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445 N Pino RdDAVIE COUNTY HEALTH DEPARTMENT a o Environmental Health Section P. O. Bog 848/210 hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003204 Tax PIN/EH M 5833-25-3514 Billed To: Ricky McClannon Subdivision Info: Reference Name: Location/Address: North Pino Road -27028 Proposed Facility. Residence Property Size: 7.76 acres ATC Number: 3780 **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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ✓ / #People #Bedrooms #Baths o� _ Dishwasher: Z!r Garbage Disposal: ❑ Washing Machine: 0"" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Q Lot Size f Type Water Supply Design Wastewater Flow (GPD) �� Site: New Repair ❑ System Specifications: Tank Size/4yA GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width36-e" Rock Depth 410' " Linear Ft. N, IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the a 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 -e theme Atallation. Telephone # is (336)751-8760.**** i �J o� CIO Environmental Health Specialist's DCHD 05/99 (Revised) nature: Date: J r Account #: Billed To: Reference Name: Proposed Facility DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990003204 Ricky McClannon Residence ATC Number: 3780 Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5833-25-3514 North Pino Road -27028 7.76 acres 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 CON/STRRUCTION IS VALID FOR A PERIOD OF FIVE YE S. Environmental Health Specialist's Signature: (/�J Date: '5 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Complotian.4h ll has been installed in compliance with Article 11 of Disposal Systems," but shall in given period of time. Septic System Installed By: system described on Improvement/Operation Permit A, Section .1900 "Sewage Treatment and e '!.S hat a system will function satisfactorily for any P Environmental Health Specialist's Signature : At/ '_s Date: !71,13e, DCHD 05/99 (Revised) 1. Name to be Billed /\ �(Y�/ M�ci�n.1 tvnn�// Contact Person Ria'/ Cc /c,hyire�. Mailing Address �67 Cornal" Z Pr Home Phone 37 -6075 City/State/ZIP /�oG/Ct,�';11 �/I/C. _2702 Business Phone ��l 7(01-1550 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ® Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House 09 Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 10 Conventional ❑ conventional modified ❑ innovative G. If Residence: # People _5 # Bedrooms 3 # Bathrooms I?L ❑Dishwasher ❑Garbage Disposal 'Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 7.76 G=C Tax Office PIN: # _5933 S35 /Y Property Address: Road Name ,AA 2'', n C City/Zip M o r k:51 e, 270.2g If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Moocksville) to PROPERTY: L(51 Al -1-o Cane, K d (S" o en/ m obi I e. Kvw�Q . " Date home corners flagged: q '3o -log 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 Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. n� DATE 4-1-30-01 SIGNATURE Y& V THIS AREA MAY BE USED FOR DRAWING YOUR SITE property lines and dimensions, structures, setbacks, and sel Sign given _e-5 Revised DCHD (05/03 all of the following: Existing and proposed Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. 3 a -d y Invoice No. l v CN N 6280 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003204 Billed To: Ricky McClannon Reference Name: Proposed Facility: Residence PROPERTY. INFORMATION Tax PIN/EH #: 5833-25-3514 Subdivision Info: Location/Address: North Pino Road -27028 Property Size: 7.76 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit 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 Structure /Z b 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RA REMARKS: i �J✓ EVALUATION BY: OTHER(S) PRESENT: v %,- � 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 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■c■■ewe■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■eee■■■■■c■■■■�■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■c■■ecc■c■■■cc■c■c■■■cc■■■■eee■■■■■e■E■■■■■■■■e■■■■■■■■■c■■■■ ■■■■c■■■c■■■■■■cc■■■■■■E■■■■■■■■c■cE■E■NEN■EE■Ec■Ec■■■■■■EOE■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■c■■■ec■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■eee■■■■■■■nc■■■■■■■M■��■■■■■■M■■■e■■■■■E■■■■■■■■■■■■■■■■■ ■■c■■■■■c■■■■��■■■■■■■■■c■■■■■■SSSS■■■■■■■■c■■■■■■■■■■■■■c■■■■ ■■■■■c■■■■■c■�i■■■■■■■■■■■■■■e■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■■ MENNENSERENEEMMEME MUMMI1MMEMNONMENNENNNE ■■■■■■■■c■ce■■i�■■c■■■■■■■■■■■■■■■s■■erre■■■■■■■■■■■■■■■■ri■■■e■ ■■■■■■■■■■■�e�■i�■■EE■■EEE■■■E■■■■■�■■►�■■■■■■■■■■■■■■■■■r,■■■■E■ ■■■■■■■■■■er�■■u■■■■■■■■■■■■■■■■E■r�Er.E■■■■■■■■■■■■■■■■Sri■■■■■■ ■■■■■■■■e■►�!�■■ire■■■■■■■■■■■■■■■■e■ew■■■■■■■ecce■■■■e■eee■■■e■ ■■■■■■■■ci�r►�■■tr■■■■■■■■■■■■■■■■■■ri■e■■■■■■■■■■■■■■■Sri■■■■■■■ ■■■■■■■■■■■■■■��■■■■■■■■■■■■■tea...,■■■■■■■■■■■■■■■■■■u■■■■■■■■■■■■■ ■■■■■■c■■■■e■■r�■■■■■■■■■■■■■■c■■■■■■■c■M■■■■■■■■■■■eye■r�■v■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■E■■■ ■■■■■■■■■ MEMO■■■■■ ■■■■E■M■■ ■■■OMM■e■ ■■M■■■■■■ i M ■ ■ ■ ■■■■■■■■■■■■■■■■■■■ SEEN SEEN ■■E■ .... 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