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535 Sheffield RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001820 Tax PIN/EH #: 5719-39-0622 Billed To: Lonnie Jones Subdivision Info: Reference Name: Location/Address: Fred Lanier Road -27028 Proposed Facility: Residence Property Size: 5.97 acres ATC Number: 2916 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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 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 0— #Baths Dishwasher. Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Ac Type Water Supply _ Design Wastewater Flow (GPD) c2 Site: NeVA!r Repair ❑ System Specifications: Tank Size /'*aGAL. Pump Tank GAL. Trench Width'/Rock Depth Linear Fl Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) 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.**** r Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Zq Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001820 Tax PIN/EH #: 5719-39-0622 Billed To: Lonnie Jones Subdivision Info: Reference Name: Location/Address: Fred Lanier Road -27028 Proposed Facility: Residence Property Size: 5.97 acres ATC Number: 2916 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 WASTEWATCONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ^1'7 �� 1 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 guarantee that the system will function satisfactorily for any given period of time. • 3 F Septic System Installed By: Z Environmental Health Specialist's Signature: TDate: DCHD 05/99 (Revised) . P IF FOODSERVICE: # Seats . / Estimated Water Usage (gallons per day) 7. Type of water supply: is County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 44 -No • � ((5+ � U � 1� PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC VVI" Davie County Health Department D I Environments/Hes/th Section P.O. Box 848/210 Hospital Street Mocksville, .NC 27028 TALHEA�TM (336) 751-8760 '';" • IRONMFN THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS /P'ROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �• p y�,g ; �,r� � , ,n�/, H PS Contact Person Gpp H e V oAtc S Mailing Address Z%� /-pr•�C ,C�`i,Xd�• �a[ Home Phone /9 �- x}833 City/State/ZIP�/zvs�i-+' 1,/(/C Business Phone 948..'-533 2. Name on Permit/ATC if Different than Above k p v� a: � G%t+rs Mailing Address � 92 iipr�t Qi dy ��✓ Ci-t�y/State/ZiP 3. Application For: Bite Evaluation Imp ovement P�mit ATC ❑ Both 4. System to service: l�House ❑Mobile Home ❑Business ❑ Industry ❑ Other 5. If Residence: #People �_ # Bedrooms #Bathrooms ,2 W"Dish►rasher El Garbage Disposal I�I"Washing Machine ❑Basement/Plumbing 1.1 If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: S, 9'7 Nc-, w Tax Office PIN: # 5- 7/9 3 9• a 6 a-�— Property Address: Road Name Fr<<1 LION;-er AV City/zip /'tio�6csu���r,/�C• If in a Subdivision provide information, as follows: Name: None - Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: '4 flo /' N , r �� Fj-•� L-tii it i r �� _1�rr� Le FT /�•^ooPr /ova A11-4 I Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) 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 falsified or changed. I, also, understand that I am responsible for all charges incurred from 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 by to conduct all testing procedures as necessary to determine the site suitability. DATE G ^ Q- -5- - V• 0.n/ SIGNATURE e. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 7- le- Revised DCHD (07/99) 37 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. I g�?- 0 Invoice No. 3 O SC)� Basement/No Plumbing 6. If Business/Industry/Other: Specify type � H � # People # Sinks # Commodes # Showers #Urinals #Water Coolers If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: S, 9'7 Nc-, w Tax Office PIN: # 5- 7/9 3 9• a 6 a-�— Property Address: Road Name Fr<<1 LION;-er AV City/zip /'tio�6csu���r,/�C• If in a Subdivision provide information, as follows: Name: None - Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: '4 flo /' N , r �� Fj-•� L-tii it i r �� _1�rr� Le FT /�•^ooPr /ova A11-4 I Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) 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 falsified or changed. I, also, understand that I am responsible for all charges incurred from 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 by to conduct all testing procedures as necessary to determine the site suitability. DATE G ^ Q- -5- - V• 0.n/ SIGNATURE e. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 7- le- Revised DCHD (07/99) 37 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. I g�?- 0 Invoice No. 3 O SC)� Qf N \ ♦ s \ \ OO� /� O•1 J j o O 1 EIP F nd Tax Lot 59 ♦ \ 5.945 Acres m A�� \ 4 � o 0 0 S ^o I nd ! Una � o ao 1 Part of ri — -- — — ---- — N 32'07" v'I IRS — _ IRS Placed in Line 536.33' — N 87037'0511W 26.88' APPLICANT INFORMATION Account #: 990001820 Billed To: Lonnie Jones Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5719-39-0622 Subdivision Info: Location/Address: Fred Lanier Road -27028 l Property Size: 5.97 acres Date Evaluated: -2,7 Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1. Sloe % HORIZON I DEPTH Texture group 77 Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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 777 SITE CLASSIFICATION: 4�� EVALUATION BY: _ZL// LONG-TERM ACCEPTANCE RATE: I Z REMARKS: 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) ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ SEEN ■EEE■■E■■■E■■■■E■■NE■■t■■■E■EE■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■S■■■■■■■■■■■■■■■■■■■■■■ NONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ecce■■■M■■■■■ME■■■■■■eee■■■EEEEE■■E■ ■eee■■■■■E■■■■■■■■■■■■E■■■■■E■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■M■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■■■■■■■■eee■■Ste■■■■■■■M■■■E■■■ ■ecce■■E■■■■EE■■■■E■e■■■■■■■■■■M■M■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■e■■ ■■■E ONES ■■■■ ■■■ ■■■■■ ■E■■■ MEMOS NONE ■ ■ ■ ■ ■ MENS■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ SOMME MOONS ■■■■■ ■O■■■ ■■ME■ ■■■■■ MOONS ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ mom MENU MENS■ ■E■■■ ■ June 27, 2001 Lonie E. Jones 697 Fork Bixby Road Advance, N.C. 27006 Re: Site Evaluation/ Fred Lanier Road Tax Office Pin : #5719-39-0622 Dear Client(s): As requested, a representative from this office visited the aforementioned site on June 27, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation 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 office. Sincerely, A4MO'Ize. g;�A. Robert B. Hall, Jr., R.S. Environmental Health Specialist RI-1/di