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162 Rock House Rd DAVIE COUNTY HEALTH DEPARTMENT ��/-2/�'l'� - " -`"` Environmentai Health Section , ' P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 � (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 9900006$8 Tax PIN/EH#: 5$40-83-5495 Billed To: Joshua Hendrix Subdivision Info: Reference Name: Josh Hendrix Location/Address: Rock House Road-27028 Proposed Facility: Residence Property Size: 4.454 Acres ATC Number:,�,3� **NOTE** This ImprovemendOperation Permit DOES NOT authorize the constcuction 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 PERNIIT IS SUBJECT TO REVOCATTON IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER S�'STEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type_��_ #People�_ #Bedrooms_ d� #Baths� Dishwasher: � Garbage Disposal: O Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/ShiR #Seats Industrial Waste: 0 Lot Size Type Water Supply r�{/G�/ Design Wastewater Flow(GPD)����� Site: New�Repair❑ System Specifications: Tank Size,�Q/Z GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft. /O�� Other: �S ��� U�.w� . Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- AP OVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINiSHED GRADE. ****NOTICE: Contact a repr ta 've o e Davie County Health Deparhnent for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m. 1:3 .m. n the ay of installation. Telephone#is(336)751-87G0.**** � �� Environmental Health S ecialist's Si ature: �C� ►' ' , Date: � ��! P � DCHD OS/99(Revised) . _. . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksvitle,NC 27028 (336)751-8760 Account #: 990000688 Tax PIN/EH#: 5840-83-5495 Bilied To: Joshua Hendrix Subdivision Info: Reference Name: Josh Hendrix Location/Address: Rock House Road-27028 Proposed Facility: Residence � Property Size: 4.454 Acres ATC Number. �/.3� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 I VALID FOR A PERIOD OF FIVE YEARS. , ��y� Environmental Health Specialist s Signature: � i � Date: �L�j>��� � CERTIFICATE OF COMPLETION **NOTE**The issuance ofthis Certificate ofCompletion 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 guarantee that the system will function satisfactorily for any given period of time. =_ � �� � i Septic System Installed By: ���� Environmental Health Specialist's Signature: . Date: DCHD OS/99(Revised) AWA110N/IMPROVEMENT PERMIT dc ATC `'�'�'-- � ` rP: � • �t ' i unty Health Department � � � � � � � .. ,�- � •. ,_.. , 1 ,, .. , - En menta/Hea/tfi Serdor� l = D .:� '1� ` B �8/210 Hospital Street t�,2 4 �=-� � JUL 2 0 �' �.iie, Hc z�oze � � �: _F'�'�' � �Lt�/J/17 (336)751-8760 ENV!pAVMENTAC Hfq1T E H at,tIl�ORT 8E PROCE3S� ���� I�Y,Ea � �tEQUIRED I 2NFORMATION I3 PROVIDED. Aefer to the INFORM�TIOI� 81DE+.'L�^�3�1 f�a� is����ttations. i. �� rA �e Hiiion ��ashua �-�e�r,c��fZ.v1c conr.aat reraon �bS� �'1 P.X�C�.11�–�— Maiiinq 1lddress �� O� (J O 5 Hamo pt►one — City/8tate/Zip`��YYtYV�O'N�. � .�. �- 1 b l� Business phone "��ri,"'t`7 1 `t Z. Name on Pes�it/1►TC it Oi!lerent thm Al�we ltailing l�ddress City/8tate/Zip �. �rpliaation sor: ite Evaluation U Improvemeat Pesmit/ATC C1�oth ' a. system to sarv�ca: 0 Housn �Mobile �ame 0 Busiaess 0 Industry 0 other e. If Itesidence: f People _�_ # Bedroans oy i Bathrooms � /� DishnasAer O Oatbaye Diaposal �1 NashinQ Nachine O Baa�t/PlumbinQ 0 Basement/No plumbing 6. i! Bnsiness/Indnstry/OtAer: 8pecily type f Peopie � Sinhs _ i Caaemodes i 8hoxers * Vrinals f Natex Coolers ITi �i'OOD3ERVICB: � 3eats 8stia�ated Nater Usage �qalloas per day) � . 7. �ps of water svpplp: 0 Cont�ty/City [�itell 0 Co�uunity �� s. Do you Anticipate additfon�or e:panaiona of t6e facllity th�s ayatem ia intended to�erve! 0 Yes No If yea,w6at type? ` � *•*IMPiORTAN7''•"CLIE�iTS�i!'i��'T C011lPLETETHE ttEQUIRED PROPBRTY INFORMATION REQUESTLD BELOW. Either a PLAT or SI 1 E PI.AN AlUST BESUB�IIITTED by the cilent �rit6lTilS APPLICATION. Property�finee�s�nm+�� `T c_._t ������/� '�VRiTE AIRECfIONS(trom Mock:vflle)to PROPERTY: Tmi Oit�ce PIN: � �S�d- 8 3 -s�q`� �5'�=�� �s��t /,��i;e,v 2q�_ Property Addresa: Rnad Npme �Qc�G�i-o c,(5�f�cQ• � � ' `UclC ����c,pe �G�, City/Zip �� lOc��S�i�IIP,N���� '���l�rr12 ��tJ ��/� � r �P�'rWPs lf in�Subdiviaion providc fnformatlon,as�ollow�: � s�� � �' � , Name: . Section: Block: Lot: Date Pruperty Fi�gged ��'���s/� ���e� This i�to certifp that ihe intormation provided is con�ect to tbe best of my kaowiedga I underatand t6at�ny permit(a) issued bereafter are subject to auspen�ioo or rewocation,If the aite pisns or iatended uae c6ange,or if t6e 3at'ormation � submltted in this appltcatioa i�falaitied or changed I,olso,anderstand tliat I am re�ottsible for o!1 cbarges�itcurred from tbis appJlcation. t,6er+eby,give con�ent to t6e Aathorized Repre�entative of t6e Davie County Healtb Department to enter apon above described property located in Davie County and owned b� to conduct all testing procedurea as necasAry to ddermine the�ite aitabilih. DATE 1��� SIGNATORE_� c�cly,s� THIS AREA MAY B�USLD FOR DRAWING YOUR SIT4 PI.AN�Iaclude all of t6e tollowing: E�atln.g and prnposed property lina and dimenaions, riructures, aetb�ka, aad�eptic locationa). Account No. CCJ� Revised DCHD(07/98) invoice No. ��� ' �" . -- ' '' ' _ � , _ . �� _ _. .. • J . . C. F. SEATS ' OEEO NORTH �.i3.a6 PG. 3t5 – ' _ CASPER SAiN 0.8. S9�':PG.44S �. I '.1 N 00� S3� 48�� _E —� ( 789.20 TOTAL ) _ EIP +. 444. 20 NI.�_ ___---�,��_�_.__--- 345.00 — �— . t . ; ; , " ; .� . . , ,. � � t. ; . r � e" . � ' ,� , _ �. MAiRY G, SMITH I ; TAKEN FROM THE MARY G. SMITH • ��. 114 PG. 552 � PROPERTY OB.114 PG. 552 �� . 2 . . OD i, ' � � �j � N . • � . � 01 � . , � Q, d' • ' t - (n i ` _ ' N \.` N � : ' t� A AREA= 5.450 , ACRES � ;� AREA= 4.454 ACRES W ° I � �ErvEva FOSTER . � - D.B.92 PG.t28 . ; m • t �� � � � � � � � � � � � � � � � � � . _..___ __--� _ . . � � � ; , � . r . i � � . . � . r . , _ ` _ : _ _ _ _ `_ _ EASEMENT .RECORDED I N PLAT &C. 4 PG. 23 3 VARIOUS _DEEDS � .— —� — — ' EX I ST ING ROAD TO SR 1639 --.. — — — .— � , . : ( TOTAL 387,84) , --- — — — . ', 3t 5.44 72.40 i NIP _ _:-__ 350.00 - _— — � 1 : . � L EG . -t— !i 00"56� 25 E (892.03 rOTAL ) EIP , . 1 S T O N E � � � . I E IP_EX�ST' � ,. W . - NIP = NEW � � Z) � , � I _ J I � yl E W , ,._.. DAVIE COUNTY HEALTH DEPARTMENT ��� � ' Environmental Health Section Soi]/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000688 Tax PIN/EH#: 5840-83-5495 Billed To: Joshua Hendrix Subdivision Info: Reference Name: Josh Hendrix Location/Address: Rock House Road-27028 Proposed Facility: Residence Property Size: 4.454 Acres Date Evaluated: �;/^� � Water Supply: On-Site Well [� Community Public Evaluation By: Auger Boring R,/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition Slo % HORIZON I DEPTH Texture ou Consistence Structure Mineralo HORIZON II DEPTH �• ��� Texture rou Consistence / Structure L 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: /�� EVALUATION BY: �l� 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-Silry 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 Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic MineraloQv 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■a�oao�■�■■���■■■�■����■�o■��■����am■■■■�■■ ■���■����■�■■����■��■�■�������■�����■■■■�■■��■e�■��■����■■■�■■�■■■ ■���■■���■�■■■�■����■�■■�■o�■ov■�■■��■�■������m��■oov�■v■�■o�■■�■■ ■����■■���v■ss��s�a�o��s�e■eaes■�■■�■■■■�■■■��■ea■������■e�■s�■s�■ ■�■���■��■e����■��■�■■�■��■��■■��■■�■■■��■������■■■■�■■■■��■■■�■■■ ■�■��■■se���■■o■�■�o■�o���■�s■s��■■�oe■■�■������eom■■■����■o■e�■■■ ■���■�■■��■■■��■��■�■��■��■��■■��■��■■■�■■��■�■■����■■■�■�■■���■■ ■�■�■�■���■��■�■�������■�■■■���■ ■��■■■�■■���■■��■■��■■��������■■ 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