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648 Pineville Rde Account M 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 IMPROVEMENT/OPERATION PERMIT /V7-- 11 989900645 Tax PIN/EH #: 5843-17-6645 Jay & Paulette Hutchens Subdivision Info: Paulette Hutchens Location/Address: Pineville Road -27028 Residence Property Size: 220 X 220 ATC Number: 2095 **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 Jy #People #Bedrooms ',�— #Baths ,— Dishwasher: e Garbage Disposal: ❑ Washing Machine: 12' Basement w/Piumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 1771Lot Size f Type Water Supply �/'Design Wastewater Flow (GPD) (L Site: New Zi Repair System Specifications: Tank Size�� GAL. Pump Tank Other: Required Site Modifications/Conditions: I GAL. Trench Width Rock Depth /9 Linear FtStV IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED FINISHED GRADE. ****NOTICE: Contact a representative of the D; system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1: m. on the d, cq�o& Xf,4,,ec e !'err P O -e C FILTER. RISER(S) IF 6 " BELOW -alth Department for final inspection of this peo"Felephone # is (336)751-8760.**** 6Lia" Llxl�kA 00 Environmental Health Specialist's Signature: &XjDate: ?�%-A DCHD 05/99 (Revised) . I - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900645 Billed To: Jay & Paulette Hutchens Reference Name: Paulette Hutchens Proposed Facility: Residence ATC Number: 2095 Tax PIN/EH #: 5843-17-6645 Subdivision Info: Location/Address: Pineville Road -27028 Property Size: 220 X 220 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 WASTE WATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 2/2/ t 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. 1.0 Septic System Installed By: Environmental Health Specialist's Signature :// Date: f DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Deparlanent " Envltnnmental Health Section' $ i9 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 j7 (336)751-8760 ***ndPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed .J (, ko I'd I - ^e ffP 1 i �-lA� AW S Contact Perste �q l j) � /�� Q / �' Bailing Address c � ar'l� r- U . Home Phone City/State/ZIP &DNvi I i of N C, Business Phone 33 cr 7c2 s. Name on Permit/ATC if Different than Bailing Address JAM E City/State/Zip 3. Application For: U Site Evaluation ❑ Improvement Permit/ATC �Bo*r: 4. Syet= to sir; ,ce: S,/Nouse u Mobile Home ❑ Business ❑ Industry ❑ Other 8. IfResidence: # People # Bedrooms # Bathrooms ID @'D/ishwasher O Garbage Disposal R AaahinlA,�'gMachine ifm Baseent/Plumbing ( em agent/No Plumbing IU 6. If Business/Industry/Other: Specify type 'A # Commodes # Showers # Urinals # People # Sinks # Nater Coolers N (p' IF FOODSEEM CB: T Seats -/ Estimated !Pater Usage (gallons per day) I7. Type of crater supply: l3 County/City VW611 ❑ Coamunity 9. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes 1A0 If yes, what type'. N ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Can X �( ) Tax Office PIN: # L:849)- e f "ffa ' � Property Add Roa Name Ncyi lleM City/Zip 1► l OC14SV i d le, c% A If in a Subdivision provide information, as follows: Name: Section: Block: Lot: VVRITE DIRECTIONS (from MockrAlle) to PROP"Z?R!71' 1 co E "�o VQrmi N��(�YV (',rQSS��S �O�r rn i N' iNeVi 11e ON 1+,� r IN o-1 ock-ed Qoo �ClSi" -Ehe Horse Arc—'Jo— C r l r ' Date Property Flagged: C'a /•b M �`-r• '/`' This is to certify that the information provided is correct to the best of my knowledge. I understand that any pe 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 fro this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departmer! to cuter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE /� �Z ?l — /' . c�rnre�rnp� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all kN the following: Existing and proposed property lines an dimensions, stru setbacks, and se tic locations). you i f V LE -T ME r-1VO � CTM��) I /fin FeNeed- � 7 I i co I 0-, e. � is a- l I o� paced-iAJ DCHD (07/98)!P° -�Owyd — r� SZ'' T,��, I -E rz LOhfM you w LcoLed a-Ee- L -14-h "Jo a l�►U' �.' 0- N. ;Ne\J1 lle dol � Account No. SC Invoice No. / To=a,,��w�� 12d 7 DAVIT: COUNTY HEAL'T'H DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900645 Tax PIN/EH #: 5843-17-6645 Billed To: Jay & Paulette Hutchens Subdivision Info: Reference Name: Paulette Hutchens Location/Address: Pineville Road -27028 Proposed Facility: Residence Property Size: 220 X 220 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 L 1— .Slo e % Slope HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group C Consistence r Structure IC e Mineralogy J, / 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: 1J -Y EVALUATION BY: LONG-TERM ACCEPTANCE RATE: / OTHER(S) PRESENT: REMARKS: antU �(%�✓ 4k2 -71j l ^\j LEG ND 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 - 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 Mineraloav 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 I)CHI) (Revised 05/99) ■■ i ■ ■E■■ MONO ■O■■ ■■N■ ■■N■ ■■E■ NONE ■■E■ ■■E■ ■ i ■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■m■ moommommm ■■■■■■■a■ ■■■■■EON■ ■■■■SINN■■ NEMRNEENE ■■■■■■■■■ ■■■■■■■■■ ■■■N■■■■■ ■■■■m■■■■ ■■■■■■■■■ ■mono■■■■ ■■■u■■■m■ ammommomm ■■■■N■ ■N■■■■ ■O■■■■ ■■■■■■ ■■■■■■ ■■■■E■ ■■■■■■ ■E■NO■I ■N■■■■ ■■■moll ■■■■ESI ■■■■■■, ■■Nu■ ■■■ ■ MONS■■ ■■Edm■ ■■1l/■■ ■ENNE■ ■■E■E■I ■■E■E1I ■■NSON ■■■■■11 ■mm■■II ■OSENL7 ■/NNE■ ■Om■■■ ■E■EE■ ■■■m■■ ■■E■■■ ■■■■■■ ■■N■E■ ■ENE■■ ■■Nm■■ No on ME ■■ No ■m■mm u■ ■■■■mmm ■■ FAME ■■ ■E■ :mo■■■■ ■■■mm"■ ■■■EEE. ■■■.■■■■■■i ■■■■►■■■■■i ■■■■■ommo■ ■■■EON►■■■. ■■■■■■■omm ■■■■ommomal ■■■■■■■■WW ■E■■■N■ ■■E■■E■ ■um■■■ ■ MONO NEEM■■■ MONSOON ■■■moo■ ■■MEN■■ ■■■■EN■ ■■■■■■■ ■HN■■■ o■n ONE ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ i ■m■■m■mm■■■m■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■