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122 Irishman Place Lot 29DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000736 Billed To: Custom Homes of Advance Reference Name: Butch Harter Proposed Facility: Residence 19",/'6;2'a-<Zf Tax PIN/EH M 5789-73-8141.29 Subdivision Info: Shamrock Acres Lot # 29 Location/Address: Irishman Place -27006 Property Size: 100 x 300 **NOTE**Thi s�inprovement/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 1 I 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 D #People _!y #Bedrooms f #Baths 12 Dishwasher: Garbage Disposal: 0 Washing Machine: �6 Basement w/Plumbing.A Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size /02K2KD Type Water Supply( j[ Design Wastewater Flow (GPD) Site: New m --"Repair ❑ System Specifications: Tank Size D60 GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft,�kZ i Other: Required Site Modifications/Conditions: )VEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) W 6 " BELOW IED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** I A—� Vt IVt Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: —1 80 —OCD DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 548/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000736 Billed To: Custom Homes of Advance Reference Name: Butch Harter Proposed Facility: Residence ATC Number. 2370 Tax PIN/EH #: 5789-73-8141.29 Subdivision Info: Shamrock Acres Lot # 29 Location/Address: Irishman Place -27006 Property Size: 100 x 300 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: CERTIFICATE OF COMPLETION Date: **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 NObe t4en as a guarantee that the system will function satisfactorily for any TY given period of time. 1 El r Septic System Installed By: Environmental Health Specialist's Signature: kladiQ Date: DCHD 05/99 (Revised) Name to be Billed Mailing Address City/state/SIp APPLICATION FOR SITE EVALUATION/IMPROVEMENT' PERMIT & Davie County Health Department Environmenta/Hea/fh Section P.O. Bos 848/210 Hospital Street Mockaville, NC 27028 (336)751-8760 Contact Person -1 /,A l 11AVk✓ Some Phone 2y6 -(0161 Business phone ?fry Cj - 3 a C- 2. Name on Permit/ATC if Different than Abnove Mailing Address r Ms 7-('j 8 /iii uao ee city/State/zip- Y 7J0 U 3. Application For: ❑ Site. Evaluation Improvement Permit/ATC ❑ Both C. System to Service: I -House ❑ Mobile Home S. If Residence: # People ❑ Dishwasher 0 Garbage Disposal ❑ Business ❑ Industry ❑ Other # Bedrooms —3_ # Bathrooms_ CI Washing Machine 6. If Business/Industry/Other: Specify type # Commodes # Showers I.V6asement/Plumb1ng # Urinals # People I.I Basement/No'Plumbing # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water usage (gallons per day) 7. Type of water supply: ;�ounty/City ❑ Well ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes p N� If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: _ 100 )SV) Tax Office PIN: #'J 7", 1 ;� — g/51 Property Address: Road Name • 1 V 1Slnv�a In City/Zip —MAV01 le 7-1601P If in a Subdivision provide information, as follows: Name: -f21dQMV0tL AL1 Section: I{— q Block: 70142 Lot: -ZAq WRITE DIRECTIONS (from Mocksville) to PROPERTY: (nil west- T6oLPta42c'.t/ I IZ �01 SDUT�1 ` T I& zNt-1 P g es Gee k TiL Dow!1LA Date Property Flagged: _3-27-146a 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 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 determine the site suitability. DATE 3 17 — Z0OC7 SIGNATURE —� ITT' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (e7/99) X00 Sag Site Revisit Charge Date(s): Client Notification Date: EUS: Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation J DATE EVALUATED PROPERTY SIZE fRG LOCATION OF SITE NAME ADDRESS PROPOSED FACIILTY Water Supply: On -Site Well _ Community Public J -Evaluation By: Auger Boring Pit 0/ - Cut FACTORS 1 2 3 1 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH V19 Texture group G Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � SITE CLASSIFICATION: �5 EVALUATED BY: LONG-TERM ACCEPTANCE RATE: r / 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 :lay loam- - SIL -Silty loam CL -Clay loam - SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay Moist - VFR-.V+.,-y 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 (01-901