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125 S Benson Lane Lot 18i DAVIE COUNTY HEALTH DEPARTMENT P --t /1.'50 Environmental Health Section ' P. O. Boz 848/210 Hospital Street ��` Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001007 Tax PIN/EH #: 5746-48-2346.18 Billed To: Jerry Patterson Subdivision Info: Twin Cedars Lot # 18 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map 66 **N&Iq i bfinproveeme nt/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 r L 005 #People #Bedrooms J #Baths -'2_ Dishwasher: 2/� Garbage Disposal: ❑ Washing Machine: 02/ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type �1 #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ,7 ype Water Supply `Ac1T' Design Wastewater Flow (GPD) &ADO Site: New Repair ❑ `) /1 System Specifications: Tank Size 1�'AL. Pump Tank GAL. Trench Width � Rock Depth Linear Ft.3DC3' '�__� 0 Other: �t P� �t? 1 a 1 t'S'fAU. Ll !J Z's ©•C lr1A 1 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.**** �� a< �o SO, L -OT Environmental HealthTpecialistQssignature: -i� 2� rrh o A %N" J Dec SL 0" �W--A L-t'r-Az' - sox -'T ►.� -V0 A. I� (� VSG Sri --tom Ptd 1J�D�- `�QLJr6 I ADO •-k�C T Date: �L12T err $ 10 • v _ DCHD 05/99 (Revised) •� �+`'� ��S=�''� ©� �� D� �►' �'� P — DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital street MockrAlle, NC 27028 (336)751-8760 Account #: 990001007 Tax PIN/EH #: 5746-48-2346.18 Billed To: Jerry Patterson Subdivision Info: Twin Cedars Lot # 18 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2669 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 Arttc e 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Tr ea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONST IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa 7 Date: CERTIFICATE 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 Y be t en as a guarantee that the system will function satisfactorily for any given period of time. s SOLA z Ids ki N $� etc Septic System Installed By: A,3 K Environmental Health Specialist's Signatur Date: 2 f DCHD 05/99 (Revised) AP U 1 N Nov 2 7 2000 11 11 ENVi�O�!`,4ENTAL FiENLTH DAVIE COUNTY FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section .O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***X,NPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL'-' ,�XHE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1_.nrn.i In 11 1 �r .) )A 1. Name to be Billed J L V I'r -I (1'. t t_1 1(4- -C-, p N Contact Person/ V C Ir Y � 1 (/(.1 r --r— V >(JV\. . Mailing Address ? (p LAO -0-k-6 ^I�'J� e71 o. Home Phone • �� �l/ �i 9 -qty ' r , GI Lf City/State/ZIP (�G1LSy 1 L LE K) 2_16 Z V Business Phone ,3 3(p [sp `-[ Z-& r_1 L4 1 2. Name on Permit/ATC if Different than Above Mailing Address City/S to/Zip 3. Application For: ite Evaluation Improvement Permit/ATC ❑Both 4. System to Service: House 0 Mobile Home ❑ Business 5. If Residence ❑ Industry ❑ Other # People # Bedrooms - _�— # Bathrooms rZ. Dishwasher ❑ Garbage Disposal Washing Machine 6. If Business/Industry/Other: Specify type # Co—odea # Showers ❑ Basement/Plumbing ❑ Basement/No Plumbing # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) z. Type of water supply: PGounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: 0 5 ri,, '' K� qL La a ( � -_1_0 � e t Ih� ^J Property Address: Road Name Wo11l 1/i/>r 1 SIS"v. 1 7--" G-) C_ LSo_� City/Zipa If in a Subdivision provide information, as follows: Q-r� Name: % (.J t t S t I / Section: Block: Lot: 8 Date Property Flagged: r.�/ t `° - tr,8,r 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 the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Repr ent flYle of the Davie County Health Department to enter upon above described property located in Davie Coun and o ed by to conduct all testing procedures as necessary to determine the s e suitab'lity. i DATE — Z�� �t—� SIGNATURE C THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN Jude a of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic 1 a ' ns). t,n,%VZ y,._V1 Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• - Account No. Q U Invoice No.19 `I ,I �/ ., APPUCA110N FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ` Davie County Health Department 11A9 14 - Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IIWCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS At IKEORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN fo p 9 R U W R NOV 17 I9Ag Name to be Billed /1zJJlils- � S ('�2/L -MQ'= ED int4,� 'r HEALTH 1. Name to be Billed /1zJJlils- � S ('�2/L �i�� contact person -f(l/ /e'euct% 5j'l%ykLp�/ Z - Nailing Address ' Home Phone City/state/Zip ;tt2. D Business Phone ¢% 2,- 57 (/ dame on Permit/ATC i Different than Above Nailing Address City/State/Zip 3. Application For: •�p�Site Evaluation 0 Improvement Permit/ATC 0 Both 1. system to service: /\ House 0 Mobile Home 0 Business 0 Industry 0 Other S. If Residence: # People 2 - � # Bedrooms 3 # BathroomJ1/ ? — Z B Dishwasher 0 Garbage Disposal "ashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/industry/other: Specify type # People # Sinks # Commodes # Showers # Urinals # Nater Coolers Ir FOODSERVICE: _ , ## Seats Estimated Water Usage (gallons per day) 7. Typr of water supply: County/City 0 Well 0 Coaaonnity e. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes 0 No If yes, what type. ***IMPORTANT*** CLIENTS A1UST CO,1fPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: i 3 0,000 5 • �, Ta: Office PIN: # 5 7 ¢ b 9� Z3 4 6 ! • Q�0� Property Address: Road Name lUt w%GSv.✓ �� City/zip /✓G. WRITE DIRECTIONS (from Mocksyll1e) to PROPERTY: X01 5 7b 7)t-NDpto,J AV. 7O bZtL% i✓/GS�ii/ �d'• If In a Subdivision provide information, as follows: Name: �z%/�✓ C�i�'1��¢2 S - 7 VM4 p Section: Z— Block: Lot: �" L ty Flagged: % J , A -e 1213�q� 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 the larormation submitted In this application is falsified or cbanged. I, aLw, understand that I am raponsiblefor all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by O�'l9M j f zfcc:" to conduct al eating procedures as necessary to determine the site suitability. DATE L, I SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLANd all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. 3/ Invoice No. g0 a_�le N �a WILLIAM 0. ROBERTS I KEVIN A. HAMLIN O.B. 129 Pg. 133 O.B. 196 Pg. 839 CA " rn• r rr',rrr. �0 /0.8 JOY N, } ►.. 1a� r 0 9 113 Z 744, �� yrNr . *664�6e i t, 26 26250 ! • ft - ----- to• OLIN cnscKrrt r o gltr [ASCw[Mt 10' uTM u.b.%• r j' ` ` w 1•' ,J �. qf. p�•• ataq {� t '�• � iJ . ^ ,t y .tot 24 27 64 .`�V :. �• `` •�, (t.w .oitq ,,t 1',w 31. (t>,+• ,raq �' •6' d' � '� b 0 O t ' a•J 4 r, ; vac t 23 ff 2 i v \��' b (tA• i �� (lTl n0 ,C,^ a +•t:; `� •`.\ �.. ar + � i" ne r�• � ♦ s . JCC All f 02 4>0: `^,COMM ON AREAS tl,� "`+ r•w t ' r µart/ ♦��!� ,} GREEN . 9 +an " • r�tr r rata THOMAS H. PRICE ; ts' ° mzz +T D.B. 126 Pg. 48741 sA t w •'' + .: �.Q�. � d ♦J•. rr� �, Ap`� `•rih its �✓y.i�` Q ar.'N n".� THOMAS H PRICE,,,; '4. • 'y Yd�� 7�. b -o• r ,�l%l `% _ ^� - D.B: 126 Pg. 487 18 ` h 4 Sc ti h. 6 dh• ca.• b o (m "�,r•J sr �Opp9. ♦J ) 16 r h � 1 ��T'` y CREEK 1 C Q i t •J•ir u• c t 7"` •• a R>o .otq to' urirn E.�/ C �fAAA SrC ttt'J 15 _ �` ,yrs r, u .f�„�1`-' • ' `. s , � • xX t - • _ ' O f K Mir r •�. Y S^ac )" ; .t•• A. "' y ` THOMAS H. PR}CE 8 s f •� 14q O.B. 126 Pg. 487 0� Mao olvm AWO 'div '°••tJ. r13 _ • w Tf•tr•rtr� f 2 a +arty .. 4 THOMAS H. PRICE r U.B. 126 Pg. 487 kyr• r Mx Tar. 1 M a•r••x• "° • r F•4 to w.., •• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT �r Soil/Site Evaluation APPLICANT'S NAME 7t� COL DATEEVALUATED IZItd`gX Landscape position PROPOSED FACILITY klrjo5 i PROPERTY SIZE Y! ASI x Zq n >< It 0 A 3Z9 SUBDIVISION I -� 1n) Lr�(as ROAD NAME Q"xLT' 1'4)1L -S'0'3 C � Water. Supply: On -Site Well Community Public Structure Evaluation By: Auger Boring Pit Cut ' FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH p - Texture group i - C � Consistence r—, S5 sr Structure G2 Mineralogyi ' ► : j HORIZON II DEPTH Texture groupL Consistence ; Structure 3 k Mineralogy (- ' / •` HORIZON III DEPTH 2 - 4 / Texturerou S _�ts_ZL'__ Consistence • S t Structure S is Mineralogy HORIZON IV DEPTH _ 4 Texture group Consistence 5P Structure Sisk Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION F5 VS LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D ••3� OTHER(S) PRESENT: G- u JAL+-�►"� 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 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 DCHD (01-90)