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367 Speer Rd (2) - DAVIE COUNTY HEALTH DEPARTMENT ,� � _l � _v� , •' •" ' Environmental Health Section � ' P.O.Boz 848/210 Hospital Street • , Mocksville,NC 27028 ` (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002727 Tax PIN/EH#: 5812-64-6422.02 Billed To: Jason Mullis Subdivision info: Reference Name: Location/Address: 367 Speer Road-27028 Proposed Facility: Residence Property Size: 1.644 acres ATC Number: 3454 **NOTE** This ImprovemendOperation Permit DOES NOT.authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 STTE 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: O Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply—�"'�-�, Design Wastewater Flow(GPD) ��o d Site: Nevr� Repair❑ / i �/ ! System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width �(� Rock Depth� Linear Ft.� Other: Required Site Modifications/Conditions: 1119PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED E FLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe a � ountyHealth Department for final inspection ofthis system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on th installation. Telephone#is(336)751-S7G0.**** � �%1?, ��/ �-- . ,ro L✓e l/ . �l �x �' � / y�// �[ly� Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � M � � � ' • � DAVIE COUNTY HEALTH DEPARTMENT , Environmental Heaith Section ` � P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002727 Tax PIN/EH#: 5812-64-6422.02 Billed To: Jason Mullis Subdivision Info: Reference Name: � Location/Address: 367 Speer Road-27028 Proposed Facility: Residence Property Size: 1.644 acres ATC Number: 3454 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ��/ Date: J r����� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemenbOperation Permit has been installed in compliance with Article 11 of G.S. ha er 0 Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a ar tee hat he system will function satisfactorily for any given period of time. S�P� - ,� -�-L J �X3 x ������ /D �---�-'_' � J Septic System Installed By. '� � Environmental Health Sp�ialist's Signature: 5�—�F�.(�1 Date: � �� DCHD OS/99(Revised) �. . f.: , ''R ����W py1(� . ��1 PPLICATION FOR SITE EVALUATION/IMPROVEMENT PER611T&ATC Davle County Health Department �1 � �j 2� Environmenta/Hea/th Section �p` O P.O. Box 848/210 Hospital Street � � . Mockaville. NC 27028 � � (336)751-8760 PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BIILLETIN for instructions. 1. Name to be Silled ���, � ''�S Contact Person JASr�r pr �{y1V�H �,�1.(.�'l<, pti Mailing Addresa �7�� 1�rO�erS I�.IJ• Fiome Phone �� g�� '�Cv y City/State/ZIP ��1fi0.U�A� ��� ,�e ag�DJ'�G� Business Phone 33b 4��/ ��9/ 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zip �,.._- -----� 3. Application For: Site Evaluation Improvement Permit/ATC Both� .. �_ 4. system to service: House obile Home Business • Industry Other 5. If Residence: # People _� # Bedrooms � # Bathrooms o�. Diahw � Garbage Diaposal ahin M ch Basement/Plua�bing Basement/No Plumbing 6. If Busineas/Industry/Other: Specify type # People # Sinks # Coa¢aodes # Showers # Urinals # water Coolers IF FOODSERVICE: # Seats Estimated' Water USage (gallons per day) 7. Type of water supply: County/City Wel Community s. Do you anticipate additions or expansions of the facility tliis system is intended to serve? Ycs No If yes,what type? ***IMPORTANTk**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQU�STED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the clicnt with THIS APPLICATION. Property Dimensions: �, �0�7 Z WRITE DIRECTIONS(from Mocksville)to PROPGRTY: Tag Office PIN: # 5� 1 a� ��o �a a-� ,�a� s /v �;br�.k, c ti • �O ��iylOr�,(�O/t Property Address: Road Name 3(0��� r�Cl• �. � 15-1- I�pr ���� ��-i�/'f��� City/zip �OC�`hl�)�C(aC c��da'� --�D � Jr�rl. Dn � �-F-i� If in a Subdivision provide information,as follows: �;���j Name: Section: Block: Lot: Date home corners ilagged: � " ��d`� , This is to certify that the information provided is correct to tlie best of my knowledge. I understand tliat auy�ermit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use cl�ange,or if the information submitted in this application is falsified or changed. I,also,u�:dersta�:d tliat I mn respo�:sible for all cl:arges i�:cirrred from t/ris applicatioi:. I,hereby,give consent to tl�e Authorized Representative of the Davie County Hcalth Department - to enter upon above described property located in Davie County and owncd by_Q������(�t��'.� to conduct all testing procedures as necessary to determine the site suitability. C� DATE e� /,�/D�- SIGNATURE����LL�� THIS AItEA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic tocations). � Site Revisit Charge Date(s): i� � �—' ,�— � � Client Notification Date: �C��— � I T � EHS: O� . Sign given �� 9��� Account No. �7 L Revised DCI�D(07/99) Invoice No. ��'� (4;16) � �LLZ) ; �, ��. (S9Z) � � � - - - -- - r'v� Q � . . _ . _ _ _ - I . O N _ __ � OLZ ` � � � o� (ZOE) /�'� �a22> N ; ` . , � , � , , � � ' zi ' � M ' . , � ; � '� ` . , �, % �8�'sJ ; ; � �„�,u ��, i , M ,� (tsS� Qap���� ir11 'r�Q � dJ' � � � \ � 1 o � N � b ��t \� �----• J ��'� fIh'J '� 1\ / �k/ � C�y``Ia;��� V V a C Q M cY � M � o � � � I � . J ;-. �� �. ' DAVIE COUNTY HEALTH DEPARTMENT r • Environmental Heaith Section - . . , Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002727 Tax PIN/EH#: 5812-64-6422 Billed To: Jason Mullis Subdivision Info: Reference Name: Location/Address: 367 Speer Road-27028 Proposed Facility: Residence Property Size: 1.644 acres Date Evaluated: 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 % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPT'H Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOI1.WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 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 � NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic tructure 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-gaUday/ft2 DC�ID OS/99(Revised)