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303 Applewood Rd �, . . 1 f�/ . � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � P.O.Boz 848/210 Hospital Street , Mocksville,NC 27028 (33G)751-87G0 Account #: 990003515 Tax PIN/EH#: 5765-23-1944 Billed To: Kelly Smith Subdivision Info: Reference Name: M r. & M r s. D u s t i n S m i t h Location/Address: 303 Applewood Road-27028 Proposed Facility Residence Property Size: 10 acres ATC Number: 4023 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Canstruction MLJST 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: Date: � �.�'�� CERTIFICATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate ofCompletion 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. r �����m���� ���� � s Septic System Installed By: � � Environmental Health SpecialisYs Signature: Date: ��/�v�/� DC�ID OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT � ; ' � Environmental Health Section l�� (�_-� o � v S ' P.O.Boz 848/210 Hospital Street � ' Mocksville,NC 27028 . (33fi)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003515 Tax PIN/EH#: 5765-23-1944 Billed To: Kelly Smith Subdivision Info: ReferenceName: Mr. & Mrs. Dustin Smith Location/Address: 303ApplewoodRoad-27028 Proposed Facility Residence Property Size: 10 acres ATC Number: 4023 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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. 'L 1 Residential Specification: Building Type 17 #People � #Bedrooms � #Baths��� Dishwasher:� Garbage Disposal:.� Washing Machine:,� Basement w/Plumbing:� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size Type Water Supply�� Design Wastewater Flow(GPD) Site: New❑ Repair❑ J� / System Specifications: Tank Size����GAL. Pump Tank GAL. Trench Width�L�Rock Depth� Linear Ft.��� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G "BELOW FINISHED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis 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(33C)751-87G0.**** T� /.S � �7v , C� / Environmental Health Specialist's Signature: �'�� Date: �� `'���'� i � DCHD OS/99(Revised) Feb 21 f5 09: 42a davie count� envhealth 336 751 8786 p• 2 . � , �� . . r � � � � �!�y � � � � APPLIC��TION FOR SITE EVALUATION/IMPROVEhiFM PERMIT A �J ✓ Davie County Health Department ti4AR ' � / � Envi�anmenta/Hea/th Section � 2 2�05 P.O. Box 848/210 Hospital Street � I Mocksville NC 270 8 � � 2 FNVIRO�ti4�7EN1A1 H � (336)751-B760 pq�E E4LI}t COUTJIY t*tIMPORTANT*** THIS APl?LICATION CANNOT BE PItOC�ESSED TlNI,ESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORbiATION BVLLETIN £or inatructions. ✓1. Name to be Billed .J� (�eontact Peraon t/Mailing Addreas 7�� �� �Y� . C�fi'ome Phono G (7 ��ity/State/ZSP aL11�11-� � �f�?ig �uaineas Phone _ �5r' (Q�-3 ��2. Name on Pezmit/ATC if Differa;�.t than Above �],/L c� �y�,(L u�'j� �j �j/Yy�t'�.. Mdillrig Addresa City/State/Zip �3. Application For: ire ]:VslustiOn ❑ Improvement Permit/ATC Hoth , �. syeeem co ser..ice: [g House ❑ Mobile Home O Busineas ❑ Indust / ry ❑ Other ,..�5. 7�.pe syetem requeated: L� Com•entional ❑ conventional modified ❑ innovativa I . r6. IE Residence: # People �_ # Hedrooms _��- q Bathrooma �L____�/ � LJDiahwaeher Garbage Diapo�81 11QWdshing Machlne �9asement/Plumbing ❑Basement/No plumbing 7. If Buaineea/Induetry /Others verify typo q People # 51nks A Commodea q S:�owera # Urinala A Water Coolera IF FOODSERVICE: � Seabg Eatimated ydater Ueage (gallona per day) / �-8. Type of water eupplys ❑ Coun�:,y/City rJ Well ❑ Con¢nvnity 9. no You anticipata additiona or expansions of tl�e facllity this system is intended to ser��e? �Yes Q"NO ..r Ifycs,�vl�at t � . ** I1ViPORT�INT''**CLIENTS MUSTCO PLETETHE RL•QUIRED PROPERTY 1NFORl�IATION REQUESTGD [3EL Eitlier a PLAT or S1TE:PL STBESUIIMI7'TED by thc clicnt �vlth THIS APPLICATION. Vl�roperty Dimensions: � ���,� "�VRITE DIRECTIONS(from 111ocksville)to PROPCR'TY: ��i'ax OfCcc PIN: # ��� _3/9 � � ��� S �TDti ��G/-�lcJ.�.� �.Property Address: Road Name�Q:,�����Z✓l�D i2� �O �.�-r' ,et�,c�' a iv C.�r'iLii�,fj�L'� City/Zip 6 _ �(1��� �D L� ��1 D� /�t�ZT��� rGt//�}-.�� f in u SuUdivision rovide in[ormation,as tollotivs: j�t; /�Z �T��'�,�1�'[��2 � �%�-t� Name: _ D�� /�� �i7�� d.v �t`1�7— Section: Btock: __ Lot: �If.�tc Gomc corncrs tlaggcd: �- �� �S� Tliis is to certif}'tl�at tt�e inform�tlon prnvided is correct to tlie best of my kno�vle�ge. I undcrstznd tliat any permit(s) issued licrcaftcr are subject to suspensiou or revocation,if dic site plans or intended usc changc,or i(tlic ia�formatiou suUmitted in tl�is application is falsificd ar cl�anged. I,a1so,u�rderslmid U1atI nn1 responsiblejor all clrnrgcs inctrrred from lhis applicatiori. I,hereby,give consent to tlie Authorized Representative of the Davic County�Tealtli Dcpartment to enter upon abovc described property :ocated in Davic County and otivned by to couduct all lestin�;pracedures us neceisary to determine tlze site sultabtlity. ! A �' s��`�.. vDATE 7'' Y6 ��1� , '�'S'GNATURE THYS 1�REA MAY 13E USED FOR DIL4'WING YOiJIt SITE PLAN(Indudc all of the following: �xlsting and proposcd property lines pnd dimensions, structure�r, setbacks, and septic locations). Site Revisit Cl�arge / Date(s): /w ��� �v/�' Client Notif►cation Date: J�,( GL(�l cti � � EHS: ' v7 � Sign given yV "� Accouut No. c=��� � � �,/ U r Rcvised DC D(OS/03 � Invoicc 1�Io. / � '���� . � ,.���*�� ' � < � � � � �� �� � ,a r � .._ � .�,, �� , »� ,� �� � � � ��� � �a� � 's ��. a �''� 3 . 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'� \ .. . : :'�. �"� .. � ' � SR,a�'xINGLETON�''a��� �_--- z ,.u. „�,w"�--_ � 1 � � 4 \ � .. � � � 696 & 7j� � 3a 2 . ���� .. ,,. . . , �. � 8�1 �( �..! � � ��' .� �I � ? / ` � — — — — � � ' >� ', / �'ro \ �' . ..� 40 68A �I . � \ �� ..: ��. � . `� ,,,,�i�..�y.� � . .� .� � ..r' . . �:s�r,r.� . .. .. f � ... ---- ... —--- - --- .: . . ..._. . __ ...�— �---;I e r DAVIL COUNTY H�ALTI1 U�I'AI2TMI;NT � Environmental Health Sc;ction Soil/Site Evaluation AI'PI,ICAd��r�N'tC�Nf���A`�1;15 Tax PIN/EH#: 5������'d�NFORMATION ;:., Bill�d To: Kelly Smith Subdivisidn Info: . Reference Name: Location/Address: 303 Applewood Road-27028 l i Proposed Facility: Residence Property Size: 10 acres Date Evaluated: �I,J.��i/� • ,. Water Supply: On-Sitc Well Community Public � Evaluation By: Auger Boring Pit ' Cut FACI'ORS 1 2 3 4 5 6 7 Landsca e osition S�O C�o �q d 1-iOR1ZON I DEPTH �i c� Texturc rou Consistencc ;� Slructurc Mineralo .�� HORIZON II llEPTH f i� � K�/ Texture rou G Consistence - • Structure � S Mineralo HORIZON III DEPTH 7-" �"� Tcxturc rou Consistence � r— Structure ' / (' Mineralo / HORIZON IV DEPTIi Texture rou Consistcnce Structurc Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCCPTANCE RATE ,.. SITE CLASSIf-1CATION: .,�� EVALUATION BY: �� LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: RCMARKS: LEGEND ' L�ndscapc Position • . R-Ridge .S-Shoulder L-Linear slope FS -Foot slopc N-Nose slopc CC-Concave slope CV-Convex slope T-Tcrrace FP-Flood plain H- Hcad slope Tcxturc 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 SONSISTENCC Moist VFR-Very friable FR-Friable FI-Firm VFI- Very firm EFI-Extrcmely Crm , � � NS-Non sticky SS-Slightly sticky S -Sticky VS-Very Sticky � NP-Non plastic SP-Slightly plastic P-Plastic VI'-Vcry plastic r t�rc 'SC-Single grain M-Massive CR-Crumb GR�Granular ABK-Angular blocky SI3K-Subangular blocky PL-Platy PR-Prisrpatic �Ii,2eraloev 1:1,2:1,Mixed Notcs � Horizon depth-In inchcs Dcpth of fill-In inches . 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