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376 Oak Grove Church Rd ~ .' y •, � �� ' DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section /�/a� P.O.Boz 848/210 Hospital Street � Mocksville,NC 27028 (336)751-8760 �' �37�o D���`��r�� �' d � Account #: 990004039 Tax PIN/EH #: 5749-46-0450 Billed To: David Gordon c/o Rodney Bailey Subdivision Info: Reference Name: Location/Address: Oak Grove Church Road-27028 Proposed Facility: Residence Property Size: ATC Number: 4549 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 CONSTRL3C ON IS ALID FOR A PERIOD OF FIVE YEARS. ,�- ^ Environmental Health Specialist's Signatur : � Date: I2 .� (� 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 oftime. ��u`..=n g � . 13 � �D 5T � ^i--�_ I i �'`� � � �� }.�anS� $ B � ,�, $. �2a�r ��I� �`.�J �r�� C,�t, �� `� k s^3a-o� — Septic System Installed By: d� Environmental Health Specialist's Signature: ate: � G�� f� DCHD OS/99(Revised) • ' DAVIE COUNTY HEALTH DEPARTMENT `�.�(} r '. • Environmental Health Section ' + P.O.Boz 848/210 Hospital Street Mceksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990004039 Tax PIN/EH #: 5749-46-0450 Billed To: David Gordon c/o Rodney Bailey Subdivision Info: Reference Name: Location/Address: Oak Grove Church Road-27028 Proposed Facility: Residence Property Size: ATC Number: 4549 **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 �1C71�i-', #People 2-- #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 �.�t; Type Water Supply����t�Design Wastewater Flow(GPD)� Site: New�Repair❑ +► t System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth ►J � Linear Ft.� Other: �C�%�-ta"1�� ���3 �1�V GT'�o-� 5�s'�T�-r�..., � 1�'1��121�uT�o�.l ��yc�S Required Site Modifications/Conditions: ��15 !� 1, � - i�� - '�,�� i..,lti� I1�ZPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFL ENT FILTER. RISER(S) IF fi"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie C nty 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 in tallation. Telephone#is(336)751-87C0.**** Nr;21�- .� ��4�7 u.��5 �� ��� _ ____� � —^— —n �e - r� � �/�.1�� `l'Qc���-1 �'T�-1 ��-p" ,, � � `Z M,� � cN � 'S' � 'J � � {-��v�1: (�[ � -J � �.�., 8 8 � � � , ��� ,_,..��.�. f� �� � ` � -.-- 5 � , 22� . Environmental Hea t pecia D e: �� O� �,Ro�Jr G�c�Re�l �� DCHD OS/99(Revised) ,� � �`:..._._.v�c�' �.�..+1.i�Y� � l. �!� 1� `• - w1 �• — � � � O1 06 01:20p davie caunty envhealth 336 .751 B786 p,3 � � � � � 3 �'006 APPLICATION FOlZ.>ITE EVALUATIC�N/TMPLZO'VEMENT I'BRI�IIT&A'Y'C ��� :�Savle County Health DeZ�artmeut �.�p��1EA�j� Bnvironmental Health.►ection �(1 p���OU� P.O.Box 84&/2l�Hospitai Street . Mocksville,NC 270..8 (33�T51-8760/Fax 336 7^i1-8786 .,�' �` �Z�����' �ppiicaeioa For: ' rce Emluaeiodlinp;ovemcnt Pernuc Auttwri�tion To nstruec(A7'� ❑Doth '•"TMPORTAN7^'•'THIS APPLIC'.A'fION CANNOT BE PROCESSED Uti1.�SS ALL OF THIi ItEQUiRED TNFORMA7ION 15 PROVIDED. Refer to tho If1FORMATION BUY-1.ET(N for inshuctioas. PJ.XCAI�IT lIJ1'ORMATLOI� .,�„ Name to ba-Biiled �Cny�� u r�y� Cor�ct�erson ��-,,,�j�� ��sar�,.. �3illinsAddress 2?.� L�c..v Rd! S, kIc>mePhone City,iStatclZ�_�!— u� u.�u,..T_ �v�, 2�u,Q{�$uaness Phone-�7 qVame on PettnidATC if Di,(fereni dian Above {.��..�•c� �n r c�o,. Mailing Address _ CirylSt�te/2ip P OPERTY INFORMATION NOTE: A svrveyplat or site plan nw:t accompany this applicaton. (Pcrnii[is �atid for}�0 monlhs• �th 9itc la ,ao expiradon with complete p1atJ Street Aeidress ll/C('7fi 1/�/1,�� �iry_ '�x. � /tiv Tax•P�1# s�lo bYSO �ubdivisionNsme IJ 1 U+r Section ,ot#, LotSizr tietts�'a Site:�W /� 'f�� a r.• ,Sa:.. I�cJ. `l�� G G n rS Q ,_('�w�fc G�... fCL.y�..�L-v nw Le'f-�- �,e�:�� 3�, ou,k C..o...�C-6.- te$ouse7FacilityCornzCS�lab+g.$ •N o�• 3 IftLe answec to any of the fopowing questions is"yez",supporting docnmenwuon�ust be attach�.�d. _ Are then nny e�cisting wastewatez sy9teetu on 1he site? UYi�CdPo AoesthesitecontainjurisiGc:iodalwetlaatls7 flY��s���� Are thcrc nny easenxnts or ri�;h�-of-ways on thn site? �Y�:s Ot�o . .tsshe aitasubject to opproral by anothacpublic ageacy? OY:s QNo�' Will wastewater o�+er than drmestic sewagc be genemcedT DY:�(�1�(0 I�RESID�NCE FII.L OUT THE BOX B�LOW t�People " #Bcdr�oms ��^,_, #Bathr�o ��Gardcn Tub/Whiripooi UYes �7No ., sasttnent�Yes UNo B:�scmentPlumbing: OYOs G1�Qo NON-�tESID�NCE FdLX.Oi.T THE BOX BELOW ype oTFacll'tylBasin.ess Total Squafe Footgge 9fBuilding,_,�,,,_�#People ,#Sinks #f Cotrustodes #t Showcrs #Ur(uals �sdmated Wata Usage(gaUons p�day) (Attach doc:umentation of similar facility watei cvnsumptionj FO�bSERY10E ONL�f: #Stats Typ�aystamYequested:t?Conventio�,al OAccepted.Olnnovativc ❑Ale;mativc I70th� Waler Supply'Cypa:t3�Councy/City V:accr �New Well CIE,:utuig VJeli 't:Community Well Do you anticipate sdditions or exp;�nt io�u of the facility this syatem is inw�ded to serveT Q Yes F�nvo If ycs,what typel Tiilsizm eettify dy�c the mfoiumtiun provided bn this applicalion is true at�d eor�ect to the bcst of my knawtedge. !undcnWnd chat asZy�scmit(s)o�.ATC(s)issucd herealter are subject to euspension or tcvo,:arioa if the�itc is alt�cd t6e intendcd use elwnges,or if the i�iCoSttation suhrtutted in dtis app ication ia falsified or ch�aged. !und�rsmnd rhai J am rrr�mnsihlejor'a11'charges ixcurretf jront rhis app(icntton. T hereby gr.mt right of entry to the Aut6oriz�d Ropr:sentetive of the Davie Caunty Health DcpatRnent to cotitluctattessan�aasyGctiont to Cekataine compliapce with appiicable la�vs and rules on the ahove described property locaud in Davic Coun�y nnci ovnted by�p,,�l�r¢. J'w���t.� ���A�"''�!� Site Revisit Charge Properry ownu's or owncr'S 1ega1 representative sigz+ature Date(s):_ �l -(-v� Cliau Nu6ficatioa Dato:____ Da�e ���. Signgiven pYcn�No �� ///��� AccouacN ' Rcvised?J06 ����� e��� r'����/ Invoicc iF ��,�/1��/J[� c� ', � ' � �ij 600/ZOO�j ,i�'It�K ��IR`�2td �[� 6L80 $66 9EE yYd 9Z�It f�i� 9QQZ/ZO/It __ _ __ _ _ ____ _ _ _ _ __ _ __ • �.��,. � �., ��� � .- �� � �.,�.�" • � , .� � � ":��� . ��.�. , . g� � � ��°,� *°' �'o�°� , e�' m b�y�: b gv;a. , � a a , w, „ ��' . y 5 1 ., , t.t n � a � �; � �4"� 1 � �,' "''� i �:t . . � � �u„ � � � � ' k �1 k, �..�9 • � ° ' "� i x w�� �= 3 .`r ' ^`..g P a r e �� II � .0 7 I d�. .` i� . � a- 9 ^ �f ae e:^ x �. L'4 . 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' ' '��. i , "�;�,. i � 39 �aan 7 � ���� ����� 234 ��� _ ��� � � � � � � � �� C� - � ........� 0 C3'� N -p► ....,,, t':�� C.�'1 IV � C.� C� ►v � �' c� -� � m N '' � � �� i � � � �., I � , O/�i ' 1 � ��` �"�� � M L.3�,'�.�sJu���'1��� �I . ' . V , � DAVIE COUNTY HEALTH DEPARTMENT � , ' Environmental Health Section � Soil/Site Evaluation APPLICANT INFORMATION � PROPERTY INFORMATION Account #: 990004039 Tax PIN/EH#: 5749-46-0450 Billed To: David Gordon c/o Rodney Bailey Subdivision Info: Reference Name: Location/Address: Oak Grove Church Road- 7028 t Proposed Facility: Residence Property Size: Date Evaluated: %% / � Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring_�„� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L_ Slo e% HORIZON I DEPTH �-- '7 p_ � - � -/cJ Texture rou S�t- LJ-- 5t_c_. L�- Consistence F/S� Fr S Structure c�._ �je� Mineralo � ��' HORIZON II DEPTH `D-3 i�-- " /�-Z Texture rou SG,� �t� 5,� Consistence ; � S Structure /< S �C i� S� � Mineralo „ HORIZON III DEPTH � -. �' �• - i_ Texture rou ��r,k SL ,r 5c�+�.n Consistence � S ; Fr S,� Structure � � �{ � �%�j1c Mineralo �1, ;, �c; HORIZON IV DEPTH Texture rou � Sc Consistence r-S Structure Mineralo �;�(,. SOIL WETNESS �- -- -- G�y RESTRICTIVE HORIZON Z� — -- ' y SAPROLITE -� - r CLASSIFICATION S S ) LONG-TERM ACCEPTANCE RATE O•" S p,^ .3J p� SITE CLASSIFICATION: �" EVALUATION BY:S�t� �a�l�Chl!�v�' LONG-TERM ACCEPTANCE RATE: D�� OTHER(S)PRESENT: REMARKS: LEGEND i, n c �e 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 Te�Ctulg 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 ANSIST .N . . �QiS� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3�'e� - 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 MineraloQv 1:1,2:1,Mixed lYQieB Horizon depth-In inches Depth of fill-In inches 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O) at�,, 170,� LT6r �w: �� 5�0 7,�� , :' : . � ; �, , t ____ �(374} °`��� ' � � ���� � ..ti. a 5a) � � � -_____._ ��... ._ � 4�,Oo).._�:�.Ga s)..r :. . (1 �)��� � _ �_. � S� ` - - _ _ _ ..._ �� SR 164 �•.—.. �SAIN R AD 179 � _�° �� �. �.. �� 146 , " � �.. _.:. . ,_. 150 476.18 '" ` �: 150 � (1.99A}' �: � ; o=� � ���, �� ' 7406 �w 9487 �y, � 6403' � '`� � ,., „ � = 1.40� 150 � � N! � � . � ,�. , ��� 73�'�' 196 � � e .-950� �er .� � N � j '� a _ . ��� � , ;: �. � , � z ,� � , 15.53A � � � � � ��,��� � � 2360 � . _ �- � „ :N h o4 i - � o N N �� j� ,� - � . �... .. - .�., ... �s.> 3 ' ..,, ' .� „ t .: " �i. �:� F"w«� .�rt�. Davie County Health Department E�zvironmental Healtli Section P.O: Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax (336)751-8786 Improvement Permit . David Gordon 228 NC Hwy 801 S Advance,NC 27006 Re: 1 Acre Tract/Oak Grove Church Road Tax PIN: 5749460450 Dear Client(s): This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. System To Serve:7'� '�=S��stewater Design Flow(GPD):��) Valid: �ears ❑No Expiration System Type: ❑Conventional �cepted ❑Innovative ❑Alternative OOther Site Modifications/Permit Conditions: Site Pla` �v �L'��� � � �� r 7 ,� � �� � � � �� � i� _� � �i.� � ! � � � --�� N �;, � � NC,��:� E- �! �� �� �' ,� �.� �- �� �1 � �--�,.�-r�,�:.��T 1 � - � _�, .. , �� � � � _, .__. ; --, z�t / �_���c�JL:- 4.� ' ' � �Z.. G ' on � n" 1 Spe �alist Date i.p.letter 7/06