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145 Brantley Farm Rd ► DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Nealth Section - •. � ' P.O.Boz 848/210 Hospital Street �-'� ��° 3 Moc 3ksvi17S N�07028 � ��� ��� b IMPROVEMENT/OPERATION PERMIT Account #: 990002854 Tax PIN/EH #: 5729-65-2654 Billed To: Bobby Brown Subdivision Info: Reference Name: V eri o�...s �3c . ���/ Location/Address: Brantley Farm Road-27028 Proposed Facility: Residence Property Size: 4 acres ATC Iy�mb�er: 3524 **NOTE** is mprovement/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 CONTRACTOR 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: 0 Lot Size Type Water Supply y/��� Design Wastewater Flow(GPD) `„_"�� Site: New1a Repair❑ /, J, I System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear FiX/� Other: Required Site Modifications/Conditions: IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"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 f s ]lation. Telephone#is(33()751-87G0.**** � � � fQ Environmental Health Specialist s Signature: Date: � � DCHD OS/99(Revised) s � � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002854 Tax PIN/EH#: 5729-65-2654 Billed To: Bobby Brown Subdivision Info: Reference Name: Verious Angell Location/Address: Brantley Farm Road-27028 Proposed Faciliry: Residence Property Size: 4 acres ATC Number: 3524 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST 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: /���It.��C w• ���• Date: �— �-9—�.3 CERTIITCATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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. t''v`�� � �Q��� `'� f�r-"' ��• ���4 I�� X �-- �� �. '3� ' ,z � ���5 `��� ���5,• F`��,�5; � ,X . � � ���� � `�T�-��- 7�Z 3�11 �}�,���� Septic System Installed By: ���1; ��..�.� c.� Environmental Health Specialist's Signa e: Da : DCI-ID OS/99(Revised) � , f�-t � � � C� C� � �1 � D �� � -� �j��I APPLICATION FOR S1TE C-VALUAT(ON/IiV1PIiUVEh1[N'I'P = i 'tk�1�1 C /� '• Davie County Healfh Department � JUL 2 3 2003 1�� � Environmeata/Hea/t/�Sectioa (��C_ `� ��v� P.O. Box 848/210 Hospi�al Stree �, �I �� j� �//�� Mocksville, NC 27028 EIWIROyPJ1EfJTALHEALTH // ���� 6 (336)751-8760 DAVIECOUNIY �'1?� � `�//.� �r% ----_.. ***IMPORTANT*** TIiIS APPLICATION C1lNNOT B� PROCL•'5SL•'D UNLLSS ALL TIIL 1t�QUII2Lll INFORMATION IS PROVID�D. Retor to the INFORMATION BULL�TIN for insLructioii:�. 1. Name to be Dilled r�bb,d �{'p1,.�1� ContacL Pei�oii ���' �C�V3N ___—__l------ ._ Mailing Address S�� �bCI� C.{�. �• IIome Phone 3���y9a-�'1�� City/State/ZIP fY1oe.Y.s�,lt,�. , NC- ���`a$ Buainesa Phone 3'sb- 75 1 -35(el _____ _ 2. Namo on Permit/ATC if Different than Above V.Qr1oVS !7 �tr' ___________._,.. Mailing Address J0� ��Qy �n ��• City/State/'Lip MpGVS+�i�Ee.. ,/�1�. a.?L� _ 3. Application For: '�ite Evaluation ❑ Improvement Pennit/ATC �L-h ► 4. Syntem to service: �'House ❑ Mobile Home ❑ IIu�ine�3 ❑ IndusL-ry ❑ OL-hcr ___J 5. Type system requested: L7 Conventional ❑ conventional modificd ❑ innovaL-ivc 6. If Residence: ik People � iF Bedrooms 3 II IIaLhroom:; o�.S� __ L�IDishwasher L'7Garbage Disposal C�3Washing Machine ❑Basement/Pliunbin� ❑Da�emenL-/No P1un�in� 7. Zf IIu3iness/Industry /Other: verify type �� Yeople t! �inl:� __ # Commode3 �� Showcra $ Urinaln I} Walcr Coolcr:� IF FOODSERVICE: ¢k Seats �stimated Water Usage (�a11on� per clay) ___ __ ___ ___ e. Type of waL-er supply: ❑ County/City L�j9ell ❑ ConununiL-Z• 9. Do you anticipate additions or CXj)A11510115 U�t11C r:1Clllfy'tI11S SJ'S1C711 1S lIIICOI�CcI l0 SG'VL`�� ❑ ��Cti LYIVi� � If�'CS�1�'�l�t�)'()C� ***IDIPOR"li1NT'�**CLILNTS NUST COAIPLGTBTIIC ltliQUIItEU PKOPGR'1'�'1N(�OR119A'CION K[iQUI?S'fl?U � I3GLOW. Eithcr a PLAT o�•SITG PLr\N dIUST BE SU13�11/TTCD by thc clicnt titi�ilh 7'1115 APPLICA7'ION. Propert)�Dintcitsiot�s: �� GtCf4�j 1V121'TL llIRGC"170NS(fruni 11locl.s��ille) to 1'!tOI'I�;IZ'I'1': •r:�a ocr►��rl�v: � _. s�a5 t�sa�s y 1�?! .�vo�-+i. .t� B�n�-k., ��h Rd�--- Property Add1•ess: Road Namc_Bc-«n�y �rcvr� �. Turn R�g�fi 0n � Sf���r ��'w. i�• Cil)'/ZI'p�,olX45�1t11G �1G a�0a�j /4rfA � �= ��alua�r� [s � y Iliu a Subdivision providc informatia�,as folloivs: curc� �ti � bch� � Sh�GI Namc: on �1.� �e�-� Scction: Block: Lot: Datc homc corucrs llag6cd: � � � Tl�is is to certify ihat tl�c iuformatiai provided is correct to tl�e bcst of my lcnoir�lcd�;c. I ui�dcrst.uid tl►n!any j�crmil(s) issucd hcrcaftcr are subject to suspcusion or revocatiou,if thc sitc plans or intcnded usc cl�avbc,or if llic iul'ormation subtnittcd in tl�is application is falsired or changcd. I,nlso,unJcrstancl tlrat I unr rc�1�unsiGlc jor�rll cltru•b es iircrn•rcrl.%runr lhis npp/icutioir. I,l�ereby�,give consent to tlie Authorized Representalive of llie llavie Couaty IIealUi l)ei�:u•(n�cut to cntcr upon abo��c describcd propert}'locatcd iu Davic Couiity and o�vncd by --- -_ _ to ronduct all tcstinb pi•occdures as i�cccss:iry to dctci•miuc tlic sitc suitabilil��. DATE 'J-c�3„l1" SIGNATURI: ��vl,� _ / TIiIS AI2EA MAY I3E USI;D TOR DRAtiVING YOUR SITE PLAN(Li ludc all oP tlic 1'ollo�vitib: Lxisliiib aiid proposcd _- property lines and dimensions,-struct eur's, setbacks, and sc 'c lo atio s). _ � . ` � Sitc 12cvisit Cltsu•�c ?�� L \ -- -- �C J llatc(s): „ _ Clicnt Notificatio►i Datc: � �� �� � � �"' � �/ �IIS: ���5 /%A'/�Z� �C � � �l ` !e � �� / / �, ,�. g � Sign givcn d /��/l / _ ! �'I'�`vz "'` Accouiit No. _.__ ._. _ ------- s 'J __o�' ` Reviscd DCFID(05/03 � � Livoicc No. �--� � � V ,%�/�„' ', «�r �.,. .., ' ,,,,i„r , �#ai' r... %//� �I �SOOS w ��,�i - . �, (HOZ"9l � � �� �g ti I , „-, � �ze ,///c r � ,.. 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; �� �: o � �, --" � a �� i%/%/%i� i�riii � � �E, � z� � : �� � ,,,,,� . � : �,,;,,, '�t ; � s � ����4� ��j//� �� �q6 � %�/ a -ii„ .� / � ///%�%/%%��/ : `� w . i <Ks���i.,;'; � - i��,i�iA�iT�i�,,� ,. ✓,�//% /y�����,;,,,, r' <<.«<.,, ,,,,,.�� . • � • DAVIE COUNTY HEALTH DEPART'MENT "� � • � � ' Environmentol Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002854 Tax PIN/EH#: 5739-65-2654 Billed To: Bobby Brown Subdivision Info: Reference Name: Location/Address: Brantley Farm Road- 7028 Proposed Facility: Residence Property Size: 4 acres Date Evaluated: rZ' � � Water Supply: On-Site Well V 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�GL cIG'G Consistence Structure Mineralo HORIZON II DEPTH �' y '� Texture rou Consistence i Structure G 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: �� 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-`�lay 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 Mineralo�v 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 Classifica[ion-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/99(Revised) ■������■����■■�����■■��������■�■��■■�■■�■■�����■■��■�■��■ ■����■�■ .........................................................C■....... ................................�.........................■...... ................................ ................................ .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. 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