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131 Walt Wilson Rd ., , � � . , � DAVIE COUNTY HEALTH DEPARTMENT (r'° • Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003955 Tax PIN/EH#: 5747-31-7887 Billed To: Justin Beauchamp Subdivision Info: Reference Name: Andy Beauchamp Location/Address: 131 Walt Wilson Road-27028 Pro osed Facilit : Residence Pro ert Size: see lat ATC Number: 4393 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST 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 WASTEWATER CONSTRUC.T.IOI*i V ID OR A PEWOD OF FIVE YEARS. Environmental Health Specialist's Signature. Date: �— � ��0 CERTTFICATE 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. , ' �� � /9 C�Am�-{ �� �.� �g �'�h��� ��; l �� ,� ��` /� '� �j�f��9� , � Septic System Installed By: �1 Q'� �i�!/ C/��lh/�i% Environmental Health Specialist's Signature: � �1�iL Date: DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' � � Environmental Health Section ' 4 P.O.Boz 848/210 Hospital Street .:- Mceksville,NC 27028 (336)75]-8760 t yl�� IMPROVEMENT OPERATION PERMI �I f / T Account #: 990003955 Tax PIN/EH#: 5747-31-7887 Billed To: Justin Beauchamp Subdivision Info: Reference Name: Andy Beauchamp Location/Address: 131 Walt Wilson Road-27028 Proposed Facility: Residence Property Size: see plat **NOTE�*This 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 Artide 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 CONTItACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type buSL _ #People Z #Bedrooms Z #Baths �— Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: 0 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size���Type Water Supply�'`��1— Design Wastewater Flow(GPD) 2� Site: NewP—f Repair❑ „ ( System Specifications: Tank Size�U�GAL. Pump Tank GAL. Trench Width_� Rock Depth� � Linear Ft. l�� Other: � l��c1f�1�U Tl t�,r.l�X-. ��-�_�" '� � TZ►=�T 10�S`l STi�'"�� Required Site Modifications/Conditions: �f�1s'r"D1_I�_ (� C—���Q, � S �(— �r�-� �'Z7 �Qo rv�. 1�'IPROVEh1ENT/OPERATION PER1V11T 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 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(33()751-87G0.**** ,�_ �p' �'� 1.._1�� i,S � � ��' � � �� ��/ t l.tjcJ�-Tt�•.� ,,� 4 1►� � �,- ��,,,"�� ��,l�x T�2�c�-1�++ � �. �., �3�i i� TI � �' 2�2 7d �'� .� �+�`�" � �,� � .....__..... � Environmental Health Specialist's Signature: at �� DCHD OS/99(Revised) . . � � �APPLICATIO R SITE EVALUATION/IMPROVEMENT PERMIT & ATC � � �-�:- � � � ��� �] [� Davie County HealthDepartment �, �� C�C� � `, � �.. Environmental Health Section ��` P.O. Box 848/210 Hos ital Street .�° 4 �',` APR 2 4 2006_ Mo�ks��iie, Nc i�o2s `��� � (336)751-8760/Fax (336)751-8786 �IROhN�EJ�aL HEALIH pplication F�Vi� mprovement Pernut ❑ Authorization To Construct(ATC) oth ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMEITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION , Contact Person � P'� Name to be Billed L -� �, 1��� , .�(� �,�,�� ; �,� Billing Address � �c �'(F Home Phone 3� �- 9 j- � .> City/State/ZIP • �� i� ' �� � ' � � � Business Phone ����.�5�/_S- �/6�/ � Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Pernut is valid for 60 months with site plan,no expiration with c mplete pl�at,.� Street Address�j/ ��.�--���,�/y�n� �� City :� ,/�',��'��-6 � Tax PIN# ��%�j�j7��'`� Subdivision Name Sectio t# _ Lot Size Directions To Site: �/-.�... �' �; k �, ' j,('� �l � Date House/Facility Corners�'lagged ' 2s"� If the answer to any of the following questions is"yes ,supporting documeri�ation must be attached. Are there any existing wastewater systems on the site? ❑Yes �13Qo Does the site contain jurisdictional wetlands? ❑Yes �o Are there any easements or right-of-ways on the site? ❑Yes [�3�0 Is the site subject to approval by another public agency? ❑Yes �o Will wastewater other than domestic sewage be generated? ❑Yes I�o IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms � #Bathrooms � Garden Tub/Whirlpool es �No _ Basement: ❑Yes �o Basement Plumbing: ❑Yes fi�3�10 IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats ` � � oe Type system requested: �onventional .B'Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water [B�New Well �Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [�Io If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes, or if the information submitted in this application is falsified or changed. 1 understand tlzat I am responsible for all charges i�zcurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to eternune comp�iance with pplicable laws and rules on the above described property located in Davie County and owned by c�-: -�-�� �tr�.� - c�t.,. /1 / � /, n 'c'r-:c. � P , erty er's or owner's al representative signature Site Revisit Charge Date(s): 25 ��,� Client Notification Date: D te EHS: / �_�� Sign given tJYes ❑No Account# Revised 2/06 Invoice# �[�(,� lf"N + f � ; i , i I j . ! � 1 ! I : I c� O3° 00� t6�E^= b5�.�J, � a � h N m �� --_.... ^ ��� � �' \ � ----- 1S8•o --_ . , � ;' � -- 1z . ` �� � / � h�` �`` .., � o � V"� � - - .. .t / ------ioz.,>_....---_ : o ; 8ti��i � � o.o c " � 6� / o ' C / �_ ., �.t g�r� i �; � � ��� i «� U\ I 'c� � ' 0 -rn / w I � / ci I �0 n , t — / Z � � � � ---.._..._. . _..... , N 02°�FO� 56'��.---�. r,;-3� !f� � � _-___ _.__..._.___---------�--��_ ; � i ----------5�-��_�805 WALT WILSprJ Yzitiv - - -----------...__---- i . -._ _ � _ . _ ; •� � _ , ' S�T�—P�AiJ SCALE I�=.SO' I • � . . �...;�'"�i 1 I ' : ' __.�_� � . ' DAVIE COUNTY HEALTH DEPARTMENT ' , r ' Environmental Health Section � .. • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003955 Tax PIN/EH#: 5747-31-7887 Bilied To: Justin Beauchamp Subdivision Info: Reference Name: Andy Beauchamp Location/Address: 131 Wait Wilson F� d 27028 Proposed Facility: Residence Property Size: see plat Date Evaluated: �� ��P �� � . Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FAC'TORS 1 2 3 4 5 6 7 Landsca e sition L Slo e % 3 HORIZON I DEPTH p� �- -I 2 � - 1 Texture rou �,,., �-�— Gt_ Consistence � S ' Structure �;,� C=Q Mineralo S.r'1L S ��t HORIZON II DEPTH A C�� I � - O - 50 Texture rou Consistence .- F� ' :S Structure � Mineralo �:''�, -�c � HORIZON III DEPTH �;�o . .2 Texture rou L�# t r Consistence ; r . Structure S� Mineralo � � �, HORIZON IV DEPTH Texture rou Consistence � Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE .. CLASSIFICATION LONG-TERM ACCEPTANCE RATE . O.2 SITE CLASSIFICATION:��'\ EVALUATION BY: C� � LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT: REMARKS: V � �\-3 �1 A`� F�%'LL�- h�w(j w'-S ,�iXZ ��J G►Sa � LE END i.andsca�e 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 CnN4iST .N . . �IQiSt VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 13..'�.t NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic SYI11S�ilI'g SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed 1Y4tgS 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 Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Revised) ■����■■■■■�����■��■�■■■■■����■�■■■■�■■■■■�����■�■��■■■■■���■�■���■ ■�■��■����■��■��■�■�����■�■■■■■■�����■�■�■■��■■■■��■����■�■��■�■■ ■�■��■�■■■■���■����■�■■�■��■���■ ■■■�■■��■��■�■■■■■■��■���■■■■�■■ ■�■■����■■■■�����■�■�■��■�■■�■������■■■�■■■��■������■�■■��������■■ ■■����■■■■��e�����■■�■��■�■■�■■��■■��■��■����■■■■■�����■�■�������■ ■��■��■�■�■��■�■���■■■■■■��������■�■■■■■■■��■����■��■■�■��������■■ ■�����■■���■■��■��■■■■��o�����■■�■��■�■■■■■���������■■��■�������■■ ■■���■■����■■��■�■■��■����■■■�■�������■��■����■■■■■■■■���a��■�■��■ ■■���■■���■■�■�■�■■■������■■■■■�������■���������■■��■■■�����■�■�■■ ■��■��■■■■�■�■■■■■���■■■■■■■■����■■■■�■■■■■■����■��������■�■�■��■ ■����■�■■■�■■■■■��■■■■�■■�■���■■ ■■■■■■■■■■���������■��■�■�■�■��■ 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■■�o�■■�����■��■�■■■■��■�����■�■■■�■■■�■�����■�■���■�■�������■�■�■ Davie County Health Department Environmental Healtlz Section P.O. Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 May 5, 2006 Justin Beauchamp 167 Walt Wilson Road Mocksville,NC 27028 Re: 3.89 Acre Tract/Walt Wilson Road Tax PIN# 5747317887 Dear Client(s): , As requested, a representative from this office visited the above site May 4, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. This Improvement Permit DOES NOT authorize the construction of a wastewater system. . An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Serve: 2. L.�� �`�1��-'= Wastewater Design Flow: ��� System Type: ❑Conventional e'Accepted �Innovative ❑Alternative ❑Other System Location: ��aJfi�i�`511�3Jc-� Valid:�3"�ears ❑No Expiration Site Modifications/Permit Conditions: v e al [e p cialist D te ps-i.p.letter 2/06