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196 Smith Rd .- , DAVIE COUNTY HEALTH DEPARTMENT /f�� /— 3 — �I ` � Environmentai Health Section �j , r.o.sog sasnio x�p�rai sr��t � Mocksville,NC 27028 (336)751-8760 � IMPROVEMENT/OPERATION PERMIT Account #: 990000753 Tax PIN/EH#: 5707-245494 Biiled To: Kip Miiler Subdivision Info: Reference Name: tGp Miiler / Location/Address: Smith Road-27028 Proposed Facility:.I��iZD� Property Size: 2 Acres q�� b r. 2599 **NOTE*'�'�iis gmprovemendOperation 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 THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �' #People_� #Bedrooms #Baths_� Dishwasher: � Garbage Disposal:� Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Faciliry Type #People #PeoplelShift #Seats Industrial Waste: ❑ Lot Size taC' Type Water Supply� Design Wastewater Flow(GPD) ��a Site: NewP�Repair� i � System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt��Rock Depth /�-Z Linear Ft./�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department fdr 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.**** � Environmental Health Specialist's Signature: Date: �(�fjf�� DCHD OS/99(Revised) . �� ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Haspital Street Mceksville,NC 27028 (336)751-8760 Account #: 990000753 Tax PIN/EH#: 5707-245494 Biiled To: Kip Miller Subdivision Info: Reference Name: Kip Miller Location/Address: Smith Road-27028 Proposed Facility: Residence Property Size: 2 Acres ATC Number. 2599 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 CONS UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Date: /� /�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Itnprovement/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. r Septic System Installed By: Environmental Health SpecialisYs Signature:�x/,x.(!/ _ Date:,�� — DCHD OS/99(Revised) �_r � c a • � , �� APPLICATION FOR SfiE EVAU1ATlON/IMPROVEMFM PERMR&AT � � � � � � �,� ��` Davie County Health Department � `�1T �� Environmenia/Hea/ifi Se�c�ion �� P.O. Boa 848/210 Hospital Street � � 7 2QQQ (�� 9 Mocksville, NC 27028 U" (336)751-8760 ;%; , ENVIRONMENTAI NEALTH DAVIE COUNTY - ***Z1�QRTANT*** THIS APPLICATION CANNOT EE PROCESSED UNLESS ALL THE REQOIRED -_ INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to � s�iiaa _�,� � /�11!1`'/1 Contact Person I��1'✓ �/�lt�-- Mailinq Addreas �� 1/>i�C'//�t;)� ,�� 8ome Phone �/,��"Z�"G� cit�r/state/zzp y�c�kru rl�l N- C z�d t� Susineaa Phone �'7�/- Z G Z � 2. Name on Pazmit/ATC if Dilferant than Above Mai.linq Addreea te/Zip„ /� �� -�� 3. Application For: C��te Evaluation �I rovement Permit/ATC ❑ Both a. syrat.�m to ser�ce: ��ouse ❑ Mobile Home Business ❑ Industry �ther� s. if Etesidence: � People � # Sedrooms i Bathrooms �_ ❑ Diahraaher D Garbage Disposal l�Washing Machine asement/Plumbing ��asement/No Plumbinq 6. I! Susinesa/Induatzy/Other: Specify type ; Peopls i Sinks / Coaodea � Shoxers # Urinais # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage tQ�iona �= aay) 7. Type of �vater supply: � County/City �ell ❑ Community e. Do you anticipate additions or ezpansions of the facility this system is iutended to serve? ❑Yes '�No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLET'ETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PL.AT or SITE PLAN MUST BE SUBMlTTED by t6e client wit6 TIIIS APPLICATION. Property Dimensions: �v ��i WRITE DIRECTIONS(from Mocksville)to PROPER7'Y: Taz OfTice PIN: # ��0�-02 y.�`��j �Q� i�n ,��4 ��) i f �rnS Property Address: Road Name S/�177� �� '� /�� 1e� c�tyiz;p r�oc,�su►tCt , � �'�>�N �'c1 0✓� /e�'� If in a Subdivision provide information,as follows: Name: C l91� S � Section: Block: Lot: Date Property Flagged: 2�/`7-od 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 suspension or revocation,if the site plans or intended nse c6ange,or if t6e information submitted in this application is falsi5ed or changed. I,a/so,understand that I am responsible for all charges incurred from tbis appllcation. I,6ereby,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 prceedures as necessary to determine the site suitability. DATE Z—�,�I('J a SIGNATURE�/� �� THIS AREA MAY BE USED FOR DRAWING YOUR SIT'E PLAN(Inclade ali of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. S`� Revised DCHD(07/99) Invoice No. �/� � �`�-R l/�� , , ,,.� �1 �� I� , , I �,.,,. . _ i� ` I ' � N�,. �,�s�+� , ,_ - � I � c� ami ' _ ` I � I ,a, _ I'" � ++ I sn u ��[N[E � � rvfi4U00� � / I j I p BBB;7�• SHEETS � 1 � J P9• 702 ��4 1 � � �i 35 � ' � 1 � �d0 Y . �1�uCc 313 �I C�1 - . so.� -lS i I p�:� � � � — � 6P ... fl GARN R➢ �c�5 1� NPIL I � 4�' MHITE 0�`W�'I�� 322 / 1 3rinit�p/VOODS IINr —� CL NMdtN Rp � N � I �' . COR V�Q➢S ' c 3 _ �6 �Tc� 318 ' 1 < L CL f ARM RD 5' � �• I <y[F�iqf;��n�1PRKED �lr — — . k l L TiM Pr�a ,'I 1 ]� pµ�.� 0`N NP�iF��S �z��K-32150 36) � C[1R 4��79 L� RO ' 3l) � � _ _ _>.C� — — � _ �._ _ _ _ � � _ _ 4}1 n_ � ��:Ila v�01i��nGS 3:9 � rv_n[;S IC'.. t :4n..�, � � � � , �' '— � "� BOBBY C. SHEETS � � cuu voo�s�� 07 �- - - - - - - - - - - - ��- - - - - - � v D.B. 189 Pg. � � � :6 � I I ' � Cl;RPVEL I ' IG � �i � ['1� RL1 I `1 CL INIC!?S[C I r � _ A7!� Iv Ct. � ,� I LL ORIVE I ' CL I +�3 1J51]6 PBO — . I 2 — � � — _ _ _r _ — — _ _ _ — I—_—— — rvPIL �L� ll] � �io � �� NnIF!�'=BEi�iJ I I � I � � I ^ � � � 5� � i I \C \ � � I �� I I � � � I • � �- - - - - - - - - J I � � I ,1AMES M. DO I p,g. 130 Pg• ` � I ! � I I � I � � I I � I � I � I � I � I � -''� �' • DAVIE COUNTY HEALTH DEPARTMENT . Environmentai Health Section � � Soil/Site Evaluation APPLICANT INFORMATION . PROPERTY INFORMATION Account #: 990000753 Tax PIN/EH#: 5707-245494 Billed To: Kip Miller Subdivision Info: Reference Name: Kip Miller Location/Address: Smith Road-27028 Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: E'j�� Water Supply: On-Site Well 'v Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition '' Slo % HORIZON I DEPTH Texture ou Consistence Stivcture ° Mineralo HORIZON II DEPTH " " Texture ou � 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 `Z SITE CLASSIFICATION: /�/' EVALUATION BY: / LONG-TERM ACCEPTANCE RATE:�_ OTHER(S)PRESENT: REMARKS: U� ..� r -� �?/�� /�'' G(iyl�' LEGEN 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 Moi VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firnt 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 Mineraloev 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) ,.., �t a . ;�+i%.�:.f+-� \:jJ�f�� . ., 1��kir�.�xa r.J�AJrI! k�li1,.*�y-.��! L — .r. ..n r.�r a e . .— a-,-.. ,.,,.� f R'.f.Y�4} 9 K7��..��'+5�21!. #Ai.IT{..�rD _�.'!:bS9Y!'N �. t3. 8ox 848/270 €iospitat &treet Courier #09-d0-06 � �friocksviiie, !VC 27a2S + -„ r.� ;.,.r►�..�r,�., ,,2F,.,,: ;";. ?:e..: ,-. 1�:�..c.".3. . .�Ct:.ot . Mazch 7, 2000 �Vir. Kip Miller 8184 Yadkinville Road Mocksville,NC 27028 Re: Site Evaluation/Smith Road. Tax 011ice PIN: #5707-24-5494 Dear Client(s): As requested, a repre�ntative from this office visited the aforementioned site on March 7,2000. Based upon the information provided on the Application for Site Evuluuti��n and after an evaluation was completed on the site,the site was found to 1W provisionally suitable for the installation of a modified,oversized on-site sewage system. Before an Improvement Permitl.�uthori�ution tv Cr»zstruct can be issu�d 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, �,�!�t��. Robert B. Hall,Jr., RS. Environmental Health Specialist RH/mp Enclosure(s)