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150 South Madera Dr Lot 10DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990004137 Billed To: Tycon Inc. Reference Name: Richard Andres Proposed Facility: Residence ATC Number: 4521 Tax PIN/EH #: 5749-63-6844.10 Subdivision Info: McAllister Park Lot # 10 Location/Address: Sain Road -27028 Property Size: as platted As stated in 15A NCAC 18A.1969(5) ziccepted Systems may also be used AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 Sewa a Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE T ION IS V LID FOR AP OD OF FIVE ,LYEARS. Environmental Health Specialist's Signature4l D �T 1`1 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in comp iance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sha 11 in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Cam - rizl 7,; jS QAr Ilk Septic System Installed By: Environmental Health Specialist's Signature: D te: Z� Ci DCHD 05/99 (Revised) ITE EVALUATION/IMPROVEMENT PERMIT & ATC )avie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (3 )751-8786 wement Permit Authorization To Construct(ATC) ❑ Both ***IMPORTANT"`** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed , Contact Person ; ki Billing Address J Z" �3Z Home Phone -7So �;�'Z, City/State/ZIP �lc.�zti� . NL 2'-7�tZ Business Phone 3t ';Lj` Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION Ci NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address City Subdivision Name Directions To Site: i< 7 _Tax PIN# Lot Size Date House/Facility Corners Flagged ,_� �--0 If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? []Yes AO Does the site contain jurisdictional wetlands? ❑Yes Ao Are there any easements or right-of-ways on the site? Cres A0 Is the site subject to approval by another public agency? ❑Yes Ao Will wastewater othet than domestic sewage be generated? ❑Yes dNo TF R'P gM'PNCP FTT .T . C)T TT TNF. R(1X RF.T .CIW # People # Bedrooms k 3 # Bathrooms oZ Garden Tub/Whirlpool ❑Yes ❑No Basement: []Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building Z`{'p # People # Sinks �� # CommO s .S # Showers 2 # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: dconventional []Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: E/County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? V Yes ❑ No If yes, what type? 1— �,S�V l ro cs �'�:i_`i oa `' Q\ '�,IA4-, 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 permit(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. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in Dand owned by _� �, ' ^ �* Site Revisit Charge Prop rty owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # /3 Revised 2/06 Invoice # �57 17 DAVIE COUNTY HEALTH DEPARTMENT ?. Environmental Health Section ' P. O. Bog 848/210 Hospital Street Mocksville NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004137 Tax PIN/EH #: 5749-63-6844.10 Billed To: Tycon Inc. Subdivision Info: McAllister Park Lot # 10 Reference Name: Richard Andres Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: as platted ATC Number: 4521 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a 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 DOSE #People #Bedrooms --E> #Baths Z•S Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type / #People #People/Shift #Seats Industrial Waste: 13Lot Size Type Water SupplNi ii 71? Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size LCGAL. Pump Tank GAL. Trench Width 13�p" Rock Depth 1 ZLinear Ft. 4oc� As stated in 15A NCAC 18A.1969(5 Other: 1'giQ tlj1 �oJ I _�-� accepted Systams may also be use t nk Required Site Modifications/Conditions: 1AS-fNu- ©a C-c+9�t�' 1 y, 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.**** �2 Z meq' PSP . 1_I --Sz- m Pao P. --, Environmental Health Specialist's Signature: ate: DCHD 05/99 (Revised) Opt 20 06 09:47a ,--9 p.i APPLICATION FOR SITE EVALUATION/lAIPROVENIENT PER511T �' 0 Davie County Health Department V EnvironlnentaiHealth Section P.O. Box 848/210 Hospital Street '['AMocksville, NC 27028 3 2005(336)751-8760 Phi ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE—Rg= "' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals 11 Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: !'County/City❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-m-o-� If yes, what type? ***IMPORTANT*** CLIENTS A1UST COAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN AIUST BESURMI7-FED by (lie client with TIIIS APPLICATION. Property Dimensions: Aj lttAee . Tax Office PIN: # Property Address: Road Namc (57i4 1i 'lzi City/Zip If in a Subdivision provide information, as follows: Namc: /yi /11115 -�e r' l �}r k - Section: Block: Lot: WRITE DIRECTIONS (from Mocksvillc) to PROPERTY: Date home corners flagged: `1- This is to certify that the information provided is correct to tlic best of my lmowledge. I understand that any pernnil(s) issued hereafter are 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. Jr, also, understand that I am responsible for all charges lacurred from this application. I, hereby, give consent to the Autliorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to deternnine the site suitability. DATE �' 1.3' DS SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Hues and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EIIS: Sign givcn_,Z\.//D Account No. Revised DC1ID (05/03 Invoice No. 1. Name to be Billed �� '—lac.= t(g ��l 1 /� Contact Person Mailing Address 6 45;i �l ! � E� J' S4— Home Phone %� -� -/�+ •.2- % S City/State/ZIP ._/� iv,j"1�'r'� <_ ' le f--- /CJ } Business Phone '-16 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Evaluation El Improvement Permit/ATC El Both 4. system to service: �lite I'H_o.,usse ❑ Mobile Home 11 Business ❑ Industry E3 Other S. Type system requested: lid' Conventional ❑ conventional modified ❑ innovative 6. iifResidence: # People # Bedrooms 3— # Bathrooms ODisliwashor ❑Garbage Disposal 311ashing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals 11 Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: !'County/City❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-m-o-� If yes, what type? ***IMPORTANT*** CLIENTS A1UST COAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN AIUST BESURMI7-FED by (lie client with TIIIS APPLICATION. Property Dimensions: Aj lttAee . Tax Office PIN: # Property Address: Road Namc (57i4 1i 'lzi City/Zip If in a Subdivision provide information, as follows: Namc: /yi /11115 -�e r' l �}r k - Section: Block: Lot: WRITE DIRECTIONS (from Mocksvillc) to PROPERTY: Date home corners flagged: `1- This is to certify that the information provided is correct to tlic best of my lmowledge. I understand that any pernnil(s) issued hereafter are 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. Jr, also, understand that I am responsible for all charges lacurred from this application. I, hereby, give consent to the Autliorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to deternnine the site suitability. DATE �' 1.3' DS SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Hues and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EIIS: Sign givcn_,Z\.//D Account No. Revised DC1ID (05/03 Invoice No. - 'DAVIE COUNTY HEALTH DEPARTMENT a . -" Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Apcount .#: 989900035 Tax PIN/EH #: 5749-63-6844.10 Billed To: Richard Short Subdivision Info: McAllister Park Lot # 10 Reference Name: Texturegroup Location/Address: Sain Road -27028 _ Proposed Fapllity: Residence Property Size: as platted bate Evaluated: 7> Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit ''� Cut Consistence ;ar�r����■��■�� .1417 illr Structure ,,Landscape position HORIZON I DEPTH Texturegroup HORIZON 11 DEPTH Texture group Consistence ;ar�r����■��■�� Structure " � DEPTH •�Texture groupUNNONNY "61 UNConsistenceHORIZON IV DEPTHTextuConsistenceStructureMineralogy_ lipSOIL WETNESSSAPROLITECLASSIFICATION SITE CLASSIFICATION: Q5 LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: 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 of 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 Mineralogy 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 DCl In 05/99 (Revised)