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672 Wyo Rd , ` .. 1 � ~ • DAVIE COUNTY HEALTH DEPARTMENT � . � Environmental Health Section P.O.Boz 848/Z10 Hospital Street Mceksville,NC 27028 (336)751-87G0 Account #: 990003790 Tax PIN/EH#: 5843-15-8112 Billed To: Marjorie Nichols Subdivision Info: Reference Name: Location/Address: Wyo Road-27028 Proposed Facility Studio Property Size: 56 acres ATC Number: 4246 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 Specialist's Signature: �/���j Date: �L ""'� �"!� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. f � � � ; /a I /�x��'�����' � J �/ � Septic System Installed By: �/`/�� � � Environmental Health Specialist's Signature: Date: �/��� —�� DCHD OS/99(Revised) . _, , DAVIE COUNTY HEALTH DEPARTMENT ,_� - , Environmental Health Section �`� �� � r � P.O.Box 848/210 Hospital Street ' Mocksville,NC 27028 (336)75]-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003790 Tax PIN/EH#: 5843-15-8112 Billed To: Marjorie Nichols Subdivision Info: r Reference Name: Location/Address: Wyo Road-27028 Proposed Facility Studio Property Size: 56 acres ATC Number: 4246 **NOTE**T'his Improvement/Operation Permit DOES NOT authorize the construction ofa 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 #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 Type Water Supply� Design Wastewater Flow(GPD) /a C� Site: New�Repair❑ �� �r System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth /� Linear Ft./t��� Other: As stated in 15A NCAC 18A.1969(5) accep e ys ems may a so e use Required Site ModificationslConditions: IMPROVEMENT/OPERATION PERMIT 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 of installation. Telephone#is(336)751-87G0.**** '�/ F Environmental Health Specialist's Signature: � Date: <! "� ��.5� DCHD OS/99(Revised) ,�` � . Please complete the highlighted area(s)and �'!UN FOR SITL- EVALUATIO�' lblP(i011Ch1CNT PLIi�S �IITG- � � � � return. � � �Y. Davie County Health Dep�rtment �—� CXIS��Nc.� � Environmenta/He�/thSection �fQ�� � P.O. Hox 848/210 Hospii:al Stzee� � � ���i�� �2����2i� Mocksvilla, NC 27028 � � (336}751—Q760 �1�RONMENTA�HEA(TH"' � � DlIb7�C011Fr�, ***ItIPORTIINT*** TIiIS APPLICATION CANNOT Z3� PRC�ESS�D UNL�SS ALL TFi� RL•'QUIR� . INFOR2•S1ITION IS PROVIDLD. Refer to the I2iFORDiI�i'ION BULLETIDI for inaCructiona. � l. Name Co bc Dilled ��J'L.�J /y/LJ(% JllIC 1�OLS Contact Peraon n7 A���lz-' NiCttocS 7•failing Addressn �0 7 � Vi!YU �'c10 r+D ]iomo Phono ��8- �� G 3 City/Stata/ZIP _h't U C��-S V i L�-C� , N-C- .27p 1.� IIu�inean Phono � 2. Namo on PermiC/]1TC ii DiffQront than J�bova 2dailin� Addroa3 City/Statu/Zip 3. Application For: �Sitc �valuation ❑ Improvement PermiL/ATC ,� Both 9. syatem �o sorvice: O IiouaQ ❑ 24obile Home ❑ Buaine3u ❑ Induutry C�Ot-her 5. Typn a}��tem requo�tad: ❑ Conventional ❑ conventional modified ❑ innovat-ivo (JacCepted 6. Tf •Ito�idenca: I! Pcoplc il IIedrooms If DaL-hrooina ❑Di�liwanhor ❑Car7�ago Di:sposal ❑�4ashing 24achino ❑Dasement/Plun�ing ❑Danemont/ilo P1umUing STuv,0 2 7. IL Bunineun/Indunt:iy /Othar: vcrify typQ,Q(��'2R/h�G # People 1P Sinkn f1 CommoQau j Jf Showora --� }F Urinaln -C�� Il 19sLor Coolorn � IF FOODSERVICE: �� 5eata Estimated {4ater Uuage (gallons I�er clay) a. Typo ot wator au�piY: � County/City ❑ Wel]. � Community s. Do �ou anticipato additions or cxpansions of thc facility this syslc�n is intcndcd (o scrvc? C]Ycs �'No If��cs,ti�•hat typc? '"**IAf1�0l�TfINT"°**CLILNTS AfUST COAIPLL71i'TIiC It�QUJItL•D PROPCRTI'IN1�OR\9AT10N RLQULSrLu ISI;i.ON. iiitlicr a PI.,AT orSITC PLA�I 1llU.ST IlESUlldfl7'TF.D In�thc clicnt �vith'C1IIS AI'PIJCATiON. 1'ropert}�lliwcnsious: 5 � ✓� ��:•S 1YIiIT�DIRECTIONS(1'ruiu 11-focltsti�ilic)Iu I'KO!'LR'I'1':' � T:i�OfGcc I'Il�l: �E S S 43� 5�-g I I ?� �v l i U 'S L1�D C !U I'Y-1�2M�NU i�� IZa I'roperty Adcli•css: Rond N:tinc 6 1�-- W�o l2 o aU L'�`� 'i, �uR-N (,�-^F i d}i i� �� � I Z/J't�-t��� City/Zip I��OGI�Sv►C.Lt , N-�' �o � �ji��� Li t����" � �36i ) Tilc2iJ �7029 If iri a Subditi�isio�i proviilc i�ifoi•►iiafioi�,as Collotivs: Lt'{'� G� � •S M /��.'J �U r � U/`� tv1,»�: (iJ'-(� ILC��� � . s�h��.cs �"� {'h/�iL/'x�X r Q �� b�-► r •—�7��. O��"" ' '�, Scclion: Bloc:lc: Lot: ���:itc liomc corncrs llaggc ��((Si tiv�, u1�� DG,� . � /3� P� 6 i.�' 12��2 a 2 a ��N . �-f-�c��� 'I'his is to ccrtil'y tl�at tlic iufoi•c�t:itiott pi•ovidcd is corrcct to tlic bcst of iuy�Itno�vlcdgc. I uncicrstaiitl tli�it any pc►•ct►il(s) �a�c.�'�`N , 'i� issucd hcrcaftcr are subjcct to suspcnsiai or rcvocation,if thc sitc plans ar intcndcd usc clian�c,or if thc informalion s � subnii(tcd in Wis applic�tion is L•ilsiGcd or cliangcd. I, al.so,tulrlcrstrtirrlll�at I�rur respo�lsiLlc for nU cicrrrgcs iircru•1•crl jrum �Z t/ris npplicnliu�r. I,l�crcb}�,givc conscnt to tlu Autl�orizccl Rcprescntatiti�c of tl�c Davic Couut}'IIs.�lfl�llcparttncht (�^r�'" � � �� lo cntcr ripun aUovc ucscriDcd property locafcd in llavic Counl}'and o�ti•necl�by��.� �Zr��.a-�.� �u- � to conduct .ill tcsting proccdu�•cs as iiccessary to dcicrminc tllc sitc suitabilit��. � . �, D�l'I'Is' �O���-f —U S' SICNA'I'URL ��z��l��-�-- ��Zt�^�'� TIIIS ARLA I11AY BL USLD rOR Dl�iti'�'ING YOUR Sl'1'�PLAN(Includc all of(Lc fotlotiviug: Lxisling and proposcd property lincs and dimensions, s(ructures, setbzclss, anJ septic locations). � L�I Si�� . Silc Iicvisit Chargc ' � �'� s�vG�/��' . . � � . Datc(s): .' � �� . ������ ° Clicnt Notification Datc: 5� �I�IS: � ��o ,� � 7�� Sign givcn �� .� o�\ccount No. ` ' 1 .� a Rcvisccl llCIID (05/03 Iuti�oicc No. 1 1 - " ' DAVIE COUNTY HEALTH DEPARTMENT , ' � Environmental Health Section ' Soil/Site Evaluation � �1PPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003790 Tax PIN/EH#: 5843-15-8112 Billed To: Marjorie Nichols Subdivision Info: Reference Name: Location/Address: Wyo Road-27028 Proposed Facility: Studio Property Size: 56 acres Date Evaluated: //�D� `�� S Water Supply: On-Site Well - Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slope% � HORIZON I DEPTH . Texture grou Consistence Structure Mineralo HORIZON II DEPTH << � Texture rou Consistence Structure � Mineralo ` ` HORIZON III DEPTH 1 Texture rou Consistence (� Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:_ EVALUATION BY: �'/� LONG-TERM ACCEPTANCE RATE: e _ OTHER(S)PRESENT: REMARKS: LEGEND i,andscape 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 Textius 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 CONSIST .N .E a141S� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �� 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 LY� 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 DCHD OS/OS(Revised) ■�■�■��■����■���■���■■�■���■■�■��■■■■��■�����■■■�■���■■■���■��■�■■ ■■��■�����■�■�■�■�■■■����■��■�■�����■���■�■■�■��■■■���■�■�������■ ■�■�■��■����■■��■■■��■�■■■�����■ ■��■■■�■���■■■■■■�■��■�■��■�■�■■ ■�■�■�■■�■��■����■���■■■����■■���■■■�■�������■�■■\�■■■�■�■�■��■��■ ■�■■���■■�■�■�r�■�■��■�■■■■�■���■■■■�■�■�■�■�■��■��■■■������■����■ ■�■■�■�■����■■����■�■■���■����■■�■�����■�■�■■���■■■■■■�■�■�■��■��■ ■�■■■■����■�■�����■■■�■��■�■■■■■■■�■�■�■�■��■■�■■�■■��■■■�����■�■■ 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