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365 Baileys Chapel Rd DAVIE COUNTY HEALTH DEPARTMENT � ` � ' Environmental Health Section �`� �� �� a � P.O.Boa 848/210 Hospital Street ��•�v Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001626 Tax PIN/EH#: 5779-25-5562 Billed To: Steve Beauchamp Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27006 Proposed Facility: Residence Property Size: 12.18.Acres ATC Number: 2761 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 � Dishwasher: � Garbage Disposal: u Washing Machine: � Basement w/Plumbing: �Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �2 ��-� Type Water Supply�i�3�D�sign Wastewater Flow(GPD)�� Site: New�Repair❑ .� ri � System Specifications: Tank Size���AL. Pump Tank GAL. Trench Width� Rock Depth �� Linear Ft.� Other: � ����t�1 1.`c7t� '�>>C.�`S , Iri�T1�Ll� LI tJ^S�l�.C. �/�-�� � Required Site Modifications/Conditions: _ �1T��� �� 1•� - {�;t�:-��'�` IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie C Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:3'O�p,m�.�day of installation. Telephone#is(336)751-8760.**** ,��� � � IS�M lr•� . A�x. �"�1-15 P.�����►`� y�� s� N ���►� �`�-� � � F 1 S��S b-.�E. �S I��.��' , �� � 1,�� ��2a ��� �� �� r� �-��-�'� U,,��S , � p�►'�� � Environmental Health S ecialist's Si ature. � Date: � �(e P �► DCHD OS/99(Revised) , , , DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section P.O.Boz 848/210 Hospital Street Mceksville,NC 27028 (336)7S1-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001626 Tax PIN/EH#: 5779-25-5562 Billed To: Steve Beauchamp Subdivision Info: Reference Name: Location/Address: Bailey Chapel-��,28 ��7°O� Proposed Facility: Residence Property Size: 12.18.Acres **NOTE*N�hib�ImprovesinendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 rl�`%-xc. #People 2 #Bedrooms � #Baths 2 Dishwasher: � Garbage Disposal: �Washing Machine: �" Basement w/Plumbing: �=�' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size l� (.:�e� Type Water Supply��Design Wastewater Flow(GPD) s!�'"fO Site: New�Repair❑ �/ �� `�� System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width� Rock Depth �z Linear Ft. L!!',J� ocn�: � �sT"P.-ipJr�Q,J �C�S l►�sTou- L��►:s Q1 'a.c. �k„J . Required Site Modifications/Conditions: I�—Y`oT�l,lr (?�✓ C�T�3�� �-� �S� �G NC'�.�� �� �� '�'►'�� `U(` IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 930 a.m.or�m.to 1:30 p.m. on the day of installation. Telephone#is(336)751-87G0.**** L� �v �- C�t-�;a.►.��x:►Ys '�� � L' � . , r G ��c�-.so �.n c --rd►JX 4�R - P�N..P�I�c� ��� � �� ,�N � � 1� � �j _ � !a �� /\o � . Environmental Health Specialist's Signature: Date: � Z� D DCHD OS/99(Revised) . ,. . . ��- DAVIE COUNTY HEALTH DEPARTMENT Environmentai Heaith Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001626 Tax PIN/EH#: 5779-25-5562 Billed To: Steve Beauchamp Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27028 Proposed Facility: Residence Property Size: 12.18. Acres ATC Number: 2761 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 Sewag eatm and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT S R T � IS V ID FO A PERIOD OF IVE ARS. Environmental Health Specialist's Signature. Date: 2Z' CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovementJOperation Permit has been installed in compliance with Article I 1 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. /'� -�-/C.,Q�,'1 � �� �t�s �L� i�J t7 Q.Dc3 Sb' t��'�1� C�.��� r �3jT� . ' ^f�4�J 1� a- ��5� 7�,,�,°ic�� �. 5 "�,A�1'��.'I� ,S�J ��� '7�' Q �-�,_, Septic System I stalled By: � �� �Y � � ��4'�lZ Environmental Health Specialist's Signature: 7 I Dat .�Z �� 6 ✓ � DCHD OS/99(Revised) � �, , , , ..• �:6� ,. � �T.� APPUCATION FOR SITE EVALUATION/I�fPROVEMENT PEii611T&ATC Q L5 sC ��j�_I�t7 � Davie County Health Department , � Environmenta/Hea/lfi Secrion � � 8 2�� � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENUIROt�n3ENTlIt NEACTN D�1Vif COUNTy . ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. . /� I 1. Name to be Billed ���� � ea c.� � l�t Contact Peraon ��l-Q __�� Mailing Addreas 1 � iiome Phone "!�— ���� �/� City/State/ZIP �('� �� �� l p� �` `��� Business Phon ��� �' )`� / -v� 2. Name on Permit/ATC if Different than Above r '� '�(�'� � Mailing Addreas ��� ���J-(��{ l Y�{q,�-� � r�/N City/State/Zip �. l � s. Application For: � Site Evaluation ❑ Improvement Permit/ATC C17lBot��� � 4. Syatem to ser..��a: � House ❑ Mobile Home ❑ Business 0 Industry ❑ Other 5: If. Residence: # People �_ � Bedrooms �_ � Bathrooms � c� ,3 �shnasher ld�Garbage Diaposal YYwashing Machine �sement/Plumbing 0 Basement/No Plumhing 6: If Buainesa/Induatry/Other: Specify type # People N Sinka � Commodes A Shorera � Uriaals �k Water Coolera IF FOODSERVICE: #��Seats Estimated Water Usage (gallona �r a$Y) �. Type of water supply: �County/City ❑ Well ❑ Community a. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �Vo If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETNE REQUIRED PROYERTY INFORMATION ItEQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the clieot with THIS APPLICATION. Property Dimensions. -- ~�� ��'v� WRITE DIRECTIONS(troro Mocksville)to PROPERTY: Tax Office PIN: o, r �'�' ��� � `Y �A 5� �C� I�K-e_�e�,f� �.�. Property Add ress: Road Name � �� / 02�- �j i y b y �ct� �{J� � City/Zip�(I,QN� -2� /U,l'� ,��(� i `�1'" � �����-P � l�� lf in a Subdivision provide information,as follows: H�UDC.1� ��-�►.�1-� aDt-�� �l���,�� rr$�,e: (�l��.e l/2� ���,' �J c���.� t�ti,�� ��'J Section: Block: Lot: Date Property Flagged: �✓ ��,j�/ 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 su6mitted in this application is falsified or changed I,also,undersland that I am responsible for a1!charges incurred from 1hls application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property locatecl in Davie County and owned by to conduct all te ting procedures as necessary t�determine the site suitability. ^ DATE � /d I SIGNATURE ��- C� THIS AREA MAY BE USED FOR DRA.WING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge ��--elZ- - �'`� � 'f-'° �`�"" Date(s): _ l.�-s � 7�'��-'- �`�- � , Client Notification Date: �E- S� cs� - � C� _ _ ___ __.�_ EHS: Account No. � `�' � � . � i � Revised DI `��" �`� Invoice No. � �� , . '�....�.,.�...._..._�, _ __ . _._. _ :;�` ' � -t.- '•. � � � � _ � �� ;�A � � ,!` „�., fr � 'v� Ch,►. �53G��'��° ''�� .,. s � �' . 1��r�','� � � � l�{>. b� �h, k, ��Q �� �'�k�� ^ � '� �� . 4'� � � �`�s����� � �aa�� � ��J,� � � f,k. �1 _ � 0546 ,�``., �/ fi�'ry��� . L�,, w\��� (11.B7A) . . \r 7':��' "J . ,d' `:���: 55e .: �`� , i. j ,,, ' �` f w` � ` �y'� � y (f).37A) n,'-�. � rt� CJ 1435 �`i �```.. . � `Y � ;, .��ti , � � � . i; ! \ j� . � �, . 7 �f. ` � 1� Q;j . �: s � �� o,; ,,.a�„ �,.%n� o�as ,� �c1, 1 :i�,, � a ;e 5079 7036 1n'i, ao �.. v, �� � , o"��.. � � INDEXLD ON � �a INDEXED ON 5779.01 ^' � 5779.01 � �,� y �€ ti , 0819 S R�6j� � "1 4� ��',. (I.75A1 / . 1)23 t.soq �'°�r � ,'�1�+ 2770 n>ej & W,. � � (1�SGA) - 7532 ,t.. �r R.oa): g 2445� �' � +� :h �V � � i'� � w`" i� ` I . 3 ��' e � t _ . . .. ' � .♦ ,,, � ' . , "'. �''" � � - DAVIE COUNTY HEALTH DEPARTMENT , `_ Environmental Heaith Section � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001626 Tax PIN/EH#: 5779-25-5562 Bitled To: Steve Beauchamp Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27028 Proposed Facility: Residence Property Size: 12.18. Acres Date Evaluated: � � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slo e% � HORIZON I DEPTH - � - � Texture rou C C Consistence � ,- 5 ,- Structure S 1L Mineralo � 1• ,`1 HORIZON II DEPTH — Texture rou C Consistence . Structure �j � Mineralo � ('� , HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE + O.`' SITE CLASSIFICATION: � EVALUATION BY. � � �'� LONG-TERM ACCEPTANCE RATE: �' � OTHER(S)PRESENT: STL-�r l�t,G�IAM� REMARK�: ` �,' ` ' ` LEGEND � Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope Texture 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 CONSISTENCE 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 Structure - SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 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-gaUday/ft2 DCHD OS/99(Revised) ■�������■■■�■■�■��■�■��■��■■����■■��■■■■■�����■■��■��■■■■■��■���■■ ■����������■■��■��■���■■�■��■■�■�■��■■������■�■���■■�■■�■���■�■�■■ ■�����■���■��■■���■■���■����■�■��■��■�■■��■����■�■■■���■�������■■ ■�■������■����■��■��■�■��■����■■ ■��■��■��■■�■■������■�■■���■��■■ ■�■��■��■�■�■ao■����a�■��■��������■■�■��■���■�����■��s��■���■�■�■■ ■����■■��■■■��■����■■■■■■���■■�■��■■�■��■��■■�■■��■����■■■�■��■��■ ■��■���■■■■��■��■�■■�■��■��■■■�����■����■■��oe�s■�■��■�■■��������■ ■�������■����■����■��■��■��■■���■�■��■■■■■��■�������■■■■���■��■��■ 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