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170 Plowman LnDAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street y� Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000674 Tax PIN/EH M 5862-14-9015 Billed To: John York Subdivision Info: Reference Name: John or Malinda York Location/Address: Plowman Lane -27006 Proposed Facility: Residence Property Size: 2.515 Acres ATC Number: 2118 **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 110l1S2 #People #Bedrooms " #Baths 2 Dishwasher: 0"- Garbage Disposal: ❑ Washing Machine: 0"- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size -46 Type Water Supply{G/ Design Wastewater Flow (GPD) _TG6 Site: New Repair ❑ System Specifications: Tank Sized GAL. Pump Tank GAL. Trench Width -?C/-' Rock Depth Linear Ft. IcOD 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)7.51-8760.**** ,cel A Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000674 Billed To: John York Reference Name: John or Malinda York Proposed Facility: Residence ATC Number: 2118 Tax PIN/EH #: 5862-14-9015 Subdivision Info: Location/Address: Plowman Lane -27006 Property Size: 2.515 Acres 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 WASTEWAAR CONSSTTRUCTION IS VALIID 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 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. KA // C� Environmental Health Specialist's Signature : /—/0 Date: � l 6 DCHD 05/99 (Revised) R ��U q R2 -- a'�PPUCATION FOR SITE EVALUATION/IMEM PROvFM PERMff & An O t5 11 Qwfi G `/ Davie County Health Department �1 Environmental Health Sec ion 4 � Z �!J P.O. Box 848/210 Hospital Street �(S� 999 Mockoville, NC 27028 6J ITv M6 � (336) 751-8760 Eti "A,1vJ � nTA HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed o11,1 e © r K• Contact Parson Ckris or MaJ1 ✓^dc,, Hailing Address 1'7() /np L ou ► m a ►) LaV1 ' d Home Phone 0 — W 0 GC` %�• �°2�J City/stat./ZIP _lyC�VC, h Cly N G o2 �10� Business Phone �1 C 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/state/Zip ❑ improvement Permit/ATC Goth 4. system to service: "ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People 4 # Bedrooms 3 6 Bathrooms eDishwasher ❑ Garbage Disposal W""Washing Machin 6''Bassmant/Plumbing G. If Business/Industry/Other: specify type 6' People # Commodes # showers # Urinals ❑ Basement/No Plumbing # sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City @Well ❑ Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑ Yes "0 If yes, what type? ***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: "2' 4C - e S Tax Office PIN: # 5� (n o1 - I'l - CIO I S Property Address: Road Name P (o W rnC'-n " n e' WRITE DIRECTIONS (from Mocksville) to PROPERTY: ISS 4%, P-eJla►j Pcl• Q or\ 'RledtCth( OOY\ �airbOu: (f) or Plow Kct, LcLhe- City/Zip _ mVa n a IVC, OLZ00i0 q raves( - proZt d� S �/ If in a Subdivision provide information, as follows: I f---e-1vi o o4ed . s Name: Section: Block: Lot: Date Property Flagged: r This Is to certify that the information provided is correct to the best of my knowledge. In lerstand 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 to conduct all testing procedures o�ceedures as necessary to determine the site suitability. nn 1 DATE r(-14 SIGNATURE cf►.d�� U) - 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). l� Revised DCHD (07/99) -kll & - /" - -� C Ya C) Date(s): Client Notification Date: EHS• C-e-� - �,/ r - �; / z 7 Account No. llJ Invoice No. �7 0 . • . ��i 61�' . s'!-«��i;:�� O ^ S�;L:�n�~ '�� 8' �^� iO 6v m � OnB2 This map is for PERC TEST and BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office assumes no liability for any information contained on this map 0 � MrC2 COUNTY-ID:D80000008408 July 13,199912:12 PM n o� Parcel Identificetion Number 5862-14-9015 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000674 Billed To: John York Reference Name: John or Malinda York Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5862-14-9015 Subdivision Info: Location/Address: Plowman Lane -270066 Property Size: 2.515 Acres Date Evaluated: 7`,1211W t/ Community Evaluation By: Auger Boring !Z — Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % el 61 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �' Texture group Consistence Structure i/fJ 6/ Mineralogy , C 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: / ;1 141_ 9e LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 - 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 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 05/99 (Revised) ■ i ■ ■ ONES ■■■■ SEEN mono ■■N■ NOME NONE NOME OMEN ■■■■M■ M■NNE■ ■MEM■■ ■E■E■■ ■EMNON MESSES ■MEMS■ ■E■NE■ ■■■■E■ ■■■■E■ MEMO mono OMEN mono SEEM ■■N■ ■N■■ OMEN NOME ■■■■ MEMO MEMO ■■N■ OMEN ■■■■ ■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■Moe■■■■■■■■ CEJ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■ SEEN ■■■■■■MM■M■■E■■ ■■E■E■■■■E■■■■■E■NEE■ ■■■■■■■■■■E■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ no 4 ,. s`=/a - � Y"