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269 Ratledge Rd . , • � . _ . �r`--"- . • . - - DAVIE COUNTY HEALTH DEPARTMENT ' ' -� Environmental Health Section . . .. ,';� � r.o.Bog sasnio x�p�r�i st��t Mocksville,NC 27028 (336)751-8760 Account #: 990002406 Tax PIN/EH#: 5727-30-3260 Billed To: David McCullar Subdivision Info: Reference Name: Location/Address: Ratledge Road-27028 Pro osed Facilit : Residence Pro e Size: see ma ATC Number: 3249 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWA CONSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� Date: �`' � �—�Z CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate o�Sifin�s indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of G. . apter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in W as a gu tee that the system will function satisfactorily for any given period of time. f , ������ ���� � s� �� � � . � ��rs ��<� ���'�` Septic System Installed By: � N- � �"� "` � >1 </ � Environmental Health Specialist's Signature: �; Date: ! � DCHD OS/99(Revised) . ' '`- � DAVIE COUNTY HEALTH DEPARTMENT . • ��- ' - - Environmental Health Section _ . � , � . P.O.Boa 848/210 Hospital Street ��// p �/v Mocksville,NC 27028 �--' ±��""'--� (336)7S]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002406 Tax PIN/EH#: 5727-30-3260 Billed To: David McCullar Subdivision Info: Reference Name: Location/Address: Ratledge Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3249 **NOTE** Th�s Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT 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 C Type Water Supply //t�e// Design Wastewater Flow(GPD) 3Gd Site: New IGI Repair❑ System Specifications: Tank Size%0� GAL. Pump Tank GAL. Trench Width� Rock Depth /.� /Linear Ft.�� Other: p� '��/,�� �4G��� �,,r Required Site Modifications/Conditions: INIPROVEh9ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW FINISt1ED GRADE. ****NOTICE: Cot esentative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.0 1:0 to 1: m.on the day of installation. Telephone#is(33G)751-87G0.**** /���� �/r �G�� ���e f,✓-A�� o'�� ������ T Environmental Health Specialist's Signature: Date: �—.�2?�'`� " DCHD OS/99(Revised) . . . � . � . � .:R , . � r - � C� C� � OM � , : _,�•K ` APPLICATIQN FOR SITE EVALUATIUN/IMI'ROVEMENi PERR9iT&�TC � ,� . .,�,,� Davie County Health Department - AUG - 9 2���_ Environinenfa/Hea/th Section � . � P.O. Box 848/210 Hospital Street ENVIRO�N�EfdTAL HE��TH - Mocksville, NC 27028 DAVIE COL1R?Y ' (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROGESSED UNLESS ALL THE REQUIRED , INFORI�TION IS PROVIDED. Refer to the INFO�TION BULLETIN for instructions. � L Cu���f 1. Name to be Billed ��J��/� �J1 ('� C, C l� I I �Ar Contact Person IJ AV�V f' C�n� M ���Ag �ess � t�a Cr�s �en t' Dr. �ome Phone 33�- �I��� �3 �3 City/State/zIP /•I�L r\S�I;ll e , ��. r„-1�1�c�g Business Phone 33 6 �3���;7 �3 l C1�dN, 2. Name on Permit/ATC i£ Different than Above �G�f • Mailing Address �(�w� ( , City/State/Zip 3. Application For: l�!'Site Evaluation ❑ Improvement Permi�/ATC ❑ Both / � a. system to sezvice: 0'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People ��"_ � Bedrooms 3 # Bathrooms �_ F� Dish�rasher L9'Garbaqe Disposal �Washing Machine �Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks �k commodes # Showers # Urinals # Water Coolers � IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. �pe of water supply: ❑ County/City CI Well ❑ Community a. Do you anticipate additions or eapansions of the facility this system is intended to scrvc? ❑Yes �No If yes,what type? ***IMPORTAN711r**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMA'TION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the client with THIS APPLICATION. a 4 Property Dimensions: 3 v�•gU,x 51,• a� ' WRIT�DIRECT'IONS(from Mocksville)to PROPERTY: Tax Oftice PI1�1: # �� � �`J d r J 2 �� 1 j Property Address: Road�N(a c� �t �2�1 ��. (�-� W11 l t �0 R ��t c�ty�z�p Mo�Ysv�I�e / ����� Rd . T�,r� R►til•fi . Pc��r��., i 5 lf in a Subdivision providc information,as follows: � � I f t I t . 1+�C —� Name: �� � ��.,.��,���,t'1 � Section: Block: Lot: Date Property Flagged: �_�To�.�f D�� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended us:.change,or if the information submitted in this application is falsified or changed. I,a/so,understand tl:at I am responsible for all cl:arges incurred from lhis application. I,hereby,give consent to the Authorized Representative of the Davie County Hcalth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determinc the site suitabili . DATE C�� � �lo�D� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: �xisting und proposed property ling�,and dimensions, structures, setbacks, and septic locations). �� _ Site Revisit Charge Ca~�"�- �`r Datc(s): � �2a-- � S��� �- �r Clie�nt Notification Date: ��r�'�.,� �-��.e_._/y -1� �,�j 3-/�z-- /� EHS• �,..� �(,_ — /�n�c/�+r�( � l � U� ' �� D�„� � �"���`,� Accoant No. 7 � Revised DCHD(07/99) � � �-u� V J]--� Invoice No. �' �� � � -t� . ' ' I �pHELL gD , � C• A• PILCHER � HAROLD P. CAMPBELL I SHA.RRI�b4.Ap�� 71 LE� �1 Q'� � D.B. 81, PC. 499 I D.B. 145, PC. 8 5 7 � � � �� �, , I _ _ I � L ` v. . � ��ev:.���� . . S 85'U'33' S 85•41'33' E —a �- ��,` . E —� ''`" 186.20 S BS'e2'S7• E � ����% 189.82 , (ilE) � . ... .,�.. 113.68 .�,.!ia: JERRY L. SHORE �;� � D.B. 105, PC. 571 .., N -. N ui o N N 0 N � `�° f VI( 'IIVITY MAP :T� � , , 52� - - - - - - - - - - - w �� ,��. � �m JOHN lY. GREEN � , . p N n D.B. PC. 180 _ 1e"' �5e, �� AREA— 4. 00� AC. ,,��NCARO'', . � ;��,, o .......o���,i, Z INCLUf1FS S.R 1142 R/W � �',r' FESSI : ;�':2C* 9��:"Y � SEAL ' L-2527 ' Q-�`�: -. �;.�y �,o• O � �, =9���^sua� ::c` N � '� Y C. TU� :� �;� LINDA C. SHORE y D.B. 140, PC. 70> � I. GRADY L. TUiTERaM, CERTIF7 1Hni UHGEF' MY OIRECTION AND '>UPERVISION, TH�°. Ma� VA$ DRAWN FROM AN ACTU �IELL �i�F�[� MADE BY f�,�\J,1TTERO SURVEYI G CO PaNr. _ _ _. ..._1`-'_[V _ "_ � - __. _��".y/VYtl_✓w - — — — — — _ _ _ _ _ RCLISTEaED �nriD uFv r❑ L-25P7 — Y;� aoi.ae TU1'18It01/ G COl[P�NY . . , -- N BS'37'22' y - ' �- � � - , 1 07 N�RTH ` a�_ I SBUkY STRFf"T �" ' � M�CKSV I LLE, N, C. �70c'��� � c336) 751 -561r. C�� �• YORX D.B. 95, PC. 96 I PLAT pF SURVEY FOR� � CINDY G. McCULLAh REVISIONS SULE� � _ �OO� MPqOVED BY� DR�VN BY� JGSHUA �� LTUTTERi�W pA7E, JAN-25-20G2 �RE HVE�R4T-WBt BEING 4.000 AC. TAkEN FRO�d THE JOHN W. GREEN PROPEPf� SOO SO O LOO zOO 3OO � ID.B. 158, PG. 180) LYING W THE MOCkSVILLE TOWNSHIP DAVIF fOUNTY. NpRTH CAROLINA ��,k P;� 5��7�s�� SCALE IN FEET °R""1N0 ""��'' TAX MAP RFF.�. r — z P '� °�q ��U� —? . ' � � . � � • - DAVIE COUNTY HEALTH DEPARTMENT � ��%� : ` • Environmental Health Section _�}_ Soil/Site EvaluaHon APPL.ICAi�iT INFORMATION PROPERTY INFORMATION Account #: 990002406 Tax PIN/EH#: 5727-30-3260 Billed To: David McCullar Subdivision Info: Reference Name: Location/Address: Ratledge Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: $�:�D "�07 Water Supply: On-Site Well � Community Public � Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition L Slo % HORIZON I DEPTH �• -� Texture rou S' �' Consistence Structure Mineralo HORIZON II DEPTH � '� " � Texture rou Consistence E'�- Structure ' - Mineralo � HORIZON III DEP'TH � Texture rou Consistence Structure Mineralo • HORIZON N DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: - LONG-TERM ACCEPTA E RATE: '' � OTHER( )PR SENT: REMARKS: (� '� V Ve�� ' � d y � �'� 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 truct re SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular 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 DCHD OS/99(Revised) ■���■��■�����■��■�■■����■e���■�■■����■■�■ ■��o��■�■��■��■���■■�■���■��■����������■�■ ■■�����■��■������■����■■���■�■■■����■��■■�■�����■���s�■�e������������■■■�■■■��■■���■ ■��■■����■■����■���������e�■■■��■■■���■�����■■����■■��■������������������■����■�����■ ■■����■■��������■���■��■�����■��o������■���������■�����■���■��■��������■��■��■������■ 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