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443 Ralph Ratledge Rd � � DAVIE COUNTY HEALTH DEPARTMENT ' -`� � ' Environmental Health Section ._ .- P.O.Boa 848/210 Hospital Street �� - " Mocksville,NC 27028 (336)751-8760 2— 3 r � 3 IMPROVEMENT/OPERATION PERMIT Account #: 990002558 Tax PIN/EH#: 5810-48-7155 Billed To: John Gobble Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 3348 **NOTE** This ImprovemendOperation 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 � #People� #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 ��I C' Type Water Supply �/1/'l// Design Wastewater Flow(GPD) '�� Site: Nevwa� Repair❑ �� System Specifications: Tank Size/�1XiAL. Pump Tank GAL. Trench Width��Rock Depth� Linear F�� Other: Required Site Modifications/Conditions: I1�'(PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 830 a.m.to 9:30 a.m.or 1:00 p.�.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.**** "� G�'S �i9/t �p �y6'� S �� s�oss��.��- A�r� ��6' � � � � f r ' n _l (J�C Environmental Health Specialist's Signature: Date: �.��,� � DCHD OS/99(Revised) � < o � • ' n� ' DAVIE COUNTY HEALTH DEPARTMENT / • Environmental Health Section P.O.Bog 848/210 Hospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990002558 Tax PIN/EH#: 5810-48-7155 Billed To: John Gobble Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 3348 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �/�/� Date: I��G� 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. d. /�� 60 %��o� � .��ie � Septic System Installed By: L° t/ Environmental Health Specialist's Signature: ��/ Date: �l `� _ DCHD OS/99(Revised) � . � � ��. . . . � . : .. . . . � . . . � . r' v .- • ? .i � . . .. - . �,-,....�.t -..�.. .� . . .. r . __.: .._..._.- _- . � APPI�CA710N FOR SITE EVALUATION/IMPROVEMENT PERMIT& � LS �jG� � � U � '�� Davie County Health Department � (/ ' Environmenia/Hea/th Section n , P.O. Box 848/210 Hospital Street UEC � O 2�:�'�� Mocksville, NC 27028 (336)751-8760 ENVI�O;�,!'��niT�t HEACTH D�,i`Ik C:�LiNTY ***II�ORTANT*** THIS APPI.ICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORt�TION IS PROVIDED. Refer to the INFORI�iTION BULLETIN for instructions. 1. Name to be Billed .�1G��1.�1/ ��`` �a6�j/•.(i Contact Person �7_�,�1� ��j�jl-�L� Mailing Address `�� K3�i(l�+L�Q��-�[dP t M ,• Home Phone ��?i {S �(O Z City/State/2IP /!/`i �. /�-7Q�g Business Phone � 2. Name on Permit/ATC ig Different than Above i�3 Mailing Address 1 CitY/State/Zip � 1,,� p �IC� '' a 3. Application For:'�te Evaluation ❑ Improvement Perma.t/ATC Bot� 4. system to service: �..House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People �, # Bedrooms _� � Bathrooms � �d�Dish�rasher ❑ Garbage Disposal �Washinq Machine �$asement/Plumbing 17 Basement/No Plumbing : 6. If Business/Industsy/Other: Specify type � People # Siaks # Commodes # Showers � Urinals � Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �galions per day) 7. �pe of water supply: ❑ County/City �D Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ,,�(No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wit6 THIS APPLICATION. Property Dimensions: � /7G'/1.`� WRITE DIRECTIONS(from Mocksviile)to PROPERTY: !` �j ._ / �L Tax Office PI1�1: # � ��Q 7 � / �� !9 7 L,IJ �o s�i.cc•�.•�.�� .� Property Address: Road Name I'��/ '�Q� 7�v ��fj�,, ��,�/�,,Q/�� City/Zip Dc�svi`�� .L� --C°9-O � �t��.-�- dr(. ��`l�'7� lf in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Flagged: �2- - �✓G - a�� T6is is to certify that the information provided is correct to the best of my knowledge. I understaad that any permit(s) issued hereafter are subject to suspension orrevocation,if the site plans or intended use chunge,or if thc information • submitted in this application is falsified or changed I,also,undetstand tlrat I anr resportsible for all c/rnrges inci�rred fruni t/tis application. I,hereby,givc consent to the Authorized Representative of thc Davie County Healtl�Dcpartment . 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 ! �— 3 G ' � Z— SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLA1�1(Iaclude all of the following: ExiSting and proposed property lines and dimensions, structures, setbacks, and septic locations). ; � . Site Revisit Charge Date(s): Client Notification Date: EHS: Account l�to. �� Revised DCHD(07/99) Invoice No. �� S �/ � t� �,.�y3��r�``�rMH� dt.:'' ' , � � fl + r � ��.v„�s � � +' � >. . .c.• � ° - �� f::�pi9i a " a.'>T } N $* m � § P �� V I - ,' F 396 :_---.------ ��« rc: �.�� , �: y o- 43 za� . � 4 3�5 ��`� ��. �� L� . �. � X1 /�� O,�aS t.( }0g��$ 4k� .. . t'_J - _ � n..-' �. �:. r. :s ro V A � � � O n � � Y • . Zd t +-', r�< t� � ✓�.4 - 'i � � �� J.36'A� e �-.3(t _ �::a N _________ �s �� 0 71`J`J� :i�` _ r �rc,�h�" ' . <. 2�' 107221 'S� `�6' s ^ � � 5 345 S °p e"� e.....:. � � N � �A' 20 63A � j 4601 @ � � � �� , —„ ? �A �. .�.. f. .. _. ^�i1 `�i" . .., .. . . ,._ . .. ... �. � � _ � ' . .. � . . j � �''.. ; ; " � V ' '� r � m i r ^ p 1 / I / v 1 i �:_.. 1�.:. �� , . . 102729 � �. s v' . DAVIE COUNTY HEALTH DEPART'MENT Environmentai Health Section " Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002558 Tax PIN/EH#: 5810-48-7155 Billed To: John Gobble Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 Proposed Facility: Residence Property Size` 2 acres Date Evaluated: l—/� �� ,; Water Supply: On-Site Well Community Public ° Evaluation By: Auger Boring Pit Cut i FACTORS 1 2 3 4 5 6 7 Landsca e osition �. Slo e% HORIZON I DEPTH �. d Texture rou eG. Consistence Structure Mineralo HORIZON II DEPTH �� Texture rou G Consistence - Structure .� Mineralo ' ` ' HORIZON III DEPTH Texture rou Consistence Str�cture Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ,. , � i SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: 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 Mois _ 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineraloev 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-gaUday/ft2 DC�ID OS/99(Revised)