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170 S Angell Rd .� • DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001679 Tax PIN/EH#: 5749-19-7801 Billed To: Edward Barnhardt Subdivision Info: Reference Name: Location/Address: S.Angell Road-27028 Proposed Facility Residence Property Size: 1.33 Acres ATC Number: 3986 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 Buiiding Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Tr ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON IS ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : � ate: CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. �. ����BVr�x�l �a 1?D ���,�,� `� ST � ��N-I r �� K�1. I�-� � S�ILd ���" 1��a1: 11-Z Septic System Installed By: �� � �- esf�l � v' Environmental Health Specialist's Signature: ` Date: d �� DCHD OS/99(Revised) . DAVIE COUNTY HEALTH DEPARTMENT � . Environmental Health Section � ' P.O.Boz 848/210 Hospital Street / a s � Mocksville,NC 27028 v2/�'y� � � � � (33G)7S1-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990001679 Tax PIN/EH #: 5749-19-7801 Billed To: Edward Barnhardt Subdivision Info: Reference Name: Location/Address: S.Angell Road-27028 Proposed Facilitji �,Residence Property Size: 1.33 Acres ATC Number: 3986 ��' **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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�. � #People � #Bedrooms� #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑ � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size ������ Type Water Supplyl� Design Wastewater Flow(GPD) L"Tv Site: New� Repair❑ ' System Specifications: Tank Size��`�GAL. Pump Tank GAL. Trench Width��t Rock Depth 12�� Linear Ft.�r Other: � �5T���J���� ��/� �j� 5 ', —_� � Required Site Modifications/Conditions: ����,u_�.J �_r�OvQ, I'�`� G�-- 'f�"• l..�a�, __C� ��� 11�1PROVEM11ENT/OPERA'I'ION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:3 a.m.or 1:00 p.m.to 1:30 p.m. on the day of installation. Telephone#is(33C►)751-87G0.**** • 'jp' � �f 5� �b t,�,ZL_ I �7� �F��--a� �.I� �� r �,�sr ��r��' '�• N�� r,�►`�j (°°, a � �5� � q�� � � qo' I C/ Environmental Health Speci ist's Signature: Date: 7 fl� DCHD OS/99(Revised) � I ` :'. . �('^ � � � � � v Q 200�n ON FOR S1TL• EVALUATION/IhiPROVEhiEN7 PL"Rhi1T S�ATC � �4 �p� 2 � Davie County Health Department Environmenta/Hea/t/�Section �Nj�N��jH .0. Box f34£3/210 Hospital Street �N1R p��COUN�( Mocksva.11e, NC 2702Q (336)751—E3760 ***IMPORTANT*** TIiI5 APPLICATION C1lNNOT I3E PROC�SS�D UNL�SS ALL TFI� REQUIR�D � INFOIZNSI�TION IS PROVID�D. Refer to L-he INFOR2•SI�TION nULLETIN for instruction�. 1. Namo to bo Dilled G�� � . � � Y Contact Pcruon L�W�� Diailing Addreuu (�j'/� ��-// v v� ,� ~ Ifome P2iono �/�J / J �� �n �/ �/ / City/State/ZIP j�G 7 ✓; ' I Q IIuaino�n Phono�..5 / �TL�� 2. Nama on Poxatit/ATC iE DifEerent than Above Mailiug Addroaa City/Stata/Zip- 3. Application For:��-Site Evaluation �7L1-Improvement Pcrmit/ATC ❑ DoL-li 4. syata�a to sorvico: ❑ Houae Ca'Mobile Home ❑ Busine�3 0 Induutry ❑ Orher 5. . 1ype ayatem roquosted: �Convontional ❑ convontional modifiod ❑ iniiovativo 6. If Rasidence: iF People �_ 11 nedroomn �_ �E Dathroomn �_ Oniahwaahor ❑Garbage Di�poaal lsdWashing Macliino ❑Dasement/Ylumbing ODaacment/No Plumbinc� 7. If Duainean/Induatry /Othor: varify typo A Poopla II Sinks # Comsaoclaa # Showora N Urinal� IC Platcr Coolar� IF FOODSERVICE: �� Soatu Etttimatied Water Utsage (gallona por day) 8. Typo of wator aupplys L�YCounL'y/City 0 Well ❑ Community 9. Do you anticipato addition� or espausions of thc fzciliry tbis systcm is intcudcd to scrvc? 0 I'cs �YNo If ycs,ivl�at typc? ***IAfPORTANT"°**CLl�N7'SAfUST COhlPLCTLI'I1L: RL•QUIR�D PROt'�RT1'IIVl�OKA�Ie\TIOIV RCQU�STCD --- BGLOIY. �ithcr a PLAT or SI7'I:PLAN AlUST!3G•SUIIAII7TGD by tLc clicnt �viUi T!IIS APPLiCATIOIY. Property llitucnsions: l l�k ��- � / / � 1YKI1'�D[RLCTlONS(froiu Aludcsvillc)lu 1'liOl'GRTY: c ����.�F—! ' i T�xorr►��rirr: f����ll��,f��UJ�f �� � a �v /�/�i y �-�..� �?� 9 -t9- '7�br roperty Address: Road Nanic -� L /� r ,/1J ..� �-- i City/Zip �OC;,��v�l��v ��� '�.-,� ^ ,, � � / � � � If in a SubJivision providc iuforliia(io»,as Collotivs: c�/ - �i/� � l_"� i" Namc: . [�1) �,—� , !—� Scction: Bloctc: Lot: Datc homc corncrs Aaggcd: o�-� s Tliis is to ccrtify tli�t tlic inforinatioii pi•ovidcd is corrcct to tlic bcst of my IuioSti•lcdgc. I undcrstanJ tliat any perii�it(s) issucd lurcaflcr:�re subjcct to suspcnsiou or rcvocntion,il tiic silc plans or tntcndcd usc cliangc,or ff(hc informaitou subu�it(cd in tl�is application is falsificd or changed. I,�lso,uurlcrslanr!!lraf I anr respoirsiLlc jor rtl!clrargcs incrrr•rcd jrvn� !lris applicatiotr. I,Itcrcby,givc cocisetit to tiic Autliorizcd Rcprescntalivc of(lic Davic Couuty IIcaltl�Dcpartmcnt to cntcr upon abovc dcscribcd property locatcd in Davic Cowit}'and otiti�ncd by � cu coi�Juct all tcstic�g proccdiu•cs as ucccssar��to dctcriuinc tl�c sitc suitabilitp. � v�. DATIs,��/,��/l/�� SIGNATUI2� t ���i� � /`��� - � l TI�IS AREA I17AY B�US�D TOR DIZA�YII�IG YOUR SIT�PLAIY(Iucludc all of tl�c folIotiviug: �xisting and proposcd property lic�es alid Jimcnsions, structures, sctbacltz, and scptic Iocations). � ' ; Sitc Rcvisit Cliarbc ��% 5 -��,� : nac�cs,: . � ' f��� Clicnt NotiCcation Datc: � .� bB,-� � �IIS: Sign givcn . �� A'ccount I�io. � Rcti�iscd DCIiD(OS/03 Invaicc No. ��� � -,,.�o �ota/ �:� � � (1 .82A) N j� �� 8188 � (1 .71A) ; S3 2174 � (1 .54A) � h`��° a �� 7130 �o� �, , / 2�� S3� � (1 .21A)r �/ 8901 i ��� '��� /; 4983 3os � �� �� 27p � G5100A000101 ; %� �� �0� i� ti � .33A) ,�`�' %� 7801 �`� ; , , l�/ S28J , 3r2 0 200 � � 2646 � (7.89A) 51 (4.40A) 0604 , (148) 4670 (1 .01A) � � � �� 2520 ti °` N . � (2.78A) ` -. 2414 . j � 1 Q � �� �,,�.�;�2 Z- �� � � �� � � r � � f f � � �.ti �� � �� t �, � �� .�„�' ., ' i �-- �� c�� _ ._ -- �- ______ � � DAVIE COUNTY HEALTH DEPARTMENT ;� Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001679 Tax PIN/EH#: 5749-19-7801 Billed To: Edward Barnhardt Subdivision Info: Reference Name: Location/Address: S.Angell Road-27028 �. Proposed Facility: Residence Property Size: see map Date Evaluated: � 2 '�� Water Supply: On-Site Well Community Pubiic � Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L.l L- Slo e% � 3 ' � HORIZON I DEPTH f] • � �� �:` Texture rou � ^ G-+— Consistene� .S� ' �SS Structure S 1� � ' Mineralo � -�'�C�" � - ` HORIZON II DEPTH le_?-ZO -2 / -- D ` Texture rou C. � G Consistence ; S �� �� Structure • S-�v"1c ,-1� Mineralo ' HORIZON III DEPTH �3 Z" -3Z - C7 Texture rou � - c�'.+S�r�CSc�. G FSt Consistence _f '� SS s/ r S Structure 5� Syk' Mineralo S�;,Q �...,�C. HORIZON IV DEPTH �tyt "'' '�ll� �!U Texture rou Cs�) /<�'�l'�c �� Consistence . �' Structure ` Mineralo u'X SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � • (�- O-.�� SITE CLASSIFICATION: P S EVALUATION BY: ����-�`� LONG-TERM ACCEPTANCE RATE: ����'��� OTHER(S)PRESENT: REMARKS: �}Tj? �L�� Qp�_ ,..�x.L'� �� 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 day loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay � CONSISTENCE Mois 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 MineraloQv 1:1,2:1,Mixed Note � 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 OS/99(Revised) ■�� � ■����������������������������������������/��0��������/�■ ■�■ �����■�\���������������������������������■�������������■ ■■ ::��: ':'::::C:::::::C:C:C:C:::�::::::::::::C:::C::C::::::::C�:: ::'�:.:A:::::::::::::::::::::::::C::::::::C::::::::::::::::::::::: ■�����■ ■�������������■�■�■�������■������������������a�������■���■ .....=.0.......................................................... :C•:• •:':CC:::::C:C::C:::::::::::::::::C::C::::::::::C::::C::C::: _:�.���:C:C:::::C:::::C::::::::o�i::::::::::::C:::::::CC:::::::::: ...0.. 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Angell Road Tax PIN#: 5749197801 Dear Client(s): As requested, a representative from this office visited the above site February 2, 2005 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to.be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally,please locate the property corners prior to making this request. If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s)