAWING YOUR SITE PLAN(Includc all of tlic follotiviiig: �xisting and proposed property lines and dimensions, structures, setbacics, and septic locations). � Sitc Rcvisit Cl�argc �� Datc(s): S�-�,`"e__.�'-� I Q � Clicnt Notification Datc: /��, cL/��`� � �IIS: �� o�`�, �`�" �� Sign givcn � ( � � �'2� `� Accouut No. ��' S � `, �,^,/ O � � ,3ra p d� T .� � �� Rc��iscd DCIiD OS/03 � �`�� I�ivoicc No. � _ � , ,n, �- ''..;� - � ,: �.. . , 7,.�p��y�'c� e�y;l�� `�'�. n�,an� u k ,�±�a�e. z '' �: . . , ' ` . � ��. � , .� . �. . . ;. , �.�i S .. .` ''�e, p, a k .�1 - . ��:.� �� u �t I� =;�.� i( r � ; � � �' . . . ,�"��_�g+j � � �I' . �1 � ' . .. , � . . � � . .� litj��.,_ 9 .W� .,...!, �, � . � , , � .:.... � � � � � z�z � . � � y � � � � �� ti�� , �� ., � , �� , ; � � � 1 � � �� a _ � , � � � � � ! � � ��, �,��o��r �:. I , � , _- � � � � �� 6'• ; 6� ;� rcv. / , / , � � � � / � , �� Z� � � � , , , � � / ; , � ' �' �� N i" � � � i w `S'o ' / �, �, � � � � � � ��`'� ' _, � �' c� � � . � ;0 , � � , �� ;� � �ti� �,. ,,,, �� ' i �' � , / "c� ; � � � � � : , � .�z� t� _ , o - �� . . � � .,, wy b'98�' _ . . �/� `� .�� G 7 Cl 1 � l i'`�—� � _ �� I � � , DAVI� COUNTY HEALTH D�PARTIVI�NT • Environmental Health Section ' � Soil/Site Evaluation APPLICANT 1NFORMATION PROPERTY INFORMATION Account #: 990003465 Tax PIN/EH#: 5717-60-1525 Billed To: Deboarh Branch Subdivision Info: Reference Name: Location/Address: 493 Mr. Henry Road-27028 � Proposed Facility: Residence Property Size: 3/4 acre Date Evaluated: __��r��,LC�- Water Supply: On-Site Well ` - Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo e% HORIZON I DEPTH �� </ Texture rou Consistence Swcture Mineralo HORIZON II DEPTH 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: �J� EVALUATION BY: ,�1�:-�� 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-Silry clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE oist 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-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed es . 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 ..........................................................�. ■��■ ■��■��■��■��■�■��o��Ce■ ::_. �� a:�::::::::::::::::::::::�:::::::::::::::::::::::::::::::: .. .. ........................................................... ..� .............................................................. :�::�............................................................. ............................................................ .�... .. ......................................................... .....�..�.......................�................................ .. . .........................� ................................ ...0.............................................................. .................................................................. .....�............................�............................... ..... ............................................................ .. .. ............................................................ �.�.. ............................................................ . .. .........................�................................ .C::':::CCCC::::C::C:C::C:::::::..::C:::::CCC:::::::CC::CC:::::::C ...�C........�.................................................... ... ......... .................................................... .... ............................................................. ..... ........................................................... ......0........................................................... :::::::C:::::::::::::::::::G::::�::::::::::::::::::::::::::�C:::: ■��■��■��■��■��■�■��■■■.==:iiii:ii:1�•A�ii.��s��■ ■��/��/��i%�%��J�11/I��/�/��■ ■��■��■��!=��i/�■■��■��!��:�ii��ir��"�iiii�l■��■ ■��■ ■��e�_e:::i��■��■��■��i��■��e��■�r��i��i��■ ■��C�■ i��i��■��...==:i��■��r��r�� 1��■ ■�� ■��I��ii��G�t!!!Li�il��■ ■��/A��i�■t!�%�11��1�■��■■�■��■�5��t■�■■��'II��I��A■ ■�� ■A��!JI►J��il��!J��\I��■��■ ■��\��■��I��/1%II/,I/��■■ C�■ ■ ■,��l::iloLGr�L'J��I��/��1�/,/:Ll�1�7�\�■ ■�■ ■I��l7/I\��I�■��■��■��■��Iirf/■ ti��■ ■��■ ■I��/II,II��,��0��■��■��■��il��l/��■ ■�/■ ■I��I�r�=�=�:!�.'��■��■��/1��/I��■ ■�� !':��I�/��1\��■ .....C.�=............�....................................�......... i�::C::.�i::C:::�::::::i�:G:G::i�i:C::::i�::::::�C:::::��::::::ii :::��:::,:.:C:::::::::::::::C:::::::::::C::::::::::::::::::�::C:��C::: ■��■��■��■��■��■�■��■��■��►�■i��t��oe �[!1ii�//�/t��/I��/��t�r��==L'��=��C:�iiiiG�:��G'/.%/I��A�\��■ ■II�I ■��l/�II��r�'ii.Cii��■��►J\��■��L��I��Il��■ ■ii�n��n��■��r�ir.i��■��i��:+�■■ ■fA'/1i11�11/��/��ll�/.;1GL�'� ■�i►a:�r��ji��l�ii(��■ ■L'�lJ ■I��fr��l,�►/■ ■�/�■��■��■ ��A��I��%1��\�� ■�� Q��r��N��a��■ :::� ��C:::::::::::::::C:::::::::::C::::::::::::::C::::::::::::C .... ...�........................�................................ ■1■�■ ��I�11��1■�I■��■��■��■ ■��■��■��■��I��■■ ■��■ i��i��e�■��■�■��■�■■�■��■ ■�■ ■�i��i��■��■ ■�� i�■��■��■��■��■��■��■��■��■��■��■ ■ ■=��i�■i��■��■��■��■�■■��■��■��■��■��■ i�i��i�iii�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ■��■��■��■��■ ■��■��■��■��■ ■��i��■��■��i�■��■��■��■ ■��■ ■��■ ■��■��s■��■��■■��■��■��■��■ ■�■■ ■��t��■��■��■��■��■��■��■��■��■■ ■�� ■��i��t��■ ■��_��a��■��■��■��■■ ■�■�� ■■��■��■��■�■��■��■��■��■��■��■ �ni"'Ciiiii�iiiiiiii�iiiiiiiiii�iiiiiiiiiiCii�CiC�i�C�:ii��:�:C: iii�?�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ■��■��■�■��■��■■■■��■��■��s��■ ■��■��■��■��■�■■��■��■��■�■��■��■�■■ ■��■��■��■��■�■��■�■��■��■��■��■��■��■��■ ■��■ ■��■ ■��■ ■��■��■�■��■��■■��■��■��■��■ ■��■��■��■��■��■��s