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1281 Ridge Rd '� , .; � # � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 - (336)751-8760 Account #: 990003103 Tax PIN/EH#: 5707-26-0688 Billed To: Kathleen Smith Subdivision Info: Reference Name: , Location/Address: 1301 Ridge Road-27028 Pro osed Facilit : Residence Pr 'z • ATC Number: 3722 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 WASTEWATER CONSTR CTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ��2� d� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 periad of time. � � � �/ ��� � � Septic System Installed By: v� Environmental Health SpecialisYs Signature: ,� Date: DCHD OS/99(Revised) ' � ' DAVIE COiJNTY HEALTH DEPARTMENT ; • . � Environmental Health Section � �' - r.o.sog sa8mo xo�P;ta�sr��t �—� Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003103 Tax PIN/EH#: 5707-26-0688 Billed To: Kathleen Smith Subdivision Info: Reference Name: Location/Address: 1301 Ridge Road-27028 Proposed Facility: Residence Property Size: see map **NOTE�*-TIi�slmprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 LS SUBJECT TO REVOCATION IF SITE PLANS OR TI�INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE TI3IS 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 Type Water Supply� Design Wastewater Flow(GPD) Site: New� Repair❑ System Specifications: Tank Siz%G GAL. Pump Tank GAL. Trench Width,���Rock Depth�Linear Ft:�� - Other: tV�� - �= (<��-- -"�-���-`—� /O f� .�'Gr4� Required Site Modifications/Conditions: IM1'[PROVEMENT/OPERATTON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 130 e da of installation. Telephone#is(336)751-87G0.**** � \ /J Environmental Health SpecialisYs Signature: Date:� � DCHD OS/99(Revised) . � . '� i •� { D � ,�: _� , � � ��� �v � . , r:. , . t!� luJ L� !3 V ..(� . � . DL'7 • , . . Y CATION 1=01i S1TL• LVEILUA710N/Ih1t'JtUVL-11IL•NT I'L•Iii1�117&/Ci'C �+�AR � 2 2��4 . Davie County Health Department � Environmenta/ffea/fh Section P.O. Box S�B/210 Ho�pzLal S�rce� ENVIRONMEMALHEAtTH 21ock�vil.le, NC 2702a DAVIECOUNIY (33G)751-B7G(� . � ***ItSPORTANT*** TIi2S I�PPLTCATION CAIVNOT D� PROCESSL•'D IRdLLSS ALL 2'!IL 1��QUI1tLll-..-• . ...I . INFORMATION IS PROVIDED. Refar to tho INI'ORMATION IIULL�TIN Lor in.^,CrucL•ion:�. 1. Nsmc to be IIilled 1�Q�['b 'E�Q/J W, .SM��i� ConCacL Pcraon �`'f-�n��.1(/� Mailing Addreas �� � ����Q.�{ R�C Ilomc Plionc 33�-4-aa—5� � � "� 'r ,� .2 0.2� 33� —'7 5 r-8'l "1 � City/Statc/ZZP �G�1�SU� G�e � � DUJIACDD L�IlU11C �.._ ., ,,.,__,,. 2. Namo on Pcrmit/ATC if DifEerent than 1lbovc � _____ ,.. ...._.. . Mailing nddress City/Statc/Zip _�___„___..,.,._., _,._..,.. �. Application For: ❑ Site Evaluation � ❑ Improvemenl: Pennit/ATC ItoL•li ;4. System to Service: ❑ Hou�e l�l 2doYzile HOme ❑ Du3ine�� ❑ InclusL'i'y ❑ OL'1 cr _______ � 5. Type �ystea reque�ted�Conventional ❑ conventional modiPicd .❑ iunovaL•ivc 6. Tf Residence: � People � 4 Dedroom� y U I�aLliroalu� . . .. Z•.----• �Dinhwaaher ❑Garbage Diapoaal L7Washing Machino ❑Basement/P1wa2�1nJ ❑us�emenL'/PIo l�lumbin� 7. IL Duaincas/Indu�try /Othar: veriEy typc � Pcoplc I! :+iul:� ______.� � Commodc� - � Shower3 � Urinaln 11 SVaLcr Coolcra IF FOODSERITICE: �� SeaLa ���imated Water U:,age (gallon� per day) ________' 8. TypQ oL- water �upply: L�J County/City ❑ WCll ❑ ColnntulliL'y 9. Do you anticipatc additiona or C\P:IIISIOIIS U�111C f�Clli�Y tI11S S)'SlCill iS 1111L'lIc1L'(1 lU 3C1'1'C? ❑ �'cS 'u if��cs,�r•liat typc? • ***ldfPOR"li1NT''°**CLILHTS�11UST COdIP,L1sT,G THL K1iQUlLtGD I'li0i'LIt'1'Y 1Nt�O1ZB�IA'1'lO1� 1tL(?UI:S'('l:ll —� 13GLO1Y. Eitl�cra PLA7'orSlT�PLt1N�titUSTIICSUIl�1iJ77'L•D by tlic dicnt iti•ilh'I'1lIS r11'I'1.lG17'IOIV. � 3 � 1'roper(}'llitllCtlsloll5: 39a X 35 d 32�X 5orJ 1VR!'TL:lllltL•'C!'lUi`lS(fruiu 11•lucks��illc) !u t'ItO1'lslt'1'1': 1:tx Officc l'lIV: fE ��O �(Z,Ca �(� Q $ � � (J,J ���w-f- �� f'1�-�_ PropertyAddress: RoadNamc I�01 �; 12 , � �� i�-���_� • City/Zip�tT��Svi��e.. ./l�� .Z7o29 �/�05 S �. / 2 /� � — `f'� If iii a Subdivisioii providc informatioli,as follotivs: ��P�� �(1 ►^-�- b ti� . Namc: ' � . � Scctioli: Blocl:: Lot: Datc liouic coi•iicrs tl:ibbcd: � � �� r ' Tliis is to ccrlify tliat tiic iufortuatioii providcd is corrcct to tuc bcst of iuy Iuiotiti�lcdbc. I uitdcrs(aud (Ii:it:tii}�pci•i�iil(s) issucd ltcrcaftcr are subjcct to suspcnsion or rcvocatiou,if tlic sitc plans�r intcudccl usc clianbc,ur if tlic iul'urui:U iou submit(cd in iliis application is f:ilsiGcd or cliai�bcd. I,also,undcrstrrncl tJrat I uut res��u�ra•rLlc jur rr!/c/rrrrb�es iircru•1•c�J fruru �lria•upplicariuir. I,licrcb�•,gicc coiisciit to tl�c Autliorizcd Rcprescii(alivc of tlic 1):ivic Cuiiiila�llc:iltli llcp:u•tuic��t to cnici•upoc�abo�•c dcsci•ibcd pr�pci•ty loealcd i�i llavic Couuty and o►viicd b�� lo conduct all tes(iug proccclures as ticccssary to dctci•tiiiiic lltc silc suitabililJ�. r DAT'L_ .�_ I�—D � SIGI�IATU12� �1L �. TIiIS AIZEA MAY B�U I:�r, R DRAWING YOUR SIT�PLAN(Li "dc all of tlic Cullotiviiig: Lxisliiib;tiiQ pi•oposcd property lincs and dim iT� tructures, sctbacics, and scptic locations). �� . Sifc Rcvisil CI►:u��c � Datc(s): -- � • Clicitt NaliGcalioii ll:itc: � , �IIS: ' n � Sigu givcn • Accowit lYo. �, "� ' Rc��iscd DCrID(05l03 - � I��voi«No. �° G�`r� �v 13S (3. 56A) 233 �s� �M � `�`� 13 , � ;� , ��,�J � ^ � � ; ;' (4.00A) i ---- ��sJ 2 � 30 8 / � . '� 1 ... ` . . . .. �i, / � � ��O �. a�1 9�S � � �i� � � � � _, 1 O � v � _ �� � � ' ��\� � -, 3. 167A �2��J 0688 � ( 1A) �.� � � CC� � 7 � �/315 � 0� 3 - -- ��� � 1� � a'' ( 15.34A) 3189 . , , �� � - . • � � ` , r `� ' DAVIE COUNTY HEALTH DEPARTMENT ^ '� - ' Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003103 Tax PIN/EH#: 5707-26-0688 Billed To: Kathleen Smith Subdivision Info: Reference Name: Location/Address: 1301 Ridge Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo % HORIZON I DEPTH Texture ou Consistence Structure Mineralo HORIZON II DEPTH Texmre rou Consistence Structure Mineralo HORIZON III DEP'TH 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: EVALUATION BY: 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 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-Slighdy 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 Mineraloev 1:1,2:1,Mixed ote 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)