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161 River Birch Ln (2) M�� :� s,�.,� Davie County Environmental Health P:O.Box 848/210 Hospital Strect Mocksville,NC 27028 . � (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT ' Account #: 990005494 Tax PIN/EH#: 5880-36-4933 Billed To: Tim and Tori Baker Subdivision Info: . Address: 4916 Cade Road Location/Address: ?�" River Birch Lane-27006 City: Climax Property Size: 7.03 Acres Reference Name: Kyle Swicegood Proposed Facility: Residence . **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. . Permit Type: J�1<Tew ❑Repair OExpansion Permit Valid,for: 0'S Years ❑No Expiration Residential SpeciScations: #Bedrooms�#Bathrooms�#People ' Basement0 Basement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):lQ�� Type of Water Supply: ❑County/City �Well �Community Well Site Modifications/Permit Conditions: S stem T e LTAR - Initial � Re air Site Plan �� ,� s� s � �-. � �, � , �, . . . � Environmental Health Specialist Date,��7 GYC� i.p.l I-06 � T ��? - . � .. . .. ..._. . • / � . - " _ �1 .:� ..,:,tii APPLICATION FOR SITE EVALUATION/IMPROVEM � � Davie County Environmental Health , ' P.O.Box 848/210 Hospital Street ApR 2 8 ZOlO � Mocksville,NC 27028 . (336)753-6780/Fax(336)753-1680 f.�MRONMEMAI HFALTH � DAVIE COUNTY Application For: Q'Site Evalu�tion/Improvement Permit ❑ Authorization To Construct( ❑ ot � _ Type of Application: G►�1ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility *�*IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT'INFORMATION � -�- Name � r' I br''i� l c� e!' Contact Person AdcYress �/l(P �,�� pc� Home Phone City/State/ZIP (; ' ti� , /V C oL�]Z3 3 Business Phone '�j(o� '7��Q '�j/�f.5' Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION I �3 �U *Date House/Facili Corners Fla ed �Z3-�a NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan �Plat(to scale) � (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name FZ v N 'F ��n!N�► S�'ro u�e Phone Num/ber Owner's Address City/State/Zip Q�/l/a�vC� ,N C .?7o d(P Property Address � (,( R,i��t '�qcli (.A'N� City ��yqNG� Lot Size rj� �� Q�I-�S Tax PIN#,��3 Cc Y`l 3 3 Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes �i1�To � Does the site contain jurisdictional wetlands? Yes �o Are there any easements or right-of-ways on the site? �s No . Is the site subject to approval by another public agency? Yes �3Qo � Will wastewater other than domestic sewage be generated? Yes v2d"o IF RESIDENCE FILL OUT THE BOX BELOW #People ,� #Bedrooms _� athrooms�_ Garden Tub/Whirlpool es ONo Basement: es ❑No Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness ' Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: �d'Conventional �Accepted ❑Innovative OAlternative ❑Other Water Supply Type: ❑ County/City Watei' �'New Well '❑Existing Well ❑ Community Well Do you anticipate additions or exp ns�s of the facility this sysfem is intended to serve? ❑ Yes �l .Pd'o If yes,what type? � � This is to certify that the information provided on this application is true and conect to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant riglit of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws ancj,rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and �' '� n flaggin or st e house/facility location,proposed well location and the location of any other amenities. Property owner's o er's egal representative signature Site Revisit Charge Datc(s): /j� Client Notification Date: Dat EHS: Sign given ❑Yes ❑No Account# �_ Revised 11/06 Invoice# 1�.�L !/� r� ` ,#• 4 T c'r I` si•" � f,i ,' .J� r.r � " _ � �:¢Y /. .. . 5',.' }i /11L� �+' '.'r if � � � .. .h /I�._ �Y._�. �r��f' � � . ^ ' . . � � li � � ��t � S',y ( f i/ �� /. �� JK ' r �y Fa y� f �� !� fT�.i A Y/ . . ,.� // ,f t ✓g II 4�f�,, �..� ?. j� ' �' � • 5 j � ' J �,j��int ' Y. � ///±±±({'� /( ' . �'v.'.' {F � y }(. • '�y .�, y'# �„5+ \ t �f ay4� : 1' .., Q(�l .J . /��.},�. �) yif. ' f � 'F f F ► rF �,�. ' f' ._ 1-f-� �, � 'j�f + �`. . � f»� '``�, � r. .. . '�. �� l.F '/•<: � � I��( � � /� � / ��.�, . `' A- �. ��A� � � , � � �., µ � ��'TF��f'� !��- � a y '.�'".�� j /4' r ` . JI-F � . ..�i}�� .,' � rR � �N;" • '. ♦�.��r.: � y j�y��/ si� f ) �. :. ! ,r ` �� Y � F, / � ' , ,� i '�``°�� `�� s�' : �"� :�.. �� f � ! � . . 4c�+`�� k�, � ,r ; � � � ! �� - �- �"`;�, .J'�' � . �N J(� �,`��.,. , 9 � : �r �' h; , /J � F� ,, ' �� y + , ��- - " ��`� `�i�-"%;, `'�`` R� - ' �� , � �� y�� ,� s , �; �—�, �.� , . � t ,�. � j � �' ,, > � �- s .�.-; y �" . , 7'i.rs„'': " r. Y, ; .� ," �� r � � �-'F � � .� ,-ri r .2..:41 r o . '�� '�. �� s/ �Y �� '� �, � r. f; � .�f��h�4, y '�� .0 ..� " � ,a� � 'C �� s ` • 4 �y � ��: �f..n �. . . YH r d � • i � ��3� �� Lsy,� �<! '. i �� 'tf��^�' .� .*t�: r a�a �`t#�4 �``y' � �++� i' � , ..�r /�-. r P � .�.�� ,�..�� c�'�.. -0l�� C,� � �: ,.,��y �Y r ' ' .�� ,/,�7 (.�'" �.! �. �� ...��' .�;';;�� .'F ' �i , / � .h � i� �,,� T J ,� g ..n�. 1 .�)3 " � ��i . '�� Y,�R^ ji�.�y,�t. � ,� �L`,%� �� (y a. f ��[` .u 'Ti��'J'./::�.�,.�� ,��Gti��73.�i �.. . . � T�'�'�t� �'�� ' e.! `'��.,�. � �� : ` DAVIE COUNTY HEALTH DEPARTMENT Environmentai Heaith Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005494 Tax PIN/EH#: 5880-36-4933 Billed To: Tim and Tori Baker Subdivision Info: Reference Name: Kyle Swicegood Location/Address: 161 River Birch Lane-27006 Proposed Facility: Residence Properiy Size: 7.03 Acres Date Evaluated: ,��z/ao�a Water Supply: On-Site Well � Community 1'ublic Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition / Slope% �j/°o 0 HORIZON I DEPTH . _ p Texture grou �. SCL Consistence Structure r � . Mineralo HORIZON II DEPTH . .� Texture rou � - ` Consistence • Structure Mineralo HORIZON III DEP'TH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo • SOIL WETNESS � RESTRICTNE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE . 3 � SITE CLASSIFICATION: �S EVALUATION BY: LONG-TERM ACCEPTANCE RATE: .� OTHER(S)PRESENT: �n c��,A REMARKS: � LEGEND Landscape Position , R-Ridge S-Shouider L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope � Tgxtura 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 .ON4 STF.N . . �I�iSt VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm - �Y4t � 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 Mineralogv 1:1,2:1,Mixed � 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) iTAR -Tnnv-iPrm arrPntanrP ratP_ aal/�av/ft� rnT�r nc�nc m__:__��