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127 Childrens Home Rd Lot 1 - l DAVIE COUNTY HEALTH DEPARTMENT ��6F Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000842 Tax PIN/EH#: 5813-88-8923 Billed To: Hope Christian Subdivision Info: Oak Grove Lot#11 Reference Name: Hope Christian Location/Address: Children's Home Road 27028 Proposed Facility: Residence Property Size: 1.97 Acre ATC Number: 2218 **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 K H 6rv1,C #People_-'!S' #Bedrooms�3 #Baths—2— Dishwasher: Dishwasher: Garbage Disposal: ❑ Washing Machine: ❑Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial 173 Lot Lot Size I R-7 /SC(1,�S Type Water Supply VA3P-Lt Design Wastewater Flow(GPD)�� Site: New E Repair❑ System Specifications: Tank Size�C C)GAL. Pump Tank&p GAL. Trench Width3t,:;' Rock Depth I2'' Linear Ft*& Other: 4 ]D1 STQt R>0 n o.-1 S 0.CG. Required Site Modifications/Conditions: It.&SUw-- O3 cormop5�! Fez,, op-u, 4&10 v4a�p r •- t IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 u BELOW // FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspgdion of this 60 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.**** I ts-©• iso' Rei u-is ► Iay Environmental Health Specialist's Signa %.,, Date: // 2 4 DCHD 0 evised) �4 t = DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000842 Tax PIN/EH#: 5813-88-8923 Billed To: Hope Christian Subdivision Info: Oak Grove Lot#1 Reference Name: Hope Christian Location/Address: Children's Home Road 27028 Proposed Facility: Residence Property Size: 1.97 Acre ATC Number: 2218 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 WASTEW O S N IS V ID FOR 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 I 1 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. N rl� ~ t)orom , -Lc.a-r►vJ C114t&-Gbi Ea>) To sepr(c- ti e� 2oo,x3&.•xiz Septic System Installed By: 1 C;"M AW A)t JOID'i Environmental Health Specialist's Signature Date: // a g�', DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMEM PERMIT&ATC Davie County Health Deparbnent Q 0 Environmental Health Secdon P.O. Box 848/210 Hospital Street OCT 2 8 1999 Mockaville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH ***2WORTANT*** THIS APPLICATION CANNOT BB PP.C=SSED UNLESS ALL THE-REQUIX&M I VOM&TION IS PROVIDED. Refer to the INSORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person SPtry-V-- 1tai11ng 1lddress31 InlC�i�c1�eI�R , Rome Phone( �l 1 9'c'% 1 1� City/state/szP Ad V AN, Nc- Burinses n"Ld 3to� . 31 3 2. Name on Permit/ATC it Different than Above Mailing Address City/a to/sip n 3. ]application For: -w#Vite Evaluation rovement Permit/ATC 4. system to service: o House . #mobile Home a Business O Industry a Other s. If Residence: # People _ # Bedrooms _ # Bathrooms t3'Diihwasher a oarbage Disposal a-Waa//king Machine a Bassmsnt/Plusbing a Basement/No Plumbing 6. If Business/2ndustry/Othes: specify type # People # sinks # Commodes # showers # Urinals # hater Coolers IS N=SERVICE: # Seats Ratimated hater Usage (gallons per day) 7. Type of rater supply: a County/City p-ll'Si a community a. Do you anticipate additions or expansions of the facility this system is intended to serve? a Yes `6� 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: l- ! WRITE DIRECTIONS(from Mocknille)to PROPERTY: Tax Office PIN: #_ Jr 613- - V� r� Af Ir Property Address: Road Name (foal eG /t e /o'/er<;;gC' � city/zip mo'- s C'r' p ey' - �— If in a Subdivision provide Information,as follows: Name: D kK Q roV2, Section: Block: Lot:# l Date Property Flagged: 0•D q -9 Q 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 ase change,or If the Information submitted in this application Is falsified or changed 1,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. DATE I )I £c L qq SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the on ng: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). l Site Revisit Charge mss): .Av Client Notification Date: EHS: �� LJ Account No. 7-� Revised DCHD(07/99) `` Invoice No. Ida-y V/ APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT& Davie County Health Department Environmental Health Section P.O.Box 848 nSEp 1996 Mocksville,NC 27028 (704)634-8760 ENVIRONMENTAL HEALTH ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED OAVIE COUNTY ,.1� ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �_�� \V � �. 'R -C Ce Contact Person 1-• -e c Mailing Address U h:ea Cross• Q44 Home Phone 910-366—V-366 City/State/Zip Q,5 So r% , N.c, -7o 17 Business Phone 910- 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 Serve: 2"'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms —.2 [(Dishwasher ❑ Garbage Disposal 9 Washing Machine * ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/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 ❑ Comm unity 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ElYes Ud'niNo If yes,what type? PROPERTY INFORMATION REQUIRED: *IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Q- \ d ! `� WRITE DIRECTIONS(from ` 1 Mocksville)TO PROPERTY: J Tax Office PIN: # A t. -} Property Address: Road Name . Q-oa�► ( , i City/Zip 13x91 1 If in Subdivision provide information,as follows: Name: to Ck �` r A 1 Section: Lot #: 1 1 1 1 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 e e L to conduct all testing procedures as necessary to determine the site suitability. DATE ` SIGNATURE Revised DCHD(06-96) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION---/ —LOT 1 Soil/Site Evaluation Lynn M. Reece APPLICANT'S NAME DATE EVALUATED House PROPOSED FACILITY PROPERTY SIZE SUBDIVISION Oak Grove ROAD NAME Highway 6019. 9 Childrens Hume Road Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit 4'1� Cut FACTORS 1 2 3 4 5 6 7 Landscape position .1— Slope 1—Slo e% .2 HORIZON I DEPTH / Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure /!h<< /,✓� /�/C Mineralogy - / HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 77, 7S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: A7 EVALUATION BY: ✓n�l��%��c' LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: �! j`9� �D//`��y'��✓� 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-Veryfriable 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(01-90) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■e■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eel■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■�■ee��■■■■■■■■■■■■■■■■gin■■■■■■■■■■e■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ \■■■\`\ ■■■■■■ ■■■■■■ ■■■■■■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■��■��■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■ ■■■■■■■■■■■e■■■■■■■■e■■■■It■11■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�i■■■■■■■■■■■■■■■■■■e■■■■■■i■■a■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■�■■■■�...........�.:�■■■■■■■■■