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231 Sain RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000792 Tax PIN/EH #: 5749-45-1726.02 Billed To: James Murphy Subdivision Info: Reference Name: James Murphy Location/Address: Oak Grove Church Road -27028 Proposed Facility: Residence Property Size: 1.2 Acres ATC Number: 2208 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths 2 Dishwasher: 2"' Garbage Disposal: ❑ Washing Machine: 173"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial/ Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 173! ' Lot Size l�e Type Water Supply e Design Wastewater Flow (GPD) �L) Site: New O'Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width ,f&l, * Rock DepthLinear Ft.67W IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: ,�� Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000792 Tax PIN/EH #: 5749-45-1726.02 Billed To: James Murphy Subdivision Info: Reference Name: James Murphy Location/Address: Oak Grove Church Road -27028 Proposed Facility: Residence Property Size: 1.2 Acres ATC Number: 2208 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This 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 WASTEWATE O TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: -r Date: zaj�D—A� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the sstem described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter t iOA, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO AY be taken as a guarana that the system will function satisfactorily for any given period of time. t Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: / — -/ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM & ATC Davie County Health Department Anvftonmenfof Hea/th Seadlon P.O. Bos 848/210 Hospital Street SEP 2 8 1999 Mockaville, NC 27028 (336)751-8760 - ***nWORTANT*** THIS APPLICATION CANNOT BE PROCESSED Ut1L>zSS ALL TIM IlE f D INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions^. 1. Name to be Billed W1 l Contact Person �-i PA - v -Hailing Address 5;5,1 ("JUL)AL JeJaRossi rhosct �f q citr/state/Lir 'J' 116 !C'o 2 22 W/ Business Rhone 2 5-3 _-5z52—' 2. Maas on Persait/ATC It Different than Above Nailing Address City/state/alp 3. Application for: O Site Evaluation O Improvement Permit/ATC ,loth 4. 6ystes to Service: A3 --House O Mobile Home O Business O industry O Other 5. If Residence: # People f Bedrooms 3 # Bathrooms _ �ishxasher 0 garbage Disposal 0/ Washing Machine 0 saseasnt/pinabing 0 sasesantMa Plumbing 6. if Business/ina. trr/other: specify type i commodes # shovers f People ; sinks Urinals f Water Coolers IF FOODSERVICE: # Seats Estimated hater Usage (gallons per dap) 7. Type of Water supply: 0--County/City O won O Community 9. Do you anticipate additions or expansions of the facility this system Is intended to serve? O Yes J° 0 If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THE APPLICATION. Property Dimensions: W DIRECT[ONS (from Mockeville) to PROPERTY: Tax 08icePIN: # 7 -��" 7z • 62 $ S iej Property Address: Road Name DCL Gr' --c (_ l %i r -4j 1A 1 o✓' n e f cl Vie; i .� �� City/Zip� / d, U, /l G N.` ' )-7v b r� )`- G rw� C �1 • Rci If in a Subdivision provide information, as follows: L Name: Section: Block: Lot: Date Property Flagged: '1-' _ L S? - y This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit($) Issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application Is falsilied or changed I, also, understand that I ani responsible for all charges Incurredfrom this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned byd im e c /1� u r/p% �a to conduct all testing procedures as necessary to determine the site sultabWty. DATE- Z —`1 SIGNATURE Jnat�— TERS AREA MAY BE USED FOR DRAWING YOUR SM PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): 1 Client Notification Date: IEHS: Account No. 2J Z Invoice No. 01L") Parcel 29.08 .6 it John M. Clement dEsite l� D.B. 194-626 Ountry Lon lain T S S.R. 1400 y Rood 1 ses W i P`~ �S8 96 • / ,� £ 2S6 Location Atop n.t.s. 8 LEGEND / RAE - �-d- way �(�/ ' � - Existing coil MMon Pipe 3139 Ep / Ni - - NowYronPI / 0 NIP Now Property OR FleceS P/L - onb%UA LIN• C A - C Reinforced Aoow RCP - RAII+<alasd Canae4 t'IDe - Center Line CH - Chm'd ll4talo - port of 0 sigm EessnlNlrt _ • - CIP - CertMeeW NAfd PfpN � � ` ` �• �� � �OO��Bounavy�W .ne. . o � � / .� ``�' 0 66.54? / • 7 V/OQ 5•W O/ N Q 256,5 / NOTE THIS FLAT IS SVhXCT To ANY EASEMENTS. AGREE1CNTS. On r4f ? / 1110-• 4' .9•,414 (D NIGHTS OF WAY Or RECORD rNIOR To THE DATE a THIS PLAT. V C) I �� mo ^^) S1JR1mer Breeze - TNis @UnWr IS su/xCT To ANY FACTS THAT WY SE DISCLOSED SY A FULL Of t Book 7 Pa a 02.3 AND ACCLIMATE TITLE SEMM OCT FWISNED TO 14 As OF TNIs DATE. co oo a 9 ,Y'o o 3 A CO� / _ _ : .Sail, a i n Read — (See Ood Book 67.368 266.57• ) / � "° +Dail. round S.R. / Plot For James Murphy See Deed Book 208..Pa9e 770 kL Parcel 29.09. Davie County Tax Map.H-5 X4111.111/(►..F I 'otal Area = 2.000 Acres by d.m.d. ,�cARo''�•. COUNN �`� DATE1. C. Roy Cates. Certify rhai' under My" r* figond 1" •. 60' Mockaville Davie North Carolina 08-76-199P supervision, this map was drawn freil�:od '�rthid 09-28-1999(newBnea)+ survey. C Ray Cates JOB 110 SEAL-•..• v 119 Depot Street. 3510 60 . ' - 0 '. 60 120 180 r L-2623 : o CRC Mocksvitb, NC 27028 "` MAP NO : .. - ,., .. Lona sures ve or t Z 23'• ?� a` CRC �,� Phone ( 3355 !! 75 3735 35100. r Re istered o y .•SNRV•,.' _ Fax ( 336`) j5i 2750 �iRAPyI�. SCALE - FEET. , _ r •'� �. •••`.•• �g ,s. +' • •.f n 6 - . ..°jiX.`s.•T�.1��%i.,.. �.:..-.:. a :.�: k .::.:. ., ..•. 3_i.. ,'i. _ .-.. .., d. .... t ... .-. .. .. ...,Yi f 1C°.r.,. .. ... .i�:'.,...... � ..... %�.'�.. .,.i•�. �• ... ,. ... .. ...��h'��%4s� r APPLICANT INFORMATION Account #: 990000792 Billed To: James Murphy Reference Name: James Murphy Proposed Facility: Residence Water Supply Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-45-1726.02 Subdivision Info: Location/Address: Oak Grove Church Road -27028 Property Size: 1.2 Acres Date Evaluated: /�&�w On -Site Well / Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: .6 LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: A `( OTHER(S) PRESENT: 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 Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 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 - gal/day/ft2 DCHD 05/99 (Revised) ■E■ OMEN NONE ■E■■ SOME soon ■■■■ OMEN SOME NOON NONE NONE OMEN NOME NOME ■■■■ NONE NOME MEMO MEMO MEMO NONE MEMO OMEN ■EM■ ■■■■■■ ■EM■■■ ■MEMO■ ■■E■■■ii ■■■■E■( ■■E■■■i ■■E■■■I ■■■■■EI ■■E■BI MEMO 1 ■ME■■■i ■MM■MMii mom MEN U■■E■ NOME MONS■ NOES MEMO ■NE■ NONE NESS ■E■■ NONE MEMO ■■■■ NONE ■E■E■ NEON ■ME■■■■■■■ ■MEM■■■E■■ ■■■■■■■■■■ MM■■MM■■■■ ■■■■■■■■■■ ■■EM■E■E■■ ■MEM■■■■■■ ■■■■■E■■M■ ■■■■■■■■M■ ■■■■■■■■■■ ■MEMO■■■■■ ■■■■■■■■■■ ■N■■■M■■■■ ■N■■■M■■■■ ■■■■■■■■■■ ■E■■■M■MM■ ■E■■E■■■■■ ■E■■E■■■■■ ■E■■M■■■M■ ■E■■■■■■■■ ■E■■■■■S■■ ■N■■■■■■■■ ■E■■■■■E■■ ■■M■MMEM■■ ■MMMMMM■■■ ■E■■M■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ MEMO■■■■■■ ■■■■■■E■■■ ■■MEMO■■■■ ■■■■■■■■■■ ■■E■■■E■■■ ==m■■■■■■■ ■■N■■■■■E■ ■■■U■■■■■■ ■■■s■■■■■■ ■■■E■■■■■■ ■■■■■■■■■■■■E ■■■■■■■■M■M■■ ■■■E■E■E■E■ ■■■■■■■■■■■ ■■■■■■MOM■■ ■■■M■■■■■M■ ■■■■■■■■■■■ ■M■■■■■■■■■ ■■■MM■■■■■■ ■E■■■■■■■■■ ■■■■■■■■■■■ MEMO■■■■■■■ ■M■■■■■■■■■■■ ■E■■E■■■■M■ ■■■■■■M■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■