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195 Triple Creek TrailAccount #: 990002172 Billed To: Suzan Minor Reference Name: Pr000sed Facilitv: Residence ATC Number: 3082 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5759-39-6273 Subdivision Info: 111,e- ITIple- CL kfi l Location/Address: Hepler Road -27028 Prooerty Size: 5.307 acres 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 WASTE WATE NSTRUCTION IS VA ID OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �7 �! -� /60M 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. „xlZ , r 5Z,- 2© - U6 Septic System Installed By: Environmental Health Specialist's DCHD 05/99 (Revised) I x3U x/L.i �t� >, �a bf(i Q--t%\V MA VC6 0 t Account #: 990002172 Billed To: Suzan Minor Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 313d /2t -5,—j /,—, CS 'L -- Tax PIN/EH #: 5759-39-6273 Subdivision Info: Location/Address: Hepler Road -27028 Property Size: 5.307 acres 115 ATC Number: 3082 **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 %%1 fig #People J #Bedrooms _� #Baths Dishwasher: e Garbage Disposal: ❑ Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industria13 all Waste: Lot Size �-�ie Type Water Supply 11111% Design Wastewater Flow (GPD) � Site: New ZrRepair ❑ System Specifications: Tank Size /DOd GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width gl "/Rock Depth 4E Linear Ft.AK�o IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISIIED 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environments/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 (N2NOM[s 2 Z -1,D- EIlVIR01,"',ENTAL HUVIi ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Address City/State/ZIP 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: Site Evaluation 4. System to Service: ❑ House K -Mobile Home S. If Residence: # People Contact Person Home Phone,2 CG L(� Business Phone 3J (� I I 3-3 City/State/Zip Improvement Permit/ATC ❑ Business ❑ Industry ❑ Other # Bedrooms # Bathrooms [I Both U16-:Lshwasher ❑ Garbage Disposal v aching Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes �_ # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes P -N If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 53D-] WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #_- 5 ] .C:'"—aggc -7 -3 l_'] D &D (-'\ ,J V 1 10 *10(1 Pd Property Address: Road Name City/Zip i r ll�hJy� l t /trQ . . �t l�lr If in a Subdivision provide information, as follows: IALI e (r, V .-Q Y\\ /t'q s'4 � l r Name: Section: Block: Lot: Date Property Flagged: 2 O 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 ain 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 sui ability. DATE C�CX SIGNATURE 0 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Inclu a all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. � 1 Invoice No. jK Q r-) L"/ MAP H-6 / PARCEL 1 ROBIN U.. HANES )S 105 PG'437 & DS 113 PG 262 i I �t I I I: i I I �I i IReber `Found o 1 50' 9 1 Rebar Set l Reber / Found i N WHITE OAK Pipe / \ Found MAP G-6 / PARCEL 105 .JOHNNY R. OLOHAU DB 175 PG 624 1 _ S OO'22" E 962.88' Total Rebar x Found x �lhj { MAP G-6 / PARCEL 106 ALBERT S. COMM DS 177 PG 726 4654,938 10.674 ACRES ( DMD) N 79.7' tj Q I Power — x --- -- 4SSW Fencex 25 w. .Box CCf ------------ r --- — --- --• -----x .._ ---, Fence M G*ovel Drive — 884.97' x y --- - Reber ' r Found DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002172 Billed To: Suzan Minor Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5759-39-6273 Subdivision Info: Location/Address: Hepler Road -27028 Property Size: 5.307 acres Date Evaluated: 0 -2 % Water Supply: On -Site Well 11 Community Evaluation By: Auger Boring 6/ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Sloe % HORIZON I DEPTH l Texture group Cel - Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure /G 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 , 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 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) ■ ■ ■■ ■■�■■■■■iii■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■■■■■■■■■■ MENU■■■■' ■■■■■■■■■■■■■■■■■ ■ ■E■■E■■■■■■■■■■■ ■■■■■■E■■■■■UES■ ■■■■■■■■■■■SSS■■ ■■■■E■■■■■N■■■■■ ■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■M■■■■■■ i ■ ■■■ NONE NOME ■ ■ ■■■■■■■■■■ MEMS■■EO■■ ■■O■■■■■■■ ■■■■■■■■■■ ■■EEE■E■E■ ■■■■■■EO■■ ■E■■■■N■■■ ■■■E■■■■■■ MENS■■■■■■ ■E■■■■■■■■ ■■■■■SSSS■ ■E■E■EE■■■ ■■■EE■E■E■ ■■■■■■■N■■ ■■NOMMEN■■ ■■EEE■■■■■