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150 Sheffield Farms Trail Lot 18Account A 990001440 Billed To: Denise Carr Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bos 848/210 Hospital Street MockrAlle, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: relC- ,�_ 2 t o ;� 4871-81-8453.0014EP Sheffield Farms Lot # 18 Sheffield Farm Trail. -28634 5 +acres ATC Number: 2600 **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 �f`bM 1loM`L #People 2 #BedroomsS #Baths 2 Dishwasher: EV� Garbage Disposal: Washing Machine: 2`0� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size t5. 1 A Cdu%S Type Water Supply Design Wastewater Flow (GPD) '3('00 Site: New Repair ❑ H System Specifications: Tank Size pLC� AL. Pump Tank GAL. Trench Width Rock Depth _L Linear Ft. ,M' Other: J a1 �iO.I�J—I10a , , INslat l— uac5 9'O. C• K,i.7, Required Site Modifications/Conditions: KoW IC6 . /D'oFF 02v, IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLU NT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE.'" "NOTICE: Contact a representative of the Davie Cou#tyHealth 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 ins t Illation. Telephone # is (336)751-8760.**** tto PoaD lr To Slit-fF+o:LD APPPow 1?5' To fQCP• Ltr3G Environmental Health Specialist' Signature: DCHD 05/99 (Revised) l W� ARD.Z. 120' Y " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001440 Tax PIN/EH #: 4871-81-8453.0014EP Billed To: Denise Carr Subdivision Info: Sheffield Farms Lot # 18 Reference Name: Location/Address: Sheffield Farm Trail. -28634 Proposed Facility: Residence Property Size: 5 +acres ATC Number: 2600 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 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW ONST UC IS 2VA7FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa e: Date: to 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 NO WAY be taken as a guarantee that the system will function satisfactorily for any, given period of time. L1 �.16'�Tb Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) �Nor\ tv�� � 1 Date: r� APPLICATION rOn SITE EVALUATION/IMPnowmENi PERMir &!/ATC Da �% (� Davie County Health Department Envfmnmenea/Nee/th Section P.O. Box 868/210 Hospital Street OCT — 9 200 s Hockevills, HC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED _ INF0Rl91TION 18 PROVIDED. Refer to the 1INSORIIATION BULLETIN for instructions. 1. same G. be Billed Z) 4(,IV f e— d �,, �// 1, /�,'4 i"r entact Verson /GGy V�— Mailing address '3 oel /el .some Phone _.�/ S -�F7 7' - City/state/LIPyey—IV5p%„t /� e a7/30 a,..inses Phone a vP 3 2. Name on Permit/ATC if Different than Above Mailing Addrea■ - City/State/sip - - 3. Application For: ❑ Site Evaluation, ❑ Improvement Permit/ATC Both 4. By*Gm to g*rvice. ❑ House omobile Rome ❑ Business ❑ Industry ❑ Other s. IfResidence: �f People ,� - / Bedrooms- _ f Bathrooms" 2 r fRDisheaehsr H garbage Disposal- [Y41aahing Machine ❑ 9ameL t/Plumbing -❑ sasemant/No Plumbing 6. it susiness/Industry/other, specify two - .+.Peoples - i Sink* Commodes - - ! Shower* I Urinal@ - -_ (' Water Coolers IF FOODSERVICE: If Seats Estimated Nater Usage (gallons per dry) 7. Type of water supply: ❑ County/City [3'Nell ❑ Community � 8. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes' yypro If yes, what type? 'IMPORTANT"6 CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: cS . R -e Yew f WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #u�' / (O T ���'� CA� o Ai erty PropAddress: Road Name A�%a hU F v m 'rr" AQ Clly/Zip r�a�/' o`l$(r If In a Subdivision provide Information, as ollows: S Frig J� � O nI Name: 51 e 54'prf�.ah�L'In Section: Block: Lot:0 Date Property Flagged: 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 Incurredfrom this application. I, hereby, give consent to the Authorized Representative of the Davie County Health De arimput to enter upon above described property located In Davie County and owned by �. r r -Me & ( �_ to conduct all testing procedures (�as necessary to determine the site sf tabfii . DATE c5 012 t tet" Fl f/ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property linen and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EIIS: Account No. Invoice No, g% S DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � Evaluation. :.,Soil/Site Site - � APPbCANT INFORMATION .. _ ! PROPERTY. INFORMATION 101 10/06 i Account -#: 990001440.. Tax PIN/EH #i 4871-81-W3.0014EP Billed To. Denise Carr � Subdivision Info: Sheffield Farms Lot # 18 Reference Name: Location/Address: Sheffield Farm Trail. -28634: ' Priipeiied Oaeihty=Residenee Prepert'y Size' '6+aeres Water Supply: On -Site Well V Community Public ATC Number: 2 Y 600 / Evaluation B Auger Boring �' I Pit Cut FACTORS .;. ,, : 1..; 2 3 4 5 . ( 7 Landscape position . Slo %a 14()RIZoN I DEPTHLP .. : . Consistence �r►�r���i';a®®® Structure;Mineralogy. •�� • �or�rx�®®® groupTexture Structure NEWIM MOM OMM MR -Mm MineralogyTexture HORIZON Ill DEPTH —MR. . 9�11roos us0 00 Structure, 0 19 .: HORIZON IV DEPTH Texture groupMineralog Structure ®®®®®®® • RESTRICTIVE HORIZONSAPROLITE ®®®®®®® LONG-TERM ACCEPTANCE RATEc V -- I Qa Iti c SITE CLASSIFICATIONr / EVALUATION BY;-- LONG-TERM Yr LONG-TERM ACCEPTANCE RATE: ©' OTHER(S) PRESENT: REMARKS: �2 t IP�Y�t-} 1 � LEGEND: Landscape Position R - Ridge S -'Shoulder L - Linear. slope FS - Foot slope N - Nose slope Te Flood plain H - Head slope Texture ConSand cave Loam sand ConvexSL SSand loam . LCLoam S "Texture Loamy y Silt SICL -: Silty clay loam SIL -'Silty loam CL - Clay loam, SCL - Sandy clay loam SC -'Sand claY :SIC-SiltYclaY C -Clay CONS ISTENCE 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 tructure 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 05/99 (Revised) cl �. r, 4. Ac - >7 Ac, '\ , 5. 1 Ac J 5.7 Ac. �aS ��• �fhZ�nK ��v f0Y �aU9� �tlm� �h�l Om I C� uJaw