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187 Northbrook Dr Lot 17 • ; DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 10 Account #: 989900571 Tax PIN/EH#: 5820-32-6531 Billed To: Shuler Building Subdivision Info: North Brook 2 Lot#17 Reference Name: Location/Address: Northbrook Drive-27028 Pro osed Facility: Residence Property Size: 120x 350 ATC Number. 3138 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 WASTEWATE N TR ON IS VALID F R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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. l� 7P 6o 7o Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99(Revised) \DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ., P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900571 Tax PIN/EH#: 5820-32-6531 Billed To: Shuler Building Subdivision Info: North Brook 2 Lot#17 Reference Name: Location/Address: Northbrook Drive-27028 Proposed Facility: Residence Property Size: 120x 350 **NOTE* iiss nprovem8ent/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 Specific tion: Building Type // #People #Bedrooms #Baths Dishwasher: Garbage Disposal:q�r Washing Machine:j2 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) �b Site: New Repair❑ System Specifications: Tank Size,&OGAL. Pump Tank GAL. Trench Width <� Rock Depth /? Linear Ft. Z66 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. Telephone#is(336)751-8760.**** d � � eC 10 � u Y Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department L� EnvifwmentaiHeaith Section APR P.O. Box 848/210 Hospital Street 26 2042 Mocksville, NC 27028 (336)751-8760 FNV/R0V7E G�bTAL UNTY ***IIdPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer. to the INFORMATION BULLETIN for instructions. 1. Name to be Billed '&I' Contact Person Uene &Ajle, Mailing Address 11/2 cShy 1,er''11 Home Phone NI City/State/ZIP I�Y)OQkSU ��Y C• -1762 g Business Phone qq 2. Name on Permit/ATC if Different than Above Mailing Address City/state/zip 3. Application For: ❑ Site Evaluation eImprovement Permit/ATC ❑ Both 4. System to Service: 13-House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms s� # Bathrooms a W Dishwasher CJ�arbage Disposal a/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 ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 4NO If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: 120 X 3S0 WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: #_LJ�oZ0 -3a - 6S3/ 601 Morik L41- 6n J;keres- Property Address: Road Name 1,4 17 ldocAbrn^k4r 6h Nvr4hied )of City/Zip lel' in L'oJde_-W e if in a Subdivision provide information,as follows: Name: --/t/O�1�li Clroo/C Section: Block: Lot: �'�_ Date Property Flagged: 2- 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. I,also,understand that I am responsible for all charges incurred front 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_.�J DATE l( - _ o7- 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). Site Revisit Charge Datc(s): Client Notification Date: EHS: _ Account No. (ice Revised DCHD(07/99) LO � v Invoice No.Is s �� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Q O U Davie County Health Department i Environmental Health Section SEP 1 8 19M I P. O. Box 665 Mocksville, NC 27028 t ENVIRONMENTAL 0VI { 1. Application/Permit Requested By ✓y�A f Mailing Address / L a C-k IXy Home Phone f�f ;�1 7 Business Phone' 2. Name on Permit if Different than Above 3. Applidation/Permit for: General Evaluation '' ❑ Septic Tank Installation 4. System to Serve: [P/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ InOugtw Other ❑ Unknown j7 5. If house, mobile home: Subdivision worav� vRDb�Setiin a Lot #—own W , t ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No.of People Served No. of Sinks No.of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: 13"Public T. ❑ Private ❑ Community 8. Property Dimensions ( /2-6 ,aAtz, G 6(`�J Sewage Disposal Contractor 7 9. Do you anticipate additions//expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: � , , �L ( a+k4 This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DAT SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(12.90) ' F0. DAVIE COUNTY HEALTH DEPARTMENT �a`� 7 Environmental Health Section ,Soil/Site Evaluation ' NAMEr.>r.v � Sr:��;�x►'` DATE EVALUATED ADDRESS S A Cn R PROPERTY SIZE PROPOSED FACIILTY d�9' LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By:o�L Auger Boring Pit Cut FACTORS I 11 2 3 4 Landscape position Slope % I r13 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH D Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE ^ CLASSIFICATION S LONG-TERM ACCEPTANCE RATE ,tel SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTA CE RATE: -- ttA OTHER(S) PRESENT: 'v d tj REMARKS: LEGEND Landscape Position 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 Aay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V?,-!-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely fine Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 3C--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(01-901 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON.■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■e.■■■■.■■■.■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ CCCCCCCCCCCCCCCCCCCCCsiiiiC'CCCC■eCCCCCCCCCCCC'�MEMEMM MMOMEMMOME mom 0 mom ONEEMEM on ■■■.■■■■■■■....me■..■■e■■■■e■..mN.M■.nm.■ ■.. ■ ■ ■■. 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