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853 Redland Rd DAVIE COUNTY HEALTH DEPARTMENT �J� �, � �v ? Environmental Health Section � • ' � � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001648 Tax PIN/EH#: 5862-26-0978 Billed To: Terry Smith Subdivision Info: Reference Name: Location/Address: Rediand Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 2785 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AIJTHORIZATION 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 Tf�INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People_� #Bedrooms � #Baths �1� Dishwasher� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply C +� Design Wastewater Flow(GPD) i�� Site: Ney� Repair❑ , ,� � System Specifications: Tank Size�('�GAL. Pump Tank GAL. Trench Width� Rock Depth�� Linear Ft.c��6 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"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 1:3 p . n the day of installation. Telephone#is(336)751-87G0.**** / � Environmental Health Specialist's Signature: , � Date: �''���,(�f DCHD OS/99(Revised) �-�( ' ' � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001648 Tax PIN/EH#: 5862-26-0978 Billed To: Terry Smith Subdivision Info: Reference Name: Location/Address: Redland Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 2785 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This 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 WASTEWA C NSTR C IS V F 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 tee that the system will function satisfactorily for any given period oftime. � 6� �D $0 r k � � Septic System Installed By: Environmental Health SpecialisYs Signature: Date: 7"'���`'�J � DCHD OS/99(Revised) J . �� � ���-` . .-_� • - ~ � a �y� � � . • • �' `�- � .._ � � � `�,� APPUCATfO(V FUR SffE EVALUATION/IMPROVfMEM PERMIT&ATC � � Oavie County Hea{th Depa�tment • � 2 ' � �j Envi�nmenta/Kea/tfr Sedion `� P.O. Box 848/210 Hospital 3treet Mocksville, NC 27028 ENV4RONMENTAL HEAITH (336)751-8760 DAVIE COUNTY ***II�ORTANI'*** TFiIS APPI�ZCATION CANNOT HE PROCE3SED VNLESS ALL THE REQUIRED INE'OR2�TION IS PROVIDED. Refer to the INE'ORMATION HUI,LETIN for instructions. 1, xsmo to bo sillod l� . � contaat Porson /� lSailinq 7►ddraei � Q Homo Fhoao��l1 ��/ City/Stat.o/ZZB H��l(XnC� 11lG �7���i Husinoss ?hono, j-r 2. Nam� on P�rmitl�C if Dilt�rant thus 7►bovo Hailinq 1►cldr�a• City/$tatoJLiP �� , 3. Appiication For: �31te Enaluation Impron�nt Permit/ATC � Both �. syst.� to sa�s�.: 0 House �Mobile Home ❑ Busineas ❑ Indust=y C! Other �a. It Residence: t People �_ � Bedrooms .� � Bathrooms �,�,,,, �Mshwashar i] Garbaqo Dispo�al �Nashin9 Hachina U Haaomant/Plumbiaq O Hseomant/No PlumbinQ 6. Zt Husino�sllndustty/Othar: 8pocily type f Paoplo t Sinks � Co�das � Shoxors � Urissals � ifator Coolors IF FOOD3ERVICE: � 3eata 8atimated Water Usage tQauon. �r amY) 7. �pe ot .rater supply: �COunty/City ❑ i�Tell 0 Community e. Do you anticipate addiHons or e�pansions of the facility this system is intended to serve? O Yes `�No If yes,what type? ***IMPORTAN7'�**CLIENTS MUSTCOMPLETETNE REQUIRED PROPERTY INFORMATION REQUFSTED BELUW. Eit6er s�T or SITE PLAN MUST BESUBMITTED by t6c client with THIS APPLICATION, -___�— Property Dimenstons: WRITE DlRECTIONS(from Mocksville)to PROPERTY: Ta:om�e nv: # ��[�� -� t� a G 7� /SS �A 5'� P d f��//�,ctd �'d � PropertyAddress: RoadName���QY1� � �-•t�� O<tJ` (��c� li4�c� �C�� City/Zip�'dlll`�"IJLE N�. /YJrf p_ 5 l9rf/` �e�`j If tn a Subdlvtston provide infocmaHon,as follmrs: Name: 1 Section: Block: Lot: Date Property Flagged: �� � � This is to certify that the informallon provided is correct to the best of my knowledge. I understand thAt any permtt(s) issued 6ereaner are subJect to suspension or revocatioa,i[the�ite plans or iatended use change,or if the information submitted in thts appticaHon is Calsttied or changed I,also,understand thal 1 arn responslble jor a[l charges tncurred jrom t61s appllcatlon. 1,bereby,glve conseat to the Authorized Representative of the Davte Co�nty Health Department to enter upoa above described property located in Davie County and owned by to conduct aU testing procedures as necessary to determtne t6e site suitability. L l�'� � � f SIGNATURE x r DATE � THIS AREA MAY BE USED FOR DRAWING YOUR.SITE PLAN(Include at f t6e following: E�.iting and proposed property Ilnes and dtmensions, structures, setbacks, and septic locations). Site Revisit C6arge Date(s): Ctient Notiiication Date: EHS: Ac¢ouat No. 1 � � � Revised DCHD(07/94) ' Invoice No. -�—. 5 � 3�3 � • " � ,� f �a �/��.o��,�.t, �� �� � �a' S a�-� � � "� _ � � :/ _�. m�. il .�.�. ! „w., � � �.. ... � ,.m p '- ___��_ � I nr Q i ♦ U f � F �__r____—_-- N J ! � � ��� w P �xo[ncuoxrrsa —��-�i � ix vam � . f m, i.oueoo.v.zoo i.oc..oa�.+.s�o� „ � .ovtoo.xn.0 _. . ..��� + w i r a Z F o � o. ----_i_ . ww N V •, wo n n�w � � a :m � i�r ! � � � u.e • . .,,, ' S • _ _. _ — ._ — . �� . � n.. [ . �n/� ,:. , � C700000038 ! � z i� 1� � 5 i o i , _ _ ___ _ .. _ . ._. ...' _ - _ . _ ¢ � F .,,. �� a,. ' '�" � � :n � e+w " 1 ' ... � �.o�,.00.�..�,o o� � � n.. f _ - •• ae�uu�+ - � 1 � mus[wEw� w� �. -- reorcixv i[»�oxs � �y�� ' .n. � � � Y nnv n } .--�_--- w� �a. �yy ' , asw e • - , e. - I i, I nmo wou[ . Rm � ney � �� 5u a�� . I / I • " • . . 'e.r ] �/ I �� - f}fi il . ��nu • > , . , f . ` . . DAVIE COiJNTY HEALTH DEPARTMENT . � • " Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 890001648 Tax PIN/EH#: 5862-26-0978 Billed To: Terry Smith Subdivision Info: Reference Name: Location/Address: Redland Road-270p6 Proposed Facility: Residence ' Property Size: see map Date Evaluated: :��2��/�l Water Supply: On-Site Well Community Public t� Evaluation By: Auger Boring b/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition ' ZL Slo % HORIZON I DEPTH �' '- Texture rou Consistence Structure Mineralo HORIZON II DEPTH " � � Texture rou Consistence Structure i 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 RATE '� SITE CLASSIFICATION: ►n� EVALUATION BY: n YcY / LONG-TERM ACCEPTANCE RATE: ' _ OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope exture 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 ois 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-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 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) ■��������■��■■■■���■��■�■■■���■■����■■■�■■■��■����■��■■■���■��■■�■ ■�■��■�������������■��■���■■���■■��■■�■�■■■��■■■��■■�■��■■■�■■■��■ ■����■����■�o����■����■■��■■�■�■��■���o�■■��■����■��■��■■��■■e�■■ ■■����■■��■���■��■�����■���■���■ ■■���o���������■������■■■�■■���■ ■■������■■�■�■�ms0■�e��■■��■■�������■■■■■�■■���■�■�■�s��■�■��■.■�■ ■■������■■�■■■��■�■��■��■��■■����■�■�■��������■�o■��■v■■■■�■���■■■ ■�■�■■■���■���■�■��■�■■�■■����■��■■��■■■��������■as■s■■■���������■ 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ENVIRONMENTAL HEALTH SECTION P. O. Box 848/270 Hospital Street Courier #09-40-Ofi Mocksville� NC 27028 _ ....,. ..; ,Phone #: (336)757-8760 ' - Mazch 28, 2001 Terry P. Smith 725 Redland Road Mocksville,NC 27028 _ Re: Site Evaluation/Redland Road Tax Office Pin: #5862-26-0978 Dear Client(s): As requested, a representative from this office visited the aforementioned site on Mazch 27, 2001. Based upon the information provided on the Application for Site Evaluation � and after an evalua.tion was completed on the site,the site was found to be provisionally suitable for the installation of an on-site sewage system Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this offce. Sincerely, /1,4�����• ._ Robert B. Hall, Jr.,RS. Environmental Health Specialist RH/di � , .