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173 Burton Rd . , , �c�- • DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section � � P.O.Boz 848/210 Hospital Street �( Mocksville,NC 27028 � (o'�� (336)751-8760 Account #: 990001568 Tax PIN/EH#: 5789-80-4103 Billed To: Larry Decker Subdivision Info: Reference Name: Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 0.767 acres ATC Number: 2704 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 S wage Trea t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON TIO I OR A PERIOD OF F VE YEARS. : Environmental Health Specialist's Signature: Date: ��Z CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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 guazantee that the system will function satisfactorily for any given period of time. �?p (�t� t "� Co�� 7 �o ' �D'�c3cP'n,2., g ��i � `• F Qo�'�' /�oT �l�l^n.6� o.� `14cJ fG �Z`L S1 Tk Lo'� Lo Septic System Installed By: �`�' <<-Ll �n/�. � ���- S Environmental Health SpecialisYs Signature• ' Date: � - DCHD OS/99(Revised) . DAVIE COUNTY HEALTH DEPARTMENT �d 5- 3 °�� ' ., , Environmental Health Section • • ' • P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 (336)75]-8760 \ IMPROVEMENT/OPERATION PERMIT Account #: 990001568 Tax PIN/EH#: 5789-80-�103 Billed To: Larry Decker Subdivision info: Reference Name: Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 0.767 acres ATC Number: 2704 **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). THLS 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 �• t1���' #People 2 #Bedrooms 2 #Baths � Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size �� � ��41'�pe Water Supplyl,F,V�� Design Wastewater Flow(GPD) �1l/ Site: New�Repair� System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�,, Rock Depth �2�� Linear Ft. �G�� ocn�: � �75�+ �Jr�.� F'o X��.Tc�S'R�U— ►���S Q"�,a. r�,�rJ . Required Site Modifications/Conditions: I �T�'�"� G��TDc�Q � {Q`� � � ,� ���� 1'ti/(.�n�``� 11�1PROVEMENT/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.�0 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installati . Telephone#is(33G)751-87G0.**** � . �rh,� �'�i-..�-� U.s�S t ,J �' ; o�� p E�; • / �a' �� .� ►�� $r�'y�31o'x12" 'a� � 50' l� �'��'�"��N _ �> . � 2�"p�� � w _ _ ���. q � ; .-._ - �2�'n�l rrJ . �— ._ � � � , rx� �_ � Environmental Health Specialist s Signa ure: cSTj,� Date: 0� � 'NFLE �V�%DN,Pi�j 1 DCHD OS/99(Revised) �-� ����N �ta, � � ' ' . aPPLIC�ATION FOR SITE NALUATION/Ifl1P(tOVER�9E\IT i'�L�fii�9i3��&R►�'C D LK �G �Q�� r Davie County Health Department � :�!� Environmenta/Hea/[fi Section � P.O. Box 848/210 Hospital Street F�8 - 7 2��) MocksvilTe, NC 27028 � � o- (336)751-8760 � EfV'JiR���1��L��J�f;,l HEALTH DAVIE CfIUNTY ***IMPORTANT*** THIS 'APPLICATION CANNOT BE PROGESSED UNLESS � THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be IIilled ��/�/�� (� , ��C�C�/`�--' Contact Peraon ��E ��yl��� Mailing Addresa ��� �y�T�/V /Y!L ' Home Phone �Jr�" �9O ��7�0 �^ City/State/ZIP ,��/�2/�L� ���� d��OL Buai.nesa Phono ' 2. Name on Permit/ATC if DiP£erent than Above 24ailing Addresa City/State/Zip � 3. Application For: Site Evaluation Improvement Permit/ATC 0 Both ' a. syatem to service: ❑ House j� Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: � People _;�_ � Bedrooms �_ A Bathrooms Z- �Diahxasher lFf'Garbage Diapoasl L! Washing Machine ❑ Hasement/Plumbing U IIasamant/No Plumbing 6. If Bueinesa/Industry/Other: Specify typo �k Paople �! Sinka � Commodes 9 Shoxers # Urinals # Wate= Coolers IF FOODSERVICE: # Seats Estimated Water U98J@ (gallona per a�y) �. Type of water supply: �County/City � Well ❑ Community 8. Do you anticipate additions or eapansions of the facility this system is intended to scrve? ❑Yes �'No If yes,what type? ***IMPORTANT***CLIENTS h1UST COMPLETETII E REQUIRGD PROPI:RTY INrOI2MATION IiEQULS7'GU BELOVV. Either a PLAT or SITE PLAN MUST BESUI3MITTED by the client �vitli THIS APPLICATION. Property Dimensions: � • �� / ��-'�:%t�.r/ VVRIT�DIRECt10NS(froro Mocksvilie)to PROI'I'sR'I'Y: TaxOncePIN: # ��� / `�� ``7''��,3 ,�Y� G'�IS� ���Svv�� /�G6it/�� Property Address: Road Name ,�.,1�/�fj �� v�.O��CS/�!�°�-"��� ��1� �,G`� , c�ty,z�p ��,�✓c� ,,�111=�� �,t/.��� �� % .�•/� o� If iu a Subdivision providc information,as follows: �C'�t Namc: Section: Block: Lot: Date Property Flagged: � � This is to certify that the information provided is correct to the best of my knowledge. r understand that Any nermit(s) issucd hcrcafter are subject to suspension or revocation,if the site plans or intended usc changc,or if tLc information submitted in this application is falsified or changed I,also,understand tha[I am responsible jor all charges incr�rred frum lhis application. I,hereby,give consent to the Authorized Representative of the Davie County Healtl�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 � """ �'—U � SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all f thc following: �aisting and proposed property lines and dimensions, structares, setbacks, and septic locations). Sitc Revisit Chargc . Date(s): Client Notification Date: EHS• Account No. ���� Revised DCHD(07/99) Invoice.No. � 3 �v 1�� �y,;ST',NG -� ... . . . �a:.�. , � CLIFT UIV L. r�v�-��,�.� .-- , : �'a :�(i.�3� D 318, PG. 431 • ' ,:tS.�;�=TtOf� i r;r / �.U. , i , . NFW —f� ' . '.�\ 2 u�oN N 87'02'32• E rvEw .- , `�ra � f 70.17 iRCN • : . 'li�\ o � ��v+\ S� �� � . _,-o� s,, s tr::,RCr,CHraE��1 � ;�cn_ ` '�'� 0� D.B.183 �'G.59t3 � '� �?`p ",��\ � �� DF_SR���TION U�IC JT '� NEW ,� - -- .._ — �, '�3 ` �tf20N \` hA•r_ -8Y..13 �� 1�� 5'O5• W ` '� A`' �9 u� �.07 �- R�K `�'---_:—.�. Sc� � � � p_�' � ;PtY.E � � ��Qy p� �� � `� J\ � ✓ � r� "1 � � � �' �, ,, � , o w o`S x � �� w s � _ REA_ 0. 767 AC. � � '� , �\ o J, INCLUO�, S.R. 1646 R/W �lw, VG � -P ,�. \�� D.B.205,f� ..84 � ` ` -(-%-�-�`"'� - � 48 �� .�'-DESRIPTIO U�� r,-trr•� _(_^- � � « �/p' EkIS1�NG N 18'S7'39' E � � �p � �ttoN 110.56' v 6.27 1 � N 87•02'QO' — — — _ � � � � � R/R �piK� � �i�. u �� F' � � � - - - ._. � " �. IACED G'�� iROfJ —' , 'W �� D � . ' - � � ''; � � HO yYELL �Y �'OLTZ i. YERNICE C. WOLTZ • `'�` D.B. 157, PG. 481 � . . - PLAT �F SURVEY REYISI�NS SCALE� 1�� = 50� oATE, JAN–12–2 . BE«tG : TRAC?S T^ ' . 50 25 0 50 . � 100 150 ,;n �; ,� .. F:,; �,;� DA.viE C�>�_;�:Tr, NOi. SCALE IN ��FEET � - Tax M� . � � DAVIE COUNTY HEALTH DEPARTMENT •� ' ' ,'' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 99n001568 Tax PIN/EH#: 5789-80-4103 Billed To: Larry Decker Subdivision Info: Reference Name: Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 0.767 acres Date Evaluated: � � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �l Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo % HORIZON I DEPTH C9 " - 2 ' 1 Texture rou L' C� c �- Consistence r` �t' SS Swcture S� �- C� Mineralo � ' � ' 1 HORIZON II DEPTH — tD Z + � 3p Texture rou k S Consistence S r.� �=S Structure 2L 2 1 Mineralo 1 - = I HORIZON III DEPTH '� —�-(0 Texture rou S Consistence Structure Sg Mineralo 1 � ' HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE 'O. � SITE CLASSIFICATION: � EVALUATION BY: �F`'t'F' �"}�-� LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT: �'���Q � L t� Ss Q£.��-'�`1 �4��J L��.1� � .J REMARKS: 1�0�� � � � C�?TS ��-a I � �•'�-- H��� _� A�Z - l�t.�JJ i A�? LEGEN ��`��-*Y Landscape Position R-Ridge S-Shoulder L-Linear 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 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 l:l,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 I Classification-S(suitable),PS(provisionally 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J r � Z�avie Gvunty,,7fealth Z�e�artment Errvirvnmerrtal,�fealth Section ' PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 February 22, 2001 Mr. Larry Decker 189 Burton Road Advance,NC 27006 Re: Site Evaluation- 0.767 Acre TractBurton Road Tax PIN#: 5789-80-4103 Dear Mr. Decker: As requested, a representative from this office visited the above site on February 19, 2001. Based on the information provided on the Application for Site Evaluation and a$er the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Please find enclosed a copy of the Improvement Permit. Please note that the septic system for the e�cisting dwelling at 189 Burton Road encroaches on the 0.767 acres that is proposed to be cut out of the parent parcel. A deeded easement for this septic system should be included in any real estate transaction if there are no plans to move the system. If you have any questions, feel free to contact this office at (336)751-8760. Sincerely, ��_ � —`\ JeffG. Beauchamp, R.S. Environmental Health Section enc(s)