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185 Will Boone Rd (3) � - DAVIE COUNTY HEALTH DEPARTMENT , Environmental Health Section ' � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001385 Tax PIN/EH#: 5756-06-7827 Billed To: Martha Childress Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility: Residence Property Size: 1.635 acres **NOTE*�"�'�iibgmprove�mendOperation 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 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)�� Site: New� Repair❑ System Specifications: Tank Size✓GDOlI GAL. Pump Tank GAL. Trench Width��j� Rock Depth/� ��Linear Ft„�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED 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.**** r � /, ✓ Environmental Health Specialist's Signature: �—��G� Date: ���v� rIo N�d �n.c� _t���F MQ ✓'1 DCI-ID OS/99(Revised) , ' DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001385 Tax PIN/EH#: 5756-06-7827 Billed To: Martha Childress Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility: Residence Property Size: 1.635 acres ATC Number: 2544 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED 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 WASTEWAT C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � Date: (� `� �—�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation Permit has been installed in compliance with Article I 1 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. �o� D � 1ov Septic System Installed By: ' ,�r � � (� , o Environmental Health Specialist's Signature: ��� "`�^�_�x�� F� Date: �� ��� DCHD OS/99(Revised) , � . ���" �v� � ° � � r �� . / • ���'j�AP� �ATION FOR SITE EVALUATION/IMPROVEMENT PERMff&ATC � � l[ Davie County Heaith Department AUG 2 4 2000 � u Environmenia/Hea/thS�+clion P.O. Box 848/210 Hospital Street Mocksville, NC 27028 EtaViRO���si:�Ef�iTAt HE.;�7H (336)751-8760 D(�t'IE.C�II;�TY ***I1�ORTANT*** THI3 APPLICATION CANNOT BE PROCESSED UNLE33 ALL TAE RL�QIIIRED , TNFORMATiON I3 PROVIDLD. Refer to the INFORMATION BULLLTIN for iastructions. s. Na.. co b. aiiioa �Yl ar-4-h�, �.C h i I d r'e ss co�r�t �.� (1�c�v-�h a � . Ch i 1 c�r.e ss Mailiag ltiddr�ss �g lP W�1��JOor�C �oA c� 8omo Qhoru � ?��e� �5� -3L��J� . city/stat./zxp (`(1t'XkSv�11Q , N C.- a-�102� sussa.s. �on. � 331p� �51-�D23`�j _ 2. N.m. on pormit/ATC it Di!leront theus llbow Sarn� !lailinq !kldrosa CiLy/Stato/Zip 3. Appiication For: ❑ 3ite Evaluation �Improvement Permit/ATC ❑ 8oth �. sYs�m to so�,►ic.: ❑ House ❑ Mobile Home ❑ Businesa ❑ Industry 0 Other s. if Rssidence: � People � - # Bedrooms �J t Bathrooms 2 ,�"MshMasher ❑ Garbaqa DisposA]. �lfashinQ Machi� ❑ Saso�aat/Plumbinq ❑ Sas�t/Ho PlumbinQ 6. I! Husinasa/iadustsy/Othar: 8pocity typo • Pooplo � Sinks i Commodaa f Sho�rora # Vrinals � Nat�r Coolors IF FOOb3ERVICE: � Seats Estimated Water Oaage (Qe�.ion. �= a.y) 7. �pe of Nater supply: �'COUAty/City 0 T�Tell 0 COmmunity e. Do you anticipate additions or ezpansions of the facility t6is system is intended to serve? �Yes ❑No If yes,w6at type7 C��C,�L, �O r C�1 ***IMPORTANT***CLIENTS MUST COMPLETETHE REQtJIRED PROPERTY 1NFORMATION REQUESTED BELOW. Elt6er a PLAT or SITE PLAN M!lSTBESUBMITTF.D by t6e client wit6 THIS APPLICATION. Property Dimensions: � � l�'1� �-��es WitIT1E DIREGTIONS(trom Mcek�ville)to PROPERTY: ' Taa Oftice PIN: # 5�15�o� �l g a `7 ��.S �(i(�1 J� �Q,��" d� �QC�t71v`n I`(f Property Address: Road Name t,l'i��k�fl� �1��t� ����'`'1� c�Yl ��i ���.�'�� �� � ) City/Zip rn�C�C�YI�I-c_,���- ���� � � � U �� ���'�- V in a Subdivisioa provbde informallon,as follows: ,� �U y��� � 1 C�d7i l �YIC �� � q , �� ,.g_ Na�e: �U� I /YI(}�eC�tl C�-`l �(�-i � ��1 y i�'�"� Section: Block: Lot: Date Property Flagged: This is to certify that the information provided Is correct to the best of my knowledge. I understand t6at any permit(s) issaed 6ereaRer are subject to anspension or revacation,if the site plans or iatended use change,or if the information sabmitted in this application is falsitied or cLanged. I,also,understand that I am nesponslble jor a/1 charges incurred jrom thJs application. I,6ereby,give consent to the Aathorized Representative of the Davie Connty Hea th Departmeat to enter apon above described property located in Davie Connty and mvned by rn Cl l�'�'yl(a �. � �"1 I �C�r�SS to conduct all tesHng procedures as necessary to determine the aite saitabillty DATE S- �`� -O O SIGNATURE � ' � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inclnde all of the following: Ezisting and prnposed property llnes�nd dlmensions, atructnres, setbacks, and aeptic locatlons). Site Revisit Charge nste(e): Cl�ent Notification Date: EHS: Account Na � g -°� ltxvised DCHD(07/99) Invoice Na � ' � . '� r x , , S �9•3q�33' � -�Er,s�r, �2.7q e ,owER �•��ti .N � yg� �•��•03'p8� E ��, N 86•20'03' E o5,�i E v ��Z 5 2A t2� ✓y��\' 99.� �5�� � �` .t� ��.tiE� 1� � �,, L.� �� . E y� 69 36'i!� QO�tR'� m :�' ��.23�51 � � �. . E %�b5'1� �,� �SG ��� c^ , 140•�9 � 2 , cRE R R "� 0�'3,' � `N .-� O � / 3'� NAiL SET .�..�/N'Z2�'?� \�r P�� dc 9RIOGE N 88'34'37' E ����N� � 122.7o r , -" e/ F--1 �f,N�'��N � � ��� � V� � , `p o� Z �; `o � � � • ` `���' / _AREA_ 69.900 AC. w � � $ � - INCLUDES S.R. 1802 R/W � (JJ -- dc INCLUDES AREA OF GRAVEYARp Z� �O �; �� / . d �I� 6�� � ., /N 81,.3�`2 . �,,��' �w N.I.P . / 8�1.8� N 8j'32'2l• M � �� E.l.c 302.31 �" E.l.P V� N 85•27•2�' W ���jN � ���' � AREA= 7.449 AC. �� _:.. � � . INCLUDES S.R� 1 g�0�%w � {� �Q��- � � n ' �� G`� r� �� C �� ti�. � al�SP\�� Z �\ R1CF S ��2 2'� E D.B, `" --- �660.Op /E.. : � �� �� i����l . 1 - � �G �h "'-- _� �� � __ � --,— —� �— .�_ � ` ��__ ^ \� _ �..j t PJ�.�„�e �:op`� ���,,,� �c�'f.�(�� _________—_�.___-- � '.c w c.� i � --------______.—_ � - ; � T�,�xr - . r � � - . � � � I �.¢�..ti� Tr�L - - ,, ,_ � � . , •v, . �,Y:..,�� *% s ,� . � ,�L �:, ......:- — .. _ ... , __ r�°`:...�a ,.� : ,rx `.. .« � � �- �i"",'' ., . � • �� ��R. APPLICATION FOR SITE EVALUATION/IMPROVEMENT &ATC .,, Davie County Health Department C� �n , �� � N � Environmental Health Section � �� v C,: �' ' P.O. Box 848 � ; .�' 1A� � , � 8199 ' { ; Mocksville;NC 27028 7 '� ' (704)�634-8760 , � 1.�� ., , � ****IMPORTANT**** THIS APPLICATION��ANNOT BE PROCESSED UNLESS ,, ; THE REQUIRED INFORMATION IS PROVIDED. ' i 1. Name to be Billed�, � .I�� � � . (�� � r S - Contact Person �y�]- �y � �I�-S - Mailing Address C �1 • � ���� Home Phone � CI� � �? 7'/R ' .,: ' ����o�a . City%State/Zip � S d� � � d a�r Business Phone 2. Nam: � P.;rmidATC if Different than Above �- � Mailit�„A;;dress City/StatelZip 3: Applica6on For:�Site EvaluaUon [ ]Improvement Permit&ATC [ ]Both 4. System�to Serve:�House [�Mobile Home [ J Business [-]Industry� ]Other � .. S. If Residence: #People #Bedrooms��#Bathrooms��2-Z [ )Dishwasher[ )Garbage Disposal [ ]Washing Machine [ J BasementlPlumbing [ ]Basement/No Plumbing � . ' 6. If Business/Other:Specify type #People #Sinks #Commodes , � , #Showers #Urinals #Water Coolers � , If Foodservice:#Seats Estimated Water Usage(gallons p`er day) : 7. Type of water supply:�County/City [ ]Well [ ]Community , , � 8: Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No ' �� If ye's,what type? ' ,1 �'',�' '� ' '�� � � ��" '��'� EZTHElt A PLsiT OR SZTE PLAN PR( ;" � `*IMPORTANT**'�T OF THE PROPERTY MUST B L � ', ` �3� SUBMITTED WITH THIS APPLICATIDN. � �� G ; Property Dim....o....._. ___,_ _� � �WRITE DIRECTIONS(from Mocksville)TO�RaPERTY: Tax Office PIN: #.575� - / '1 _- 'ri�l1/,2� ; � O � Spc.�`� � C-, h-GC�.SV C.Q 1^h�EY" PropertyAddress: RoaS ame �� ���d�ne�� � � �f � �� �p�_��� � � I� _/ � City/Zip �b�S ����P ��� :? Do y � .�tYS'�" 15U.r5Ci b LPi� " r7 Yo�'J�r�-V If in ii `�divis' provide informafon, s follows• —'�` � .j�1L�,�`�'P-✓' �S�d e- '�' Ct ►'"c� S �Q.C�. ` � Name: . ����`�� � � .i- � �nm d I�.�S P/ , � Section:�� Lot#: ' � � , , �- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter aze 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 am responsible for all charges incuned from this application:I, hereby, give consent to tl,e Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie Count� and owned by,�S�G,`�t O�!'IV'S . �/j,�.(�. �c,,U�S to conduct all te ting procedures as necessary to determine the site suitab.lity. DATE SIGNATURE � � Revised DCHD(06-96) L� . �r/�r �l/l�b THZS ,. .�l �IAJ $E USEb �OR blt�tWZNC� JOUR SITE P1.ttN: `.I �� � ;� ; ';i , . - . � • .�-k . � � . � . � . � . . � �"� ,. - .. . � . � . . :.�.�:t _ � .. . �. � . . � �. � .��t ` . . .. _ . . - � .�L . . . �, . . . . . ' . . . ,�..t I . .. . . .. . .. ,...' . , . . . . . ' I ' � . ',� :} . ,. ' � , � . . . ,�,4 . � � . . ' . . � . �.. .�1?. . � . � ..�.; � � � ' ' . . . . . ...�\1 . , . . . � . � . � . , � � . �.. � '. . . . . . . . �.,. . . ., _.. .....,. , :�v: . . • � ' �� - DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section SECTION�LOT� � SoiUSite Evaluation APPLICANT'S NAME �j` /�S DATE EVALUATED ����V�� PROPOSED FACILITY PROPERTY SIZE �� �-�.—��5�i� SUBDIVISION ROAD NAME �'�,�//�,[�!1/l�A Water Supply: On-Site Well Community Public v Evaluation By: Auger Boring 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 ' .C,/ � �/��- Texture rou I ' Consistence ` r— i Structure S Mineralo ` /;- HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: �P/� EVALUATTON BY: � ��l� LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Lineaz 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 Mineralo�v 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 DCHD(OI-90) ■■■�■■■■��■■■■■����■��■■��■��■����■��■��■■�■■■������■�■�■■■���■�■■ ■�������■������■■��■������■■■■■■����■■■■�■■■■■■���■■■���■��■�Y��■■ ■��■■■��■����■■■��■■��■���■■■■■■ ■��■■■■�■■■■��■���■■�■■■■����■ ■��■�■��■��■■■�■��■����■■■■■■������■■■■�■■■■�����■�■��■■����■�■� ■■■■���■■������■■■■■■�■��������■■■■�����■�■����■■���■��■■■�����■■■ ■■■�■�■■■�■■�■■�■■��■�■■■■■■���■■���■��■��■�■����■■�■��■���■■■��■■ ■�■���■���■■�■���■��■■■���■��������■��■■■■■■���■■■���■■�■■�■��■��■ ■■�■■■■���■����■■■��■��■�■�■■�����������■������■��■■������■���■�■■ ■■�■■■■■����■�■■■■■■��■���■■�■���■■�■■�■�����■■■��■��■■�■■�����■■■ ■■■����■■���■��■■■�■�■���■���■■■�■■�■■■■■�■■�■■■����■��■�����■�■■■ ■�■�■��■■��■������■�■■■���■����■ ■■■���■���������■■■■������■��■■■ ■�■�■�■���■■■■■■�■��■�■■■■■■■��■������■■■■�■��■■■���■■■■■■■�■���■ ■■■■■■■���■�����■■■■■��■����■��■�����������n�����■���■■■�■■■■���■■ 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