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252 Bramblewood Ln t . DAVIE COUNTY HEALTH DEPARTMENT �� �G� � ' ' Environmental Health Section 2 P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 .. (336)751-8760 O� � IMPROVEMENT/OPERATION PERMIT Account #: 989900133 Tax PIN/EH#: 5823-53-0199 Billed To: Swicegood-Wall Realtors Subdivision Info: Reference Name: Edward Gerdes Location/Address: Brambleweod I..ane-27028 Proposed Facility: Residence Property Size: 4.1 Acres ATC Number: 2267 **NOTE** T'his 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 /�jd� #People � #Bedrooms–����--t— #Baths–�� Dishwasher: � Garbage Disposal: � Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Cr Type Water Supply C�6 Design Wastewater Flow(GPD)� Site: New�Repair❑ i� �� System Specifications: Tank Size��7 GAL. Pump Tank GAL. Trench Width �C Rock Depth /� Linear Ft � Other: ��� Required Site Modifications/Conditions: IMPROVEMENT/OPERAT[ON 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 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.**** � Q1�`� ,", .� � ��' , �� �a � ,�� l �� � Environmental Health Specialist's Signature: � Date: ��– f'''�J� DCHD OS/99(Revised) , + DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 989900133 Tax PIN/EH#: 5823-53-0199 Billed To: Swicegood-Wall Realtors Subdivision Info: Reference Name: Edward Gerdes Location/Address: Bramblewnod Lane-27028 Proposed Facility: Residence Property Size: 4.1 Acres ATC Number: 2267 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 WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �U, � - Date: /c�— /—�� IFICATE OF COMPLETION 1` �� **NOTE** T'he issuance ofthis Certificat o� om e ion shall indicate the system described on ImprovemendOperation Permit has been installed in compli ce ith i le 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and Disposal Systems,"but shall W Y t s a guarantee that the system will function satisfactorily for any given period of time. i'� L�r � v � � � �� ���� ���3 X�� �. � � 0" � � Septic System Installed By: ��" Environmental Health Specialist's Signature: �G�� Date: � �`�'11�' DCHD OS/99(Revised) I . > • . � r APPLICATION FOR SITE EVALUATION/IMPKOVEMI;NT PI;RMIT&A � � � ��� Davic County Health Dcpartment Environmcntal Hcalth Scction P.O. Box 848 N�V � 5 �� Mocksville,NC 27028 � (704)634-8760 , _ ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U ALLTHE REQUIRED INFORMATION IS YROVIDED. 1. Name to be Billed � Q�� ����-� Contact Person �L�� Mailing Address v� I ' Home Phone City/State/Zip �"��1� V� `�� 1VI�_ ��0�� BusinessPhone k����ZZ 2. Name on Permit/ATC if Different than Above ��-1W+�r� � �e�Es Mailing Address City/Statc/7ip 3. Application For: 0 Site Evaluation ❑ Improvement Permit&ATC �` Both 4. System to Serve: 0 House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People � # Bedroo►ns Z # Bathrooms � �Dishwasher ❑ Garbage Disposal Y Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Peoplc # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: ❑ County/Ciry LY Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: I�u X I010� � I�J� /� I�U� � WRITE DIRECTIONS(from ��Z� _ �� _ � Mocksville)TO PROPERTY: Tax Office PIN: # � � 1� to I N ^- 12�C,t+T PropertyAddress: RoadName 1�rQrnblewaxl �� � IV�oC►Csv�`I � IrU G Z�oZ� ; o N 8o I -v ,rnX. i n�,�� c�cy�z�p � jZ 1C-� �-{-T — ��-�w�3tF. t��D i If in Subdivision provide information,as follows: 1 1 -}a �N!,� ^ SF� S 1 Cz Name: � I 1 Section: Lot #: � 1 7'his is to certify that the information provided is correct to the best of my knowledge. [ understand that any permit(s) issucd hereafter are subject ro suspension or revocation, if the site plans or intended use change,or if the infonnation submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from 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 ���_�'T.� � • ( l��� 1v� to conduct all testin�procedures as necessary ro determine the site suitability. DATE � S SIGNATURE Revised DCHD(06-96) �� /� ��'G �� � �� w 4 �.Yi � �.�j � • H ✓.,,'��t,�,r�A,�a� • R ' � q '�+i�•� ' �`I� � � � p� ..� t11'��+€�iya. .���,� �� �ti y , s w,*�1•�.+.� .��y�,.r� Y V`.._ . , ��V 5Z•�7� '�' _y.i� s�, � '�.� �4s -�'r"fin,� G 3�R �°t`�a� � ?T� ; yi i :# �� `'"4 '�i�d��/�Y '�� � �1���...._� f t a,., 'i .k��-. 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"�: ' ��S '� �z� .s���.s�,-.�,.. .� , n�7�y�rt. ry.i.:• +� a' • �. . ...�.... � ' =+, s, '' j ` � T ��/ / _ e� �S. �,.--� �-�-•_ � ...!i��C e{:+� . _ ,,,_.�--�'_ L � � ' � • � ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900133 Tax PIN/EH#: 5823-53-0199 Billed To: Swicegood-Wall Realtors Subdivision Info: Reference Name: Edward Gerdes Location/Address: Bramblewood Lane-27028 Proposed Facility: Residence Property Size: 4.1 Acres Date Evaluated: /,�--/-��' Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring r/ Pit Cut FACTORS 1 2 3 4 ' S 6 7 Landsca e osition L L Slo e% HORIZON I DEPTH Texture rou Consistence Structure ' Mineralo HORIZON II DEPTH ;►.Q'• ��'" Texture rou Consistence .�;• Structure t 2 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 � SITE CLASSIFICATION: B✓� EVALUATION BY: �,�� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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 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) ■������■��■����■��■�����■■�■■�■��■■���������■�■■■■■�■■■���■■�■■■�■ ■�����■■��■■���■�■�����■�■��■��■�����■��■■■���■■■��■�■■��■�������■ ■������■�����■■���■������■��■�■■����■�������■��■■�����■■�����■�■ ■�■���■■��������■��■�■■��■■■��\■ ■��■���■��■■��■��■��■■��■■ ■�■�■ ■�������■■���■■■�e��s��■■■����■■�■■■���■�■■■��■�■��m■�■��s���■�■�■ ■�■�����■■■�■■■������■���■■����■�■■�����■■■■���■��■���■�■���■■�■�■ ■���■���■��■�■��■�■��■�■■���■■�■■��■■■■■■■��■■�■oo■s�■��■�■■■■���■ ■���■��o�■���a■��a�e,���■�■�■��������■■�������■��■��■■�■■���■����■ ■�����■�����■���■��■�■���■■�����■■�■�����■�■���■�■���■�■��■�■■��■■ ■■�■��■■■■���■��■■�■�■��■��■e■o■���■■�■■■■���■■■��■�s■�■��■■■�■�■■ ■�����������■��■■■�■�■�����■■�■����■■■�■■���■■■■�■����■������■��■ ■�■�����■�■■��■■���■�■���■■����■ 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