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166 Shelton Ln . , DAVIE COUNTY HEALTH DEPARTMENT �GC �- 3v_ �/ . • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001452 Tax PIN/EH#: 5823-65-8326 Billed To: William Perkins Subdivision Info: Reference Name: Jack Perkins Location/Address: Shelton Lan�27028 Proposed Facility: Residence Property Size: see map ATC N�u�pb r: 2708 **NOTE** Thls�mprovemendOperation 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE TAIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type (' #People� #Bedrooms #Baths�_ Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement wlPlumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � ��� Type Water Supply /rt�<�l Design Wastewater Flow(GPD) Site: New❑ Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width,���Rock Depth� Linear Ft� Other: Required Site Modifications/Conditions: � INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTiCE: Cantact a representative ofthe Davie County Health Department for final inspection ofthis 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.**** O Environmental Health Specialist's Signature: Date: �"oC�1 � � , DCHD OS/99(Revised) . ' , � � � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001452 Tax PIN/EH#: 5823-65-8326 Billed To: William Perkins Subdivision Info: Reference Name: Jack Perkins Location/Address: Shelton Lane-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2708 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: G� Date: �'�-� �� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 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 period of time. 1�a X��'� �. ,� , , � `� 1 r'' r Septic System Installed By: Environmental Health Specialist's Signature: -----����.i' Date:�"���� `� DCHD OS/99(Revised) s ��p�r��a� b n-� �-�`"� �. �^ � ^°� �` u� . ✓� ....._.. � - .�' �o�� � �APPLIC,ATION FOR SITE EVALUATION/IMPIiOVEMCNT PEIiA'il�'&ATC ` �t � � Davie County Health Department OCr � � ^ � � Environmenia/Hea/ifi Section ��'+�� � �� P.O. Box 848/210 Hospital Street � � Mocksnille, NC 27028 � � a 5���� (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruc�ions. 1. Name to be Billed �U+/�/��f/ �`-� /� �+-/E'� 1�� Contact Peraon I/< <J Q/�s � Mailing Addrese f CJ IC� ��({��%O✓t^ �/�n'C�y. Fiome Phone � ' 1 C' �7 r .3 �G� City/State/ZZP �//�Cf�'SGi�/�i �'`�OC?�vZ �•Businesa Phone 2. Name on Permit/ATC if DiPferent than Above � t'i � �'�!�/�-/� S �S��� � Mailing ]�,ddreas City/Sta /2i � J 3. Application For: Site Evaluation �.,Zmpx�o�em�t Permit/ATC � ❑ Both � � a. syat� to sesvice: ❑ House e ❑ Business � Industry �Other ��r`n 5. If Residence: � People � 8 Bedrooms /'� � � Bathrooms � y II Diahxasher I�I Garbaqe Diaposal �Washing Machine ❑ Basement/Plumbing (7 IIasement/No Plumbing 6. If Bueinesa/Industzy/Other: specify type $ People It 3inks # Coaodes i Shoxers $ Urinals � Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (qallona �r a�y) 7. �pe of water supply: ❑ County/City [�Well fJ Community � / a. Do you nnticipatc additions or eapansions of the facility tf�is system is intended to serve? ❑Ycs �o � f ycs,what typc? � ***IMPORTANT''`**CLIENTS h1UST C0�11PLETETIiE REQUIRED PROPERTY INFORMATION IiGQUI;STLD � BELO\V. Either a PLAT or SITE PLAN�tUST BESUBMITTED by tl�c clicnt with TEIIS APPLICATION. Property Dimensions: ✓ e� � � �OC�A� WRITE DIItEGTIONS(from Mocksvilic)to 1'[t01'GIt7'Y': Tuz Officc PIN: #�� a+ �- � s' S��J ��' - �c.� �/ %fl ,�'�� � %�---- 12� Jc--�. Property Address: Road Nam�-��'f�►^� �—`�-r'1 � a /� �� /r .3 i�.. �r s �%� c;cy�z�p S�P /��,� 1�---- ��-�--- �'J�-'�'�'�� � lf in a Subdivision provide information,as fallows: � '�o �-����`'/. Namc: Section: Block: Lot: Date Property Flagged: 1� I� � � � T6is is to certify that the information provided is correct to the best of my kno�vledge. I understand that any pern�it(s) issucd hcrcaftcr are subjcct to suspension or revocation,if tt�c site plans or intendcd use cUangc,or if thc int'ormation submitted ia this application is falsified or changed I,also,understand lhat I am re�roasible jor a!1 charges incurrer!jrnrri Ihis application. I,hereby,give consent to the Authorized Representative of the Davie County I�eaitL Departsnent to enter upon a6ove described property located in Davie County and owncd Uy ______ to conduct all tcsting procedures as necessary to detcrminc tlie site suitability. DATE �C� '' J� ^ ��� SIGNATURE � ��_ TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inclu all of thc followinb: �aisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Rcvisit Chargc Datc(s): Clicnt Notification Datc: EHS: • � Account No. I �� Rcvised DCHD(07/99) Invoicc No. � � , , :., . , :. � ��. , . ' ` - - _ DAVIE COUNTY HEALTH DEPARTMENT � . Environmental Health Section sECTiorr LOT � SoiUSite Evaluation APPLICANT'S NAME �P��`�`� S DATE EVALUATED �a 1J �� PROPOSED FACILITY ��r l� PROPERTY SIZE � ��G SUBDIVISION ROAD NAME ��8�4�. �17"� Water Supply: On-Site Well t� Community Public Evaluation By: Auger Boring_;(�__ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slo % � HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH '` � Texture ou C Consistence ..E`� � Structure b K /I << 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 TE: ' � OTHER(S)PRESENT: REMARKS: �/ GV � C/°jj'JC��� 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 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 t ct re SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed N es 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 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._...�_.__._.,__�.,�,._ . .. ._..._.. _ ._. :� ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksvilie, NC 27028 Phone #: (336)751-8760 October 26, 2000 William B.Perkins 166 Shelton Lane Mocksville,NC 27028 ' Re: Site Evaluation/Site 1 Tax Office PIN: #5823-65-8326 � � Deaz Client(s): As requested, a representative from this offce visited the aforementioned site on October 25, 2000. 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 at your barn. ._ 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, ���r�t�o•�.rl�,�,• � Robert B. Hall,Jr., R.S. Environmental Health Specialist RH/di Enclosure(s) •