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190 Smith Rd . ' _ _. DAVIE COUNTY HEALTH DEPARTMENT ) . � Environmental Health Section ,� �� � O/ vZ_- ' • ' " ' P.O.Boa 848/210 Hospital Street � -- Mceksville,NC 27028 p�� �� � (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990002345 Tax PIN/EH#: 5707-25-6288 Billed To: Marty Cook Subdivision Info: /�j0 S/sfi-��? �1' Reference Name: Location/Address: �f'Smith Road-27028 - Proposed Facility: Residence Property Size: see map � **NO�'�"� ►l�i' P�cfrprd�+�ndOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON 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 THIS PERNIIT BEFORE INSTALLING SYSTEM. - Residential Specification: Building Type T`"/ #People� #Bedrooms S� #Baths � Dishwasher;�Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #PeopleJShift #Seats Industrial Waste:.❑ Lot Size �l�� Type Water Supply��/�Design Wastewater Flow(GPD) �6 d Site: Netir�Repair❑ System Specifications: Tank Size�IJ6D GAL. Pump Tank GAL. Trench Width�C��Rock Depth /,� ��Linear Ft.J�'d � Other: Required Site Modifications/Conditions: IN[PROVEM11ENT/OPERATION PERh11T LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact 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 ofinstallation. Telephone#is(33G)751-87G0.**** . ��� v Environmental Health S ecialist's Si ature: Date: �v2"��i ✓ P � DCHD OS/99(Revised) . • • o`�. ' . , . DAVIE COUNTY HEALTH DEPARTMENT � Environmental Heaith Section r.o.Bog sasnio x�p�t�i sr��t Mocksville,NC 27028 (336)751-8760 Account #: 990002345 Tax PIN/EH#: 5707-25-6288 Billed To: Marty Cook Subdivision Info: Reference Name: Location/Address: off Smith Road-27028 i ee ma ATC Number: 3195 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **KOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 O STRUCTION IS VALID OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � � Date: �'��� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenUOperation Permit has been installed in compliance with Article I 1 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. � Qb����a �, � Septic System Installed By: Environmental Health Specialist's Signature: Date: 7✓� � 2 ��/ DCHD OS/99(Revised) w� . � • . • APPUCATION FOR SiTE EVAlUAT10N/IMPROVEMFM PEfiMIT& '� ' Davie County Health Department /� Environmenta/Hea/th Se+ction D �ti (� �'��""''� . P.O. Hox 848/210 Hospital 3treet U � � , Mocksville, NC 27028 (336)751-e�so JUN � 8 200? ***I�ORTANT*** THIS APPLICATION GAIVNOT 8E PROCESSED UNLES3 T D INFORMATION IS PROVIDED. Refer to the INE'ORMATION BtJLLETIN 'ns � '"fl� 1. Name to be Hilled �Y i V t i�0'� Conta�ct Poraon n C. � Mailinq Addreas �g�, \�����/) ��P��Q('! Home Phone " City/State/ZIP �������1� ��, /Vl� �7�.�� Husineea Phone � c�1� ,�„��� 2. Nemo on Permit/ATC if Differont than Above Hailinq addreas City/State/Zip 3. Application For: � Site Evaluation ❑ Improvement Permit/ATC ,�Both a. systam to sa�toe: �House � Mobile Home ❑ Business 0 Industry ❑ Othar s. rg Residence: � People �_ # Bedxooms �_ � Hathrooms �_ . ,�Diahrasher U Garbaqe Disposal �Washing Machino O Baaeme:it/Plvmbing �Sasement/No Plumbing 6. Zf 8uaineaa/Induatsy/Other: Specify type � Peopla �F 81nka # Commodea � Shoxera i Urinala � Water Coolera IF FOODSERVICE: # Seats Estimated Water�Usage (gallone per aay� 7. Type of xater supply: � COunty/City 0 Well C1 COmmunity e. Do you anticlpate additions or eapansions of the facillty this system is intended to serve? �Yes 0 No If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PLAN MUSTBESUBMI?TED 6y the client with THIS APPLICATION. Property Dimensions: �.�(��Sx 7b7x 3'17X3�,2x�3���RITE DIRECTIONS(from Mocksville)to PROPERTY: Tax 011Ice PIN: # �J`7D��'TJ�e o��� �,�1 il ���A� �� �rl'�,'El� ��i�� ��[ 7 b �1�1�' Properiy Address: Road Name ��m)`�1 /'laQ. �n 1 �i�r°, �C(Xf�Gr h�=� /b �f�t/C��� 1�y1 City/ZIp 1 J11�-5V1 I�� �7�(.� �?�G��G? ��(�C'?�„�D �7'7 nl1 `J�71/��1 /CN • If in a Subdivision provide information,as follows: '�('� ►Gl1t�t� �Fi 1"�� -�Ctrm �1�c� %h�0 �� . \ , Name: :�i� I c� �5e e �.�YG che� n�a r�� Section: Block: Lot: 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 6ereafter are subject to suspensioa or revocation,if the site plans or intended use change,or if the information submitted in this applicatioa is falsified or changed I,also,understand that I am responsib/e for al!charges lncurred jrom thls appltcation. 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 ��aQ 1'1'LT � �l }�" L to conduct all testiag procedures as necessary to determine the site suitability. DATE �Q I2�7��?v�— SIGNA �� " — �l� i� JL! T7iIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). �Site Revisit Charge Date(s): Client Notification Date: EHS: � � r Account Na � � � � 1 Revised DCHD(07/99) . � '�''�' J•�� Invoice No. v� t/ _ � ��'"� i� � . , " V_.a� � , � .,.� �--. �.y� --.� ��.�"` _.F"....� r+�.-' �""F"�" 'C--'3.-•- �'- oS „� r-� � "�+ � j����� �'; kr � � � a'�� x - i :� ,, '�t-� �."� c-� '.s . l� �"(' : .:: *4 - ;c - � (.. � §�� L7 . ���,' � y�^_� _ . . � , . - erP s ��: � 2 g,:� riJ�l� � _ _ GAR�Y SWAN : � . �9��'E� �� _ g ¢ -�uCjt�JS�.; D.B, 178 , � � ,'' -\ - , . . 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' -,'.: � 202 � � 26� d� � ; {� ��$�����' �F f � :.£ F � .2., fI'A••^.• . � � ' �t - 29.550A � � (37.01A) . � . . � �l 9044 2693 = • � DAVIE COUNTY HEALTH DEPARTMENT , , � ,. ' �� • ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION ,, Account #: 990002345 Tax PIN/EH#: 5707-25-6288 �� Billed To: Marty Cook Subdivision Info: - Reference Name: Location/Address: off Smith Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated; �`' �62 Water Supply: On-Site Well Community _Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � " �G•' Texture rou Consistence r' Structure S' .� Mineralo . 'l HORIZON III DEPTH Texture rou Consistence ' Structure Mineralo ' � HORIZON IV DEPTH Texture rou Consistence S[ructure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: �� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: r OTHER(S)PRESENT: REMARKS: 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 Mineraloav 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 DC�ID OS/99(Revised) ■����������■■�������o��■��s������s�■■����■����■���■��■���������■■■ ■��������■��������■�����■�����■��■���■����������■�■■��■�■����■��■■ ■■���������■���■����������e�■■�■�■�����■■■�����■��■�■■���������■■ ■�■■���■�■�������t■■�����■��■�■■ ■■�■��■�■e�������■■��������■■��■ ■����■■�������■�■���■�■■��■��������■■■■�■■���������■■�■■���e���■�■ ■��������■����■��■��■���■�■��■��■���■�■��■■�■�■e����►_,��������■�■ ■�����■���������������������������������������e��i����o���������a�■ ■��■����■■�■�■�■��■o����■■�■■�■��■■��■�■■�■�■�■■�i����■�����������■ ■o�■���■e■�■�������■a�■■�■��■�■����■�■��s���■��■�i�■■■����►��■■■�■�■ 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