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1526 Yadkin Valley Rd (2) DAVIE COUNTY HEALTH DEPARTMENT �� —�� -` ' � � Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)7S1-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001104 Tax PIN/EH#: 5863-23-4526 Billed To: Deborah Anderson Subdivision Info: Reference Name: Deborah Anderson Location/Address: Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 292 X 255 X 45 ATC N�p�b�r: 2409 **NOTE** "1'his mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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•✓ '/� C��'►r #People�_ #Bedrooms �� #Baths�_ Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: �� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size��x 4� Type Water Supply Design Wastewater Flow(GPD)��^Q Site: New��epair❑ ll a/ / System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.� O � Other: � , �--�n�. . .� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT AYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW F�NISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health 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 the day of installation. Telephone#is(336)751-8760.**** Y�� 1��1� ! - 1 + �' o`�0.�-� , ��'�) ./ � � �, � �(l..rl ' � 3--��°-� L�� ( � : � � �� .�� ,,, sr��'�.� �jr� �°� `� �� , m �� , � -��Environmental Health Specialist's Signature: " Date: � J DCHD OS/99(Revised) ,� � �� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mceksville,NC 27028 (33G)751-87G0 Account #: 990001104 Tax PIN/EH#: 5863-23-4526 Billed To: Deborah Anderson Subdivision Info: Reference Name: Deborah Anderson Location/Address: Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 292 X 255 X 45 ATC Number: 2409 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � - Date: ��-"C�G� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementJOperation 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. I��?k,n ��I f E �i��E � T� � aj� �x;s�-� �-7�F-� sT -I Ig'' ��'� ._. Tx;��,`� s--- C� oMF � �ofoN � S � s�,�� z � Septic System Installed By: CtE't � Environmental Health Specialist's Signature: � Date: cJ 8 't�� DCHD OS/99(Revised) . � . � , . ' � �.,.-,.�. � �,c l^'�`� APPLICATION FOR SffE EVALUATION/IMPROVEMFM PERMR&A . D � U � 0 `'I�� A�� /x� D a v i e C o u n t y H e a l t h D e p a rt m e n t � C w p�,� Envinonmenta/Hea/th Se�ction �R , 2 2 0�� S jt,� < �,�,. P.O. Box 848/210 Hospital Street a,� S' Mocksville, NC 27028 (336)751-8760 Ei��3i��:u':'"t!l'�RL HEALTF� t'��'ifi t^t1l1;JTY ***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQIIIRED INFORI�TION IS PROVIDED. Refer to the INFORMATION BULI.ETIN for instructions. 1. Name to be Billed ��'('(1�1'1 �-1 na e�S bh Contact Pereon /�!�n e �✓�Q W S�n. Mailing Addresa��L/ �P(1�IS-! �P_M � �c� Home Phone /� !J � U �C!J I City/State/2IP ��►'Y'�(�(1 C!►'15� /�/C �� oc Susinesa Phone �� 2. Namo on Permit/ATC if Different than Above Mailinq laddresa City/State/Zip 3. 1s.ppiication For: 0 Site Evaluation ❑ Improvement Permit/ATC � Both a. syat� to se=,►i�e: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: # People _� t 8edrooms � N Bathrooms � ❑ Dishnaeher ❑ Garbage Diaposal �ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. IE Buaineae/Induatzy/Other: Spec3fy type A People Y Sinks Y Co�dea � Sho�rera # Urinals N Water Coolers IF FOODSERVICE: # Sests EStim3ted WBter Ussge (gallona per day) 7. Type of water supply: fA�County/City ❑ Well ❑ Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes FlAFo If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by t6e client wit6 THIS APPLICATION. Property Dimensions: �9 a x �5S X y�U WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taz O�ce PIN: # c�0 �3 " �3 - y sa b .-�- y� �G��. ,�X i�- c�.�c �d� Property Address: Road Name /'�o�[o ��G i h ��K.( L�1-�1/'� �C��- O� �i»n• �6 c�tyiz�p /�va n c�e �J � , � v � b �,7p0(o 1" a,n en�r r��. If in a Su6division provide information,as follows: � j5 � � �. �� hr- Name: j�' t^CGtc� C�1'1 �C'�� Section: Block: Lot: Date Property Flagged: r + I � 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 revceation,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 am responsible jor all charges incurred from this appllcation. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County aud owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 'y" ��'a O O� SIGNATURE � �.�'C��J THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: E�sting and proposed property lines and dimensions, structures, set6acks, and septic locations). _ Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. � Revised DCHD(07/99) Invoice No. �� .v : � 141 : � . � �� b as� , . : . , P� �° S- � . N�-�� 1 : 2 56 �O�Je y��) ' �y , 532- : C'�6,� - � �� , � . . 1 40 : 1- �. 1 � 15 0 �. � '~� ' DAVIE COUNTY HEALTH DEPART'MENT Environmental Health Section Soi]/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001104 Tax PIN/EH#: 5863-23-4526 Billed To: Deborah Anderson Subdivision Info: Reference Name: Deborah Anderson Location/Address: Yadkin Valley Road-27006 Proposed Facility: Residence Property Size: 292 X 255 X 45a Date Evaluated:��J5"'-� � Water Supply: On-Site Well Community ublic Evaluation By: r ring 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 / —/ — s Texture rou Consistence SS � Structure 7 Mineralo ° ' HORIZON III DEPTH — O— Texture rou Consistence �' S Structure "� Mineralo ; �� HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE o - . SITE CLASSIFICATION: /Y� EVALUATION BY: e.,�"� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: / �l��.�� , � � f !'�. LEGE Landscape P �tion 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 oist 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 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-gal/day/ft2 DCHD OS/99(Revised)