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152 Belaire LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Pat CO / / P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001849 Tax PIN/EH #: 5739-28-2382 Billed To: Roy Shores Subdivision Info: Reference Name: Location/Address: Belaire Lane -27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2937 **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 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 INST LING SYSTEM. Residential Specification: Building Type #People � #Bedrooms #Baths_ Dishwasher Garbage Disposal: 13Washing Machine; 2 Basement w/Plumbing: ❑ Basement/No Plumbing: 13 Commercial Specification: Facility Type #/People #People/Shift #Seats Industrial Waste: ❑ Lot Size :4 (2 Type Water Supply iVC 1l Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Sizelb-0GAL. Pump Tank GAL. Trench Width(_VZ Rock Depth Linear Ft.'5-'IW Other: "o�Yy-70t'S Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) 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.**** 3�v i a� 7 IP Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001849 Tax PIN/EH #: 5739-28-2382 Billed To: Roy Shores Subdivision Info: Reference Name: Location/Address: Belaire Lane -27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2937 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 System Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. �yc Environmental Health Specialist's Signature: Date: Z� "c:-2 —01 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. C!ap 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: � `,V — �9 !% L r ((�� ly CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department Envifonmental Health Section Jt►�_. 2 n 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 EIMRONMEMALHEALTH (336) 751-8760 VIE COUNT( ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Reefer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed t7 Q L A ,, k o r e-,5 Contact Person R D q 1- - S No ras Mailing Address eja%' c e i t�0.yie, ^� Home Phone S 3 -7 y 1 ►1 City/State/ZIP ©c,kS V i I 1 Q_ 1 ( C . � [ -7 o c.L R' Business Phone rpU' 2 . Name on Permit/ATC if Different than Above sam Q., QS aI in C 1i q. Mailing Address %�A City/State/Zip 3. Application For: O<Site Evaluation ❑ Improvement Permit/ATC /Both 4. System to Service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms _Q U Dishwasher U Garbage Disposal Washing Machine ❑ Basement/Plumbing rl Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City Well CI Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes b j40 If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: O'Cr o, WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # ���-� / z 2 39- 2 O� �U wow-+% --y CgnCl IM Property Address: Road Name �-t La-�: r Tat- 1 Zi4 hl —Ar Al 1 /� UN rdl Rd City/Zip Ttk Fdc4 rt' Loll e �L11 If in a Subdivision provide information, as follows: ^(1 �a- - Q h z F P r �/ L�GtnS Name: Section: Block: Lot: Pas -4- c� A bac i\ O A US -f - Date Property Flagged: _'7-03 O 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 submitted in this application is falsified or changed. I, also, understand that I ani responsible for all charges incurred front this application. I, 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 all testing procedures as necessary to determine the site suitability. DATE 7- �" 61 SIGNATURE • ,/�� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 0 'J Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. v Invoice No.�`"�� ��-� IN 228 C0 253.86 0 0 co CD N 346 --%. 2.77A co 5374 (\ G40000003405 --------------------------------------- 3.77A= as 4143 � 384 N 0 W DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001849 Tax PIN/EH #: 5739-28-2382 Billed To: Roy Shores Subdivision Info: Reference Name: Location/Address: Belaire Lane -27028 Proposed Facility: Residence Property Size: Itcre Date Evaluated: e -Q / Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure C �� 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 SITE CLASSIFICATION: 40 LONG-TERM ACCEPTANCE RATE: 1-2 REMARKS: LEGEND Landscape Position EVALUATION BY:Gi��1 OTHER(S) PRESENT: 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 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 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) i ■ ■ ■ i ■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ MENNiEN EMMEME ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■ ■■■■ OMEN ■EM■ NONE ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■EM■EE■■ ■■■■■■■■■■■■■■M■■ ■■EM■■■■■E■E■■M■■ ■■■■■■■■M■■■■■■M■ ■■■■■■■■■■■ME■■■■ ■E■■■■M■■■■■■MM■■ ■■■■E■■■■■■E■■■■■ ■■EE■■■■■■■■■■E■■ ■■■■■■M■■■■■■■■■■ ■■■M■■■■■■■E■■I■■■ ■EEE■■■■■■■■■■ ■■ ■■■■■■■■■■■■■■E_■ ■E■■E■■■■■EME■■ ■ M■■■■■■■■■■■■■M■■ WEENE■■■■■■■■■■■■ ■'■■■M■■MM■■■■■■■ ■■■M■E■■■■■E■ME■■ MEMO■■■■■■E■■■M■■ ■■EEE■E■E■■■M■M■■ ■EEM■■■E■■E■■EME■ ■■■■■■M■■■■■■■■■■ ■■■■■■M■■■■■■■E■■ ■■■E■■■■■E■■■■■■■ ■■ MEMO■■ ■■■■■ ■■�■■■■■■�■■■■■ ■MEE■■E■■E■■■■E■■ ■■EE■■■E■■■■E■E■M ■■■■■■■■■■■■■■■■■ ■■■E■■■■■■■■■■■M■ ■■■■■■■■■■■■■M■■■ ■■■■■■■■■■■■■■■■■ ■■■M■■■■■EEE■■■■■ ■■■■■■■M■■■■■■M■■ ■■■■■■■■■■■■■ ■■■■E■■■■■M■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■