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179 Persimmon Grove Ln (2) « � � i _-, � � . , DAVIE COUNTY HEALTH DEPARTMENT P ( • - "� Environmental Health Section + �� �p P.O.Boa 848/210 Hospital Street • �� Mocksville,NC 27028 . (336)751-87G0,. � Account #: 990003720 � Tax PIN/EH#: 5727-59-7580 DH Billed To: Deborah Hendrix Subdivision Info: ��� � ReferenceName: � Location/Address: ��7�� ��Q.S�i!�2�Lll�it!(�cuU�' � Proposed Facility Residence Property Size: 10.36 acres ATC Number: 4192 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 CONSTR CTION IS VALID FOR A PERIOD OF FIVE YEARS. / Environmental Health Specialist's Signature: Date:���'�� o� I��RF�i-� � t3��2Do CERTIITCATE OF COMPLETION **NOTE** T'he 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. �ter 130A,Section .1900"Sewage Treatment and Disposal Systems,"but shall i O WAY be take �s a tee that the system will function satisfactorily for any given period of time. 0 � � fb liSi �bTC� � �' Septic System Installed By: ��'�/I�C� (� Environmental Health Specialist's Signature: �i� Date: ������� DCHD OS/99(Revised) 1 . : ` DAVIE COUNTY HEALTH DEPARTMENT ' � '� Environmental Health Section ` ` P.O.Boz 848/210 Hospital Street � � Mocksville,NC 27028 � (336)7S]-87C►0 !� IMPROVEMENT/OPERATION PERMIT Account #: 990003720 Tax PIN/EH#: 5727-59-7580 DH Billed To: Deborah Hendrix Subdivision Info: Reference Name: Location/Address: 555 Greenhill Road-27028 Proposed Facility Residence Property Size: 10.36 acres ATC Number: 4192 **NOTE**T'his Improvement/Operation Permit DOES NOT authorize the construction ofa 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� Dishwasher: � Garbage Disposal: ❑ Washing Machine:f� Basement w/Plumbing� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � � Type Water Supply��_ Design Wastewater Flow(GPD)���� Site: New❑ Repair❑ System Specifications: Tank Sizei��`�`�' AL. Pump Tank GAL. Trench Width��{Zock Depth�z/Linear Ft�< Other: .5�te� ;,, ��A NCAC 18A;1969(5) accepted Systems maY a �e Required Site Modifications/Conditions: IMPROVEMENT/OPERATION 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(33(►)751-87G0.**** � ' �,�/�� �.�C �� �� �� / �ls � ��- � � Environmental Health Specialist's Signature: Date:��, '��'� DCHD OS/99(Revised) � r ""e"' . � . , � � , p � � � � � � , � A � ' ` APPLICEITIUN FOR SITC CVALUATION/IhiP[iOVChiCNT P - �i A�'1�(� � � .---� , Davie County Health Department Y'' ��� • Environmental Healt/�Section P.O. Box 848/210 Hospital Streo �;;,,�,�x��;j7t��•-;�r� Mocksville, NC 27028 �':::�t�U;ti� � (336)751-8760 ***IISPORTANT*** TIiIS APPLICATION CANNOT BE PROCESSED UNI,ESS ALL TFiE RLQUIRED INFOItbS1�TI0N IS PROVIDLD. Refer to the INFOR2dATI0N BULLETIN for inatructiona. 1. Namo to ba IIilled ��UC�rGti/� � / C�L[/�/./�. Contact Peroon �(J�fJtlrGt/L yL/��f//1 Mailinc� Addresn ��� p 0�/Cli G�(ii)(�U(� V� . Ifoma Phone 4���'" /(�(p' /1�'� Ci ty/3tato/ZIP ��C- ���'b��_N(� � /��r� Dusino�u Phono ��IG�' /�c�n' ��'7S 2. Name on Permit/ATC if Difforent than Abovo S/°}!h � Mailing Addroas S/�;1'�.L (,t..� ;(j/j�9��� City/State/zip 3. Application For: I� 5ite �valuation C�"Improvement Permit/ATC � IIoth 4. System co sarvico: � Fiouao � Mobile Home ❑ DuBiness ❑ Induatry ❑ Other 5. Typa nyatom requoutod: L41 Convantional ❑ conventional modified ❑ innovaL•ivo pacCepted 6. IE ita�idenca: tF People �_ # IIedrooms _� 1F Bathrooms � L1J3Tinhwashar LY�arbaga Dinposal LtWashing Machino �ment/P1unJ�ing ❑Dartement/No Plumbing 7. If Duuinesa/Znduutry /Othor: verify type ��A # Peoplo � Sinku � Commodoa � Showora ?f Urinals If WaL•or Coolora IF FOODSERVICE: �� Seata 1� EsCimated Water UAaga (gallons per day) 8. Typo oE wator aupply: L�]" County/Ci.ty � Well � Comtttunity 9. no you anticipato addition� or expansions of thc facility this systcm is intcndca to scrvc? �1'cs �— If��cs,titi�tiat typc? ***I�IIPORTANT'�**CLII'sIYTS d1UST COAIPLETL•TII� RL•QUlRED PROPCRTY 1NrOR11�1AT10N lZLQULSTCsD [3I;I,01Y. Cithcr a PI.AT or SITG PLAN hfU.ST BE SU/111flTTED bv tlu clicnt witl�'1'I I1S AI'PLICATION. I'roperly Ditncusious: '�< <� � ��;�F� lVRITG DIRGCTIONS(frum A-luci<svil(c)to I'KOI'1;K7'1': �r.�a orr,��i�1N: �E�7� 7� 5 y_ 7��5� ___.._ s s s � �/ /�� Property Address: Road Nan�c rrCh i City/Zip �''�D� I�S ��� �c N�C �a`7 v�d If in a Subditi�ision providc inforn�ation,as folloSvs: N�II1C. NO Scclion: �Y _ I3locic: _N l� Lot: �� Datc t�omc corncrs IIaggcd: �'..��" C`�.S Tl�is is to ccrtify tl�at tlie iuforniatiou providcd is corrcct to tlic best of my�I:noivledgc. I undcrstaud iliat any permil(s) issucd hcrcaftcr are subjcct to suspcnsiou or revocation,if tl�c sitc plans or iutcndcd usc c1�ingc,or if lLc inforivation S�li►��;cc�a„� u�;s�nn���ac;�»;s ralsiGcd or clianged. I,also, ruidcrslrriirl!/�at I am res��onsiLlc fnr n!(clirrrgcs incnrrcrl jronr tlris applicntion. I,Iicrcby�,givc conscnt to tlic Autl�orizcd Rcpresentati��c of tt�c Da��ic County IIcallli llcparhncnt to cntcr upon abovc dcscribcd pc•operty Iocatcd ii�Davic County a►id otivticd by to conduct all icsting proccdures as ncccssary to dcicrmiuc tlic sitc su' ility. DA'I'� �- <��J ' ('_� SIGNA'I'UI2L .G�l'co'�Gzr6l ;��tG�' • .�r, ' TIIIS AIZ�A A7AY B�US�D rOR DRAWIh`G YOUR SI FL�' ul dc all of tLc follotivii�g: Lxistiug and proposcd property lii�cs and dimcnsions, structures, sctbacks, and sep-t�ic l-o-c�at_io ` � ��l'� �7 . Sitc Rcvisit Cliargc ��'. �+ Datc(s): .� ��J � ,_.._, Clicnt NotiCcatioii Datc: �� �IIS: .��� �� �� Sign givcn t1�j �)� •. - Accout�t No. �� .� ry Reviscd DCIiD(05/03 Livoicc No. ���!J � � R I... .... . . . , ' / I , / / LESLIE E C. LAKEY / � & PHOE �_BE F. LAKEY � �B ' ��. p� 271 / JAMES RAYFORCARTNER P�N� 5728503492 / � DB 157, PC36 PIN: 57286+43 � / I ' / I ———— -- —. S88'50'01"E S88'50'00"Ei 1.25"EIP ' � EIR 387.59' 1-1/4" PIPE 612.56' l � � � �� 1 � v NOW OR Fl f ;RMERLY � ,�r WILLIAl�A H. JOYNER w o 1 & PEGGY A. , JOYNER �, .�1 � OB 78, I' �G 333 � tD P/0 PIN: 57 �27597580 �" � . 3 1 � � (DB 77, PG 271) ,n LAKEY � N � RD. (EASEMEN'f) o � EIR S88'52'S6"E ASEMENT �"'�--_ \ 86.03' EIR N � TRACT "B" 10.36 AC.f � . I . ' - a I � . p �, . I 10 � . . � � � � ' . I O 17 � x � . � I I I. � I "TIE L1NE" S88'08'55"W EIR ! N89'27'12"W 235.10' S86'OS'55"W P L10 P "NEW LOT LINE" 641.25' 36"E �� �71�'-;'_'.._-,—.--- EIR 131.31� � � � ��F . - - - -_ P I I �_ �P FROM : PHOIJE N0. : Oct. 17 1997 05:23AM P1 � r ` � !11'!'UC�1'fIUN 1'Ult Slil I:YAUTA]'ION/tAll'lIUV[:AIEN71'Ltllit7&�1TC , Davie County Health Department � Ei�viromuenta/Healt/�Section P.O. Box 040/210 Hospital Straot . Mocksville, NC 27020 . � (336)75I-8760 ' rrirplPOR1'AN1'** 1'tiYS A1�1�LICATZ027 ClWNOT D�i PIi0ClS8ED UNLESS A� TIt� R�QIIIR�D ZNFOItIl11TZON ZS PROViD�D. Rcf¢r Co L•he INFORMATION BULLETIN fo= inatructionn. 3. Naose W Do D112ad ,��`�(�%���/� � �`��C�P/X COntxt Ycroon dJ��D�GC/� //f/�l�jX �7 ,y �' ' 3 / �d�� . Ma11lo�Addro�a /_S�_A. � �CCiG�GIi[.'[�� �� _ ttoma Yl:ona;����.�U�' 7 C11;y/9CqEo/ZSP Ll�(.V I.S i1��/C� %V 1.� .X 7�1� Duslnnna Vlwnp i�'����.n'.J� � 2. Ncse OA POif�l.t/J�7C SE DSLEaten[ t6aa ADOVo 5 H-'�t � Ra111uQ�Mldroos %l,m< (t.,s //hc��`[� CitylBtats/Zlp . ]. Epplication Forc L�7 Sitc Evaluation L�ZmDrovement PenuiL•/7�rC ❑ Doth �. sy,tcm to Snrvice� �l'J Ilouno ❑ t2obilc Iiomn Q Jivaiaeon O xndunl•ry ❑ other S. �'pe oyateo i�qYODle�: 1!�Convantlon� ❑ convontianal mo�lticd ❑ lm�owtivo pac�epted 6. Tf itnnidenea: 1 Peoplo �' 1 Dadzaoma y,�� A IIaL'hzoome � 1tlAiuhvashot LJOarYags Dlepoaal b�7.tft�ing Machine aaomont/Plunyiag ❑Uaaomoat/Ilo F1uM>!ng r 7. Z! Auelnoae/Induncry /Otbort vcrlty tyya p ��A p Peo la Y 31nka / Cornno0eo 0 �1�ovorn O,urinals 9 xacoe Coolore ' XF POODwERVYCE: !! �eatn N/� Eal'1aWL'nQ HaGCi Usago (poliona per ttay) �µ1'ype.od_wator_supply_�_,LTi�,County/City.. . ....._,__._�...-.II..14ci1 .._,_ . . D CouuuunfCy � - 9. Do yau anG.lclpato addltlons or cxpaiuia�s af tLc[acilily tl�is syslem is inlcuJcJ t�scr�•c?U 1 a C7No I[ycs,n•Lat typc?. **"l�T,fN01C7�ilNT'r"'�CL1CN7'SAfUJTCOA!!'LG7C711L•' RCQU/HCD PAOPL�RTY INI�OitMA'fION IiliQUt:STtCll DI:LOt\', rttt�cra�'/,ATarSITFP4AfVAlU.STUESURAl77'YEDbvthccllcnt iri(hTUISAI'PI,ICA7101V. ' Propertr Dimcnsions: 'O�.� �� C t.•r� �ViZIYC DIRCCf10nS{G•wu Alvticsvillc)l0 1'Ji01'Bll'i'1': �:orr,c�t�trr: te�-P�D Ol'n - z 7 7S/�'�S�'C� Property AJdt'css: Rond I�fame C��'f'/7 i l� ��. qty2ip )''1 D�!1S�;11 E• NC, '�o�d . If7n a SuLdi�'lslou p�pviJO jnCormaUott�us Iolloirs: Namc: NO Scction:�✓1,,,, IIlocic:,�� Lot:_p��, Datc Lonu coriscra(loggcd: O'..s��'(7.S Z7�is Is ln ccr(ifj�lGat tl,c inlvrmallou��rovidcd is eorrccl lo tl�c bcst of u�p laiotirlcdgc. I uuQcrsts�ud fiud any permil(s) issucd liercaRer arc subJeet to'aicspcusio3l or rcvacatiuu,IflLe site plans or infcndcd usc chauge,w•i!lLe hiformnliun suLuullcJ in ll�u applicaliun islalsificd or dtaugal. !,alsu,urulcrshuid t/+af I an�tesparsiblajur all cLurgcs lncrrrrc�l jrua� �f��pnn���n�fo�r. I,lurcby,�givc cousaU lo Uic Autborizcd Itcprescutstivc of thC Daric Couuty]Ica11L llcparluicut lo cr�(cr upun aLorc Jcscribcd properly locafcd!n Davfc Counly au�oirncd Ly Io eondu�l aU tcsting proceclurcT as uccr.ss•rry(o JcfcniJiic thc silc s �Iily. DATC �-v�`l'd S� S1GNA7'UI�1: �.�2�) rft ..C�tG Tl!!5 AREA AiAy B�r/SGA TOIi DIUIWINC YOUR SiTt PLAN(Includc all uf iLc follon•in�: �isisliu&�ud�iropusc0 properly Jij�es and diuuasimu, strucWres, sclbacks, and septie locu(Ious). " --�--- .�.. _ Si(c ltcviai�Cl�argc i � • An(c(s): �' BUCK HALL,RS i Clicut NoltTicaUott Dalc: EnvirWimental He8/th Specia/is! �.I$. ' P.O.Box 8�8.210 Nospitai Street i ' • . Moclavipe,Nprth C�na 27028 � Telephona:(336)�51-e�Bo I • ' Accouut No. fAx:(33�751-8T66 : ♦ amal:robart.l�an@co.davfe.nc.us ; � It1v4ICC Nu. , � ,� . ' ' � , • DAVIE COUNTY HEALTH DEPARTMENT . . .� � • Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003720 Tax PIN/EH#: 5727-59-7580 DH Billed To: Deborah Hendrix Subdivision Info: Reference Name: Location/Address: 555 Greenhill Roa 7028 �. Proposed Facility: Residence Property Size: 10.36 acres 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 sition Slope % HORIZON I DEPTH ce �c �/ Texture rou L Consistence � tr- � Structure r � Mineralo � HORIZON II DEPTH �'' �� �T Texture rou �'i Consistence Structure /-, /L 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 RAT SITE CLASSIFICATION: � � � � �� ' ��EVALUATION BY: '' _ LONG-TERM ACCEPTANCE RATE: " ��' � OTHER(S)PRESENT: REMARKS: LEGEND i.�ndccape Pocition R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 .ON4I�T�.N . . 1�Q1S� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plas[ic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed lY4�s 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 OS/OS(Revised) ■�■�■■��■�■■■��■��■■■�■■�■��■��■�■��■\�■����■■��������■■�■�������■ ■■■■■■�■■■■����■■�■��■�■■�■�■■�■ ■■�■�■���■■�������■■■■�■�■�■���■ ■����■��■���■■■�■��■�■■�■����■■■����■���■��■■■�■����■■��■�■�■�■�■ 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