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148 Buckingham Ln � � DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT �(� �'� Account #: 9900D1214 Tax PIN/EH#: 5801-84-8865 Billed To: Piedmont Housing Subdivision Info: Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 1 Acre **NOTE�*Tfii b�mprovem9ent/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 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�ia�_ Design Wastewater Flow(GPD)�'�`�" Site: New Lti]' Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth�/Linear Ft�� ") t Other: � � �. n.� F h Required Site Modifications/Conditions: ��- � aM� 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 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-8760.**** ���• �.�o� � u�� � � �`_� � � � \ �. �� i � �/ . �. � � � , Environmental Health Specialist's Signature: .�� Date: � 0�1 '� DCHD OS/99(Revised) � � . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (33G)751-8760 Account #: 990001210 Tax PIN/EH#: 5801-84-8865 Billed To: Piedmont Housing Subdivision Info: Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2459 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 SpecialisYs Signature: Date: � �a� ''CJv CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 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. Vvv�� � J �, �� C15o �6�� � o �,� � � � � � � e � Septic System Installed By: Environmental Health Specialist's Signature: /`'t�1_� Date: �-/�r�� DCHD OS/99(Revised) . �� �-ao-� � ` , t + J ,� t�.� � I� � l..! �. ...... , APPIJCATIQN FOR SITE EVALUATION/IMPRUYEMEM PERMff&A Davie County Health De�artment ' ,�.,,., Environmenta/Hea/IfiS�rion �� ��� �::��u,J P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8 6 `� '-.. , . . . � . ***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED INFORt�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions. 1. Nama to be Silled - � Contact Person � _� Mailinq Addreae 1 � ` Home Phone City/State/2IP . .1��`�� 11`�° . 1�1\_ ���(7�� Buainesa Phon��� �l la— V� 1 1 2. Nama on Permit/ATC if DifFerent than Above Mailinq Addresa City/State/Zip s. Appiication sor: ❑ Site Evaluation ❑ Improvement Permit/ATC � 1 Both a. sy8t�► to se�►ice: � House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: � People � # Bedrooms � t Bathrooms C�_ L��Oiahvasher ❑ Garbage Disposal �Waehing Machine ❑ Basement/Plumbinq ❑ Hasement/No Plumbing �� 6. If Buaineaa/Induatsy/Other: Specify type i People # Sinka i Commcdea / Showera # Urinals # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (g�iona �= a$y) 7. �pe of water supply: 0 County/City ][] Well ❑ Comm ity !\ e. Do you anticipate additioas or eapansions of the facility this system is intended to serve? ❑Yes No If yes,w6at type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLiCATION. Property Dimensions: 1 QC�� WRITE DIRECfIONS(trom Mocksville)to PROPERTY: Taa Office PIN: # �SiO��s`���iln� �c� y0 l�2��' . �P� t1���c'] Property Address: Road Name '3 � �y� e -}��f�' (��.,���_�'S �Qy � Xw�-�,. City/Zip �0�"�l`_yJ;,�P `(��� \C�YIP ��� , � C�c�_��l �Qy �Q� If in a Subdivision provide information,as follows: �(1��` �..(C},.� C�C�5� C'�c�1' c� ��� Name: �-�S`«`QC�. ,�C_z�P �S� � -�t� �e�' �Ca�h�� Cs'� �co _`��P 5\ . 'Th�s S f� iS vLr ��, Section: Block: Lot: Date Property Flagged LP ` ` '-�'� y ��`� 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. 1,also,understand that I am responsible for all charges incurred jrom 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 Couuty and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE l,(�` I `-v� SIGNATURE __,..._ � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, struct�res, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: ' EHS• Account No. ���0 Revised DCHD(07/99) Invoice No. �1�� ' ' ` ' ' DAVIE COiTNT'Y HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001210 Tax PIN/EH#: 5801-84-8865 Billed To: Piedmont Housing Subdivision Info: Reference Name: Renee Poteat Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: � gefBorinf Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH ..� Texture rou Consistence Structure Mineralo � � HORIZON II DEPTH — S Texture rou Consistence � Structure Mineralo ' � HORIZON III DEPTH �.11� Texture rou Consistence Structure � Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE s CLASSIFICATION ..� LONG-TERM ACCEPTANCE RATE a � SITE CLASSIFICATION: EVALUATION BY: � LONG-TERM ACCE ANCE RATE: • OTHER(S)PRESENT: REMARKS: �G LEGEND Landsc e Positi n 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 Mineraloav 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 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