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681 Becktown Rd , � � DAVIE COUNTY HEALTH DEPARTMENT �,�`�---�-Z-�3cf Environmentai Health Section P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 �� �!� (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900422 Tax PIN/EH#: 5755-69-5373.00OE Billed To: Erin Spry Subdivision Info: Reference Name: Erin Spry Location/Address: Becktown Road-27028 Proposed Facility: Residence Property Size: 1 Acre **NOTE'��Tfii b�mprovenient/Operation 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 CONTI2ACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �� #People � #Bedrooms � #Baths�_ Dishwasher: � 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)�(Z Site: New� Repair❑ � �l �( System Specifications: Tank Size��'iAL. Pump Tank GAL. Trench Width �� Rock Depth�� Linear Ft�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Deparirnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 .m. n the day of installation. Telephone#is(33G)751-8760.**** � � � — -� Environmental Health Spec�alist s S�gnature: i Date:_ � � � DCHD OS/99(Revised) , � DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section r.o.Bog sasnio x�p�ta�s��t Mocksville,NC 27028 (33G)751-8760 Account #: 989900422 Tax PIN/EH#: 5755-69-5373.00OE Billed To: Erin Spry Subdivision Info: Reference Name: Erin Spry Location/Address: Becktown Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2361 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction 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 WASTEWATE CONSTRUCTION IS VALID OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ..� Date:��:�.�-� CERTIFICATE OF COMPLETION **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 NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. �,�1 �� � � Septic System Installed By: Environmental Health Specialist's Signature: Date: 7 �'��� DCHD OS/99(Revised) ' ` i ' � APPIICAiION FOR SITE EV1W1Al1UN/IMPItOVEMENT PFRMI 1b � � � � 15 • •� � Davie County Health Department 1 • �Q - - Envfronmental Nea/tfi SerHon F� � 0 (999 S � � P.O. Box 8�8/210 Hospital 3treet � , Mockaville, NC 27028 � � (336)751-8760 �1VIRONP�1ENTAL�LTH S DAVIE COU ***SF�ORTANT*** THI3 APPLICATION CANNOT BE PROCESSED UNLE33 ALL T'�iE REQUIRED INFOP.MATION I3 PROVIDED. Refer to the INFORMATION BOLLETIN for iastructions. i. Name !to be Billed L }T"'i� �, J 0 r� Contact Beraon lisiling �ddreas � (�� �r.�e....��-�,� /_ � , $� rt►�,e �3 � G ��7�/ -�13 7� City/8tate/2ip �6 C.1�S J�.``2 1V.l�� ��C] ��,� Bueineas Phone ��/ ^ � I I 2 � Z. tiame or. Pe�it/ATC i! Different than Abave � T/�h �t'f'�� riailinq l�ddreas City/8tate/21p 3. licatioa For: fd 3ite Evaluation �� ✓22-U App �Im¢�rov+ement Per�t/s'='C � Sotin 4. sy,t.em to servtce: C) House �l Mobile Homa ❑ Busineas I] Industty 0 Other s. If Reaideac�: # People f ; Bedrooms �_ � Bathrooms �_ O Dishwa�her � (iarbaqe Diaposal I� ttaahinq !lachlna 0 Baaement/plumbinq 0 Basement/No Plumbinq 6. ii Bnsineaa/induat=y/other: Specity type # Beople f Sitil�a • Coa�odea f shrnrera � Urinala • Nater Coolers • IF FOOD3ERVICE: � 3eats Estimated iiater Usaqe (qalions per day) 7. Type of �+ater snpplp: el Connty/City 0 Nell ❑ Co�unity e. Do you anticipate addition�or e:pansions of tde tacility thia eyatem is inteuded to serve! ❑Yes � No It yes,what type' **"IMP�ORTAN7'•'"CY.IENTS 1HUST CO�1tPLElE THE REQUtRED PROPERTY INFORMATION REQUESTED r BEL(A4'V. E��ber a PLAT or SlTE PLAN hfUST BESUBhtITTED by the dtent with TEi1S APPI.ICATiON. Property Dlmenaiona: 1 aerc. WRI'1�DIRECTIONS(tmm Mocl�ville�c�o A��P?R'II'Y: ia:iiiiice�'YN: # � -�� � dDO��a I Socx{� �{-a �ec-l�%{�'a,c�r` Q,�, rt Property Addresa: Road Name ��ck��«,�.. ��. Sd �.��.c�s� ko end O�- 1}'b��, • - �� City/Zip_,j`l�v�'il�v�lr�.�'LC. Zzvz�' �'o�e��tY l�e-��„cQ� �.��,�,.�e- c�.��, � ' If in a Subdivision provide inSormation,a�followa: �f�r.e k�r y�S�p e �k� '�5 w��e� Name: Q.C�c. , • Section: Block: Lot: DAte Property Fiagged: Z � ID ---`�� This i�to cerlify that t6e ioformalion provided is correct to t6e best of my knowledga I underatand that any permit(s) issued hereafter are subject tv su�pen�ion or nwocatioo,ii the aite plans or intended use c6ange,or if the information submitted fn fB1�Applicatlon ia t�tlsitied or changed I,also,anderstand th�I an�responsib/e for all cbo,ga lircurred fronr this application. I,6ereby,give consent to the Aut6or'rud Repreaentative of the Davie County Healt6 Departmeat to enter upon above described property located in Davie County and owned b�� f�o•��, �ol E. 5 pr� to couduct all testing procedurea as necessary to dMermine the�ite auitabilih-. DATE � ��' f �'9 SIGNATURE � - '*'�::ti ti;.��;.rrnn it i�L Y�SED Falt r�RA�+ING YOUR SI'I'E PLAN(Inciude xll of the toilowing: E�ning�nd proposed property lines and dimensions, atructures, aetbacks, and aeptic locations): �L ,/ . C� (� C� � �IC� �� e��r D /Q � � � �R I � 2oao �t�v� �� � _ C^`'❑ r T I� 7l� �°��� O �J��yQ' �a�� T u�Ylf\�i\i�t�t.��11'1L�'�Lr\�7f1 � � pAVIE COUNTY �, �, , � ---� ____� ,1 � -s Account No. � [3 e�kte,�•`�R.�. �'/,�,�Q� v Revised DCHD(07/98) ���� Invoice No. ��v�- �s T � �%lJ � e � t � � ' "� � DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section SECTION LOT SoiUSite Evaluation � APPLICANT'S NAME �!�.`yt /I J'�/ DATE EVALUATED �If��� PROPOSED FACILITY �f�"+ PROPERTY SIZE 1 ��e SUBDIVISION ROAD NAME ��CO✓/�� (i� Water Supply: On-Site Well Community Public t� Evaluation By: Auger Boring �� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition �L. ,L Slo e% HORIZON I DEPTH �' °� Texture rou / Consistence Structure Mineralo HORIZON II DEPTH � '� '� Texture rou G' Consistence � i Structure /c. Mineralo � `/ /� " HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION i LONG-TERM ACCEPTANCE RATE � , � SITE CLASSIFICATION: �� EVALUATION BY: .0 /'Cb // LONG-TERM ACCEPTANCE RATE: i OTHER(S)PRESENT: REMARKS: ��rnC� �C�C �`l�(JLLyI��lG' � LEGEND Landsc�e Position R-Ridge S-Shoulder L-Lineaz 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 et 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 Mineralogv l:l,2:1,Mixed otes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-T'hickness 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(sui[able),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD(O1-90) ■■�������■�■�■��■�■■■�����■■�■�■��■■���■■��■�����■�■■�■�■�■�����■■ ■■�■������■���■■�■���������■■�■����■■�■��■��■■��■�■��■■■����■■■��■ ■�■��■■■��■■■�■■�■��■��■�■■���■■ ■■■��■�����■��■■■��■■■�■���■■��■ ■�■��■■■■�■����■��■■■���■�■���■■�■����■■�■■�■�■■■�■■���■■■■���■�■ ■�■��■�■■����■��■���■���■�■��■����■■���■��■■���■�■����■�������■■�■ ■■������������■�■■�■�■��■��■���■■��■■���■■��■�■��■■�■■�■������■�■■ ■��■■■■���■�■�■��■���■■�■■��■■■��■�■■�■���■����■�■■��■■�■�����■�■■ ■■���������■■��■e���■�■���■�■��■�■■���■�■�������■������■■�■����■■■ 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Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 (336)75i-8760 March 5, 1999 " Erin E. Spry 169 Green Iron Lane Mocksville, NC 27028 Re: Site Evaluation Becktown Roadll Acre Tax Office PIN: #5755-69-5373 Dear Client(s): As requested, a representative from this office visited the aforementioned site on March 1, 1999. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, � �� ���� �� �� Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/wd Enclosure(s)