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130 Irishman Place Lot 28DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section IND_ �-- P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000736 Tax PIN/EH #: 5789-73-9169 Billed To: Butch Harter Subdivision Info: Shamrock Acres Block A Lot # 28 Reference Name: Butch Harter Location/Address: Irishman Place -27006 Proposed Facility: Residence Property Size: 100 x 300 ATC Number 2152 r **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 I 1 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. i Residential Specification: Building Type #People S #Bedrooms QS-:' #Baths Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply_ Design Wastewater Flow (GPD) Jp,/? Site: New Repair ❑ System Specifications: Tank Size AeR GAL. Pump Tank ,e."I8'A Required Site Modifications/Conditions: 11 GAL. Trench Width 3G � � Rock Depth Linear Ft.c` d 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.**** Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account t. 990000736 Billed To: Butch Harter Reference Name: Butch Harter Proposed Facility: Residence ATGNumber 2152 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 TaR PIN/EH #: 5789-73-9169 Subdivision Into: Shamrock Acres Block A Lot # 28 Loca'tionfAddress; 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 WASTEWAWR CONSTRUCTION ISS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: F� fig �J� Date: i CERTIFICATE OF COMPLETION 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. mi I 96f (90, M-5 '50. 600 - Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: � `3o 'f)'b r NAME ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT �� Environmental Health Section E al So11/OIL ev ue on DATE EVALUATED / SIM PROPERTY SIZE Q��i9C LOCATION OF SITE Water Supply: On -Site Well Community Publicy Evaluation By: Auger Boring - Pit 4_� Cut FACTORS 1 2. 3 4 Landscape position 4— Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ri Texture group Consistence Structure L. S 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 i SITE CLASSIFICATION: N��I LONG-TERM ACCEPTANCE RATE: l• Y REMARKS: DCHD(01-901 EVALUATED BY: j4 OTHER(S) PRESENT: 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 "" 4Vl\JJ•IIl\VG " 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 3C -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 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 Silt Loamy sand SL - Sandy loam L - Loam SI,- Silt SICL y clay loam SIL - Silty loam CL - Clay loam SCL -Sandy clay loam -Sandy clay SIC - Silty clay C Clay SC CONSISTENCE 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 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT - ' Environmental Health Section SoiVSite Evaluation . APPLICANT INFORMATION '' PROPERTY INFORMATION Account #: 990000736 Tax PIN/EH #: 5789-73-9169 Billed To: Burtch Harter Subdivision Info: Shamrock Acres Block A Lot # 28 Reference Name: Butch Harter ; Location/Address: Irishman Place -27006 Proposed Facility:. Residence Property Size:, 100 x 300 Date Evaluated: Water Supply: On -Site Well Community Public `Evaluation By: Auger Boring Pit Cut 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 Silt Loamy sand SL - Sandy loam L - Loam SI,- Silt SICL y clay loam SIL - Silty loam CL - Clay loam SCL -Sandy clay loam -Sandy clay SIC - Silty clay C Clay SC CONSISTENCE 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 05/99 (Revised) ■■■■■■■■■0000■ ■o■■■a■■■oo■o■ ■■■■o■■oo■o■oo ■■■■■■■o■■■■■o ■■■■■o■oo■■■o■ ■■■o■000■■■■o■ ■■■■o■■■■oo■o■ ■■■■oo■■■0000■ 0000■■■■■■■■o■ ■00000■o■o■oo■ ■0000■■■■■000■ ■■■■■■o■■0000■ ■■■o■■oo■■o■o■ ■o■0000000■000 ■■■■■■■o■■■■o■ ■o■■■■0000000■ 61' \ 41p ray erg. /a M O 49 9w' I! �rJG.:. AIX Z, �/ C7 no NOW ° f?� °A, f0 ^p APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Deperttnent E YImnmenfel Haalo Section AUG 2 3 1999 P.O. Bos 848/210 Hospital Strut Mookoville, HC 21028 (336)751-8760 „<.. ENV] RONME..A'HEAI DAVIE COUNTY ***IWCRTMV** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INBORMATIgtI I8 PAO{ISDED, Refer to the IMRIMION BULLETIH for inetruations. 1. Ww to be Billed Halling address Citr/stat./szp a. Bar on Remit/ASC it Different than Hailing Address Contact parson nor inion. 9140 — 63 in r Business Rheas 33(o 310 3Z 3. Application for ❑Sita !valuation D�mprovament Porait/Am ❑ Both 4. systen to service, $onw ❑ Mobile Rome O Business ❑ Industry O Other r 7 a. If llers':a*: i People s Bedrooms J e Bathrooms Z— p'D/iehruter D Garbage Disposal 1aeUne O Baeernt/Dlmbing O auernt/ne il:mbiog 6. I! awirss/Sndcetrr/other: &pecifr type e Corollas a shovers 1 Urinals e people a &Sake e Water Coolers If 11=SERVIC=: # Stats Estimated Nater Usage (gallons per day) 7. Type of Water supplys ountp/City O well ❑ Community e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yee filDle� If yes, ghat type? ***IMPORTANT'***CLIENTS MUSTCOMPLETETAE REQUIRED PROPERTYINFORMA71ONREQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client With THIS APPLICATION. Property Dimensions: /00 SC WRIT^ �DIUZC IONS(fromMod 011e) to PROPERTY: Tax OfiicePINt n ('9 Ll F e t Property Address: Rad Name City/Zip H In a Subdivision provide information, as follows: Sections j� 9� Blockt Leh Date Property Flaggedt This is to certify that the Information provided Is correct to the best of my knowledge. i understand that any permit(.) Issued hereafter are subject to suspension or revocation, if the site plans or Intended see change, or if the Information submitted In this application b falsified or changed I, also, understand that I am respona161e for all charges incurred from this applicadom 1, 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 aft testing procedures ss necessary to determine the site suitability. DATE `Z 3' % SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following( Existing and proposed property Una and dimenslons, structure, setbaelm, and septic locations) 2� Revised DC1D (07/99) J I:. I 30[) Client Notification Date: I EHS• Account No. Invoice No.