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247 Willow Creek Ln „ DAVIE COUNTY HEALTH DEPARTMENT 2• �0 � Environmental Health Section . P.O.Boz 848/210 Hospital Street ' . '� Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001534 Tax PIN/EH#: 5820-$0-5237 Billed To: Randall 8� Pamela Durham Subdivision Info: Reference Name: Location/Address: Willow Creek Lane-27028 Proposed Facility: Residence Property Size: 1.39 acres ATC N�1r b�r: 2678 **NOTE** 'lhis mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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 3 #Baths a. Dishwasher: � Garbage Disposal: ❑ Washing Machine: �' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size /•.3 g �• Type Water Supply WG/( Design Wastewater Flow(GPD) 3 L D Site: New�' Repair❑ System Specifications: Tank Size �d� GAL. Pump Tank GAL. Trench Width���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 ofthe Davie CountyHealth Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(33G)751-8760.**** „/ ���QG` � � � . � o��J , � I' , / / Environmental Health Specialist's Signature: � Date: J"o? �`D j✓ DCHD OS/99(Revised) • •. DAVIE COUNTY HEALTH DEPARTMENT � � � ' ' ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990001534 Tax PIN/EH#: 5820-80-5237 Billed To: Randall�Pamela Durham Subdivision Info: Reference Name: Location/Address: Willow Creek Lane-27028 Proposed Facility: Residence Property Size: 1.39 acres ATC Number: 2678 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). 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: vP/"� G��' 6�.�' Date:��„2�� CERTIFICATE OF COMPLETION **NOTE** 'The issuance ofthis 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. ,, --�-p �—�G� �--�^i�=s L�..�CLr�I�� A'�' � �ij - t3�X AR'��. � S,ry � �`�o �s� 1 � �� � '� � 'r�,�''' �_ G . x ' � „�L,n.L �j' X. � '` N � � � ��19�v ���� ryor Septic System Installed By: �A� ���A i `vsP�� � Environmental Health Specialist's Signature ate: DCHD OS/99(Revised) . . , . n i1 L� � � 0 l'1 L5 K- U ' � �/ APPUCJiT10N FOR SITE NALUATION/iAiP{30VEh9f���fiPrRij�&R�'C ���� Davie County Health Department � � � ��� ; J �.� � Environmenta/Hea/[fi Section ��-�- � P.O. Box 848/210 Hospital Street ��^^�`-1 `' �"'`"� Mocksnille, NC 27028 ENVIRONMENTAL HEALTH S . +-e- P � "^ (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS �1LL THE REQUIRED INFOR2�ITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Hilled yi Ar�r,, /����A»'��� [ )u�f/l G;� Contact Peraon � m Mailing Addresa �7� G ,�r,����' �Q� Home Phone ���/-�jlyG City/State/ZIP ���s/ ./�O f�L-q���� Business Phone / ;J/ -�y 9 q����� �� «� 2. Name on Permit/ATC iF Different than Above �J a�� �. Mailing ]lddress City/State/Zip � �� r'.2(ovi c�9^-�'' /��r _ 3. Application For: Site Evaluation ❑ Improvement Permi �ATC_ Both a. sy8tem to se=,.ice: ❑ House �Mobile Home � Business ❑ Industry ❑ O�her 5. If Residance: A People � R Bedrooms �^ # Bathrooms �_ U Dishwasher [l Ga=bage Diaposal [7�Washinq MacYii.ne ❑ Hasement/Plumbing U IIasament/2lo Plumbing 6. If Buainesa/Induatry/Other: Specify type # Paople �1 Sinka Y Commodes �i Shoxera �I Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallona per a�y) �. TyPe of water supply: 0 County/City ell ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Ycs k�o If ycs,whut type? ***IMPORTANT***CLIENTS MUST COMPLETETIiE REQUIRL'D PROPGRTY INrORMATION ItCQUF.S7'CD BELO�i'. Either a PLAT or SITE PLAN MUST BESUl3MITTED by the client witl�TI-IIS APPLICATION. I'roperty Dimensions: �, 3� �L' WFUT�DIRECI'IONS(from Mocksvilie)to PROI'CR7'1': Tax OiTice PIN: # �Sa O�fl5a3� �D` �O�T/�" � � D � CJ3-�J/�- t�/�-C� �'� p� LL'� G 49a o000`!-9 Ty/� p(p ,�� L' Property Address: Road Name S {� 1 �.}p� p� r��'a /1-so v� �rw��{� `�'�- �'►J /►1 R-�'"� C�K� ��� vv�)lv�,,+ ci�e�K )yN�t c;ty z�p �r-v �3a�T�� ri,;I� 7� a�v ,,��,�'h�w c�ee.�.� � ��N� If in a Subdivision prov�de mformation,as follows: ��Q 195T 1'�.c7 �c.7cJ��� w�C�Y T,��y�-l��S . � Namc: ('L_���� ►��l�e R. `("h� SCCaar� a�v�le t,c.�o CY fl ra )ti I� ,�c.+c'i' 1�-t' �s S��"� RC��s5 �R�M Section: Block: Lot: Datc Property Fla�ed: �$�y —1 -�- - 3r�owN:�.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 tt�e information su6mitted ia this application is falsified or changed I,also,understand that I am responsible jur all charges incurred from rhis vpplicatioa. I,hereby,give consent to the Authorized Representative of the Duvie County HealtU Depurtment to entcr upon a6ove described property locatcd in Davie County and owned by to conduct all testing procedures as necessaty to determine the site suitability. DATE — � � SIGNATURE � ����� �'� " THIS A.REA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc followin�: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Rcvisit Chargc Datc(s): Clieut Notiiication Datc: EHS: Account No. ` �� � Revised DCHD(07/99) Invoice.No. � � � ✓ 241 0 . � ...______.__.._......... 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' ��� ���.I�� 9.21 A "°: .a�'�I;e :;: . ��1 .;;'i. .i:i - 't.- ��,�., ��,-. � � 7773 ' �.��.;'p������� '� {�-� -�ay;� , 'S. : \ _���'��j�l� �; i 1 -�.+�'"�?5, 5 ;� .:_��.. �t � I.- ��.+: � � �_ - ,,� 4 .� • : .,:. � r �- � � ' i :, � f i � � O � . � F-+ r ' 780.58 "_ Dv au�M, R m : 75 � - v 3�� " ,, , , . ..__ ._ _... _, ,. ._ __. . .,,. ... .. , _ _.:. ._..._ . _. ...,,;., ... _�. �� ' . � .,D.��l'I���IUNTY iiF.�LTii I}����T1��1i1'T.._....: ... .. . ._::...::.� �. . .... ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 January 26 , 2001 . Randall&Pamela Durham 141 Legion Hut Road Mocksville,NC 27028 Re: Site Evaluation/Willow Creek Lane Tax Office Pin : # 5820-80-5237 Dear Client(s): As requested, a representative from this office visited the aforementioned site on January 23, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, /�,�o�;�..�c��.�l�. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di . ��� � �� DAVIE COUNT'Y HEALTH DEPARTMENT Environmental Health Section � W - • ` Soi]/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001534 Tax PIN/EH#: 5820-80-5237 Billed To: Randall & Pamela Durham Subdivision Info: Reference Name: Location/Address: Willow Creek Lane-27028 Proposed Facility: Residence Property Size: 1.39 acres Date Evaluated: /--��T -lj f Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L L Slo % 02 HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH l, '� � " Texture rou Consistence � � Structure � IC 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 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 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 OS/99(Revised) ■�■��■���■■■■��■�������■■�■��■�■■��■■�■���■��■■���■��■■■■■����d��■ ■���■■■■��■�■�■■�■■�������■■���■�■��■■■■■■■��■■���■■�■�■�������■�■ ■�����■■��■■������■�■■����■��■�■���■■���■■�■■���■■�■■■■■��■��■��■ ■��■■�■��■■�����■���\�■■��■■■■�■ ■■��■����■�■■■�■����■■������■��■ ■��■����■■�■�■��e�s�v��■���■���■���■���������■■�■��v���������■�■�■ ■����t��■■�■�■■�■�■�■��■��■��■�■■��■���������■��■���������■�■■���■ ■������■■■������■�■■■�����■■���■���■������■�e■■■����■■�■■�����■��■ ■�■■■■��■■■���■�■�■■�■�■■��■�■�■��■■�■��■���■�■■��■�■■■■■■�■����■■ ■�■�����o�■o��■vs�■o���■■a���■�■■�■��■��■��■��■��������■��������■■ ■�■��■����■�■�■������■����■■�e�■���■���■■�■■■�■��������■�����■�■■■ ■����■����■��■��■�■■���■��■■���■�■��■■■■��■����■��■��■�■�■■���■�■ ■�■�■■�■��■��■��■���■��■��■���■■ ■��■�■��■■t������■����■■�■��■■�■ ■���■�■■�■��■■������■��■������■���■���■■��■��■�■■��■����■�����■�■■ 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