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767 Burton Rd �. � DAVIE COUNTY HEALTH DEPARTMENT � u������ • ' Environmental Health Section � � � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001064 Tax PIN/EH#: 5798-42-2755 Billed To: Michael Minor Subdivision Info: Reference Name: Michael Minor Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 10 Acres **NOT�*�'�iibginprovement/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 �} #People� #Bedrooms�� #Baths�_ Dishwasher: �Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:�BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size_��/1'(� Type Water Supply ll� Design Wastewater Flow(GPD)S_�.�j1L Site: New,O'�Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��Rock Depth 1�7 Linear Ft. �� Other: Required Site Modifications/Conditions: IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROV LUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of �e County Health Department for final inspection ofthis system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 130 p.m. y of installation. Telephone#is(336)751-8760.**** L.-/ /� Environmental Health Specia]isYs Signature: , Date: S '/���� DCHD OS/99(Revised) . ,.. �oE . • . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/Z10 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990001064 Tax PIN/EH#: 5798-42-2755 Billed To: Michaei Minor Subdivision Info: Reference Name: Michael Minor Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 10 Acres ATC Number: 2403 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). 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 STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �� � Date:S^/-'� 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. ``a` \` a � � \ � ` � \ r� r��f Septic System Installed By: �TC� � � 1 Environmental Health SpecialisYs Signature: ��'F" - Date: �� /,3—�O�_ DCHD OS/99(Revised) �r?t, � � 1p�� . _ �,� F � APPLICATION FOR SffE EVALUATION/IMPROVEMENT PER .� � p/,e�'S Davie County Health Department � s �� r /`� Environmenta/Hea/tfi SetYion � �e � P.O. Box 848/210 Hospital Street �n� ^� -,I �'1�iR � ���� Mocksville, NC 27028 � ����-� ` 6i�yG, (336)751-8760 /�� J ***I1�'aRTANT*** THIS APPLICATION GINNOT BE PROCESSED UNI,ESS ALL THE REQU .. INFORMATION IS PROVIDED. Refer to the INFORMATION BLtLLETIN for instructions. 1. Name to be Billed C I � Contact Peraun �I G/1C/� ` �/G�i��1� Mailinq Addresa ll� }� 8ome Phone �9g-?sa� City/State/ZIP �vq�`e �� (� a��� t3usinesa Phone `�� �'"D.�� / 2. Name oa Permit/ATC if Differeat than Above Mailing 1lddsesa City/State/Zip 3. Application For: C�Site Evaluation ❑ Improvement Permit/ATC �Both a. sYetem to s6�-.ri�e: q/House ❑ Mobile Home O Business ❑ Industry ❑ Other s. If Residence: M People NF- � Bedrooms �_ M Bathrooms --�- [�/biahnaaher �Gazbage Dispoaal [4�fdaehiag Machine C4�Sasement/Plumbinq fJ Saeemant/No Plumbinq 6. If Buainaea/Induetsy/Othar: SpeciEy type � People 11 33nka Y Commndea i Shorera � Urinala � Water Coolera IF FOODSERVICE: # Seats Estimated Wa�:er Usage (gallone per a8y� 7. Type of water supply: � CountyfCity lf�Well � Community a. Do you anticipate additions or ezpansions of the facility this system is intended to sP:ve? ❑Yes C�1�to If yes,what type? , ***IMPORT�lN.7'***r!.:�:'�'.'*'�.'.:'.'S:"�:::..:�.,c:�.:ri� itc�ZltF�D P[�OPER'S'Y INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN wfUST BESUBMI7'TED by the client with THIS APPLICATION. Property Dimensions: /v�L� WRITE DIRECI'IONS(from Mocksvilie)to PROPERTY: Taz OtTice PIN: # � ���4� �� �.s �p � -{'p � (�� -� � Property Address: Road Name Q U i` T (7 I'1 I� � 1-?�� p��e 'S C�'p e �'( � i� — (v✓' l'� , � c�tyiz�p d � � � � e n c (� -� ��' A a 1 � r,-��� �o - - If in a Subdivision provide information,as follows: ��-�� h ��� • G o �'o ��� • Name: ('l �i fC c �.�e -��' � t �� I S a�'t ��y}�,cj` SecNon: Block: Lot: Date Property Flagged: �"����� 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 iute►:ded use change,or if the information submitted ia t6is applicallon is falsi£ed or c6anged. I,also,understand that I am responsib/e jor a/l charges incurred jrom this appllcatlon. I,hereby,give consent to the Authorized Representative of the Davie Coun Heaith nDepartme t to enter upon above described property located in Davie County and owned by 1�1��'�n�� U 1�/Yi,,,r�-ei ���%V�'� to conduct all testing procedures as necessary to determiae tbe s'ste suet?1�E�E+•�. T � s�TP� DATE �� YI'"Qd SIGNATURE � � THIS AREA MAY BE USED FOR DRAWING YOUR S;TE PLAN(Include all of t6e following: Ezisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Accouat 1�10. �(l/ Revised DCHD(07/99) Invoice No. // � r .t- t a .:,,Ht t - . .. � . 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K� y �� * ��s= _.;< _. .�- �>>-�s.; x'?' � �` tab��5t�ed °�On9reet to eS�abGs . .. . , , . r • ' .� • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001064 Tax PIN/EH#: 5798-42-2755 Billed To: Michael Minor Subdivision Info: Reference Name: Michael Minor Location/Address: Burton Road-27006 Proposed Facility: Residence Property Size: 10 Acres Date Evaluated: ����l`GU Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition �-- L Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH .� `" ,�6•i Texture rou Consistence i �' Structure � / 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-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firrr► 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 �CI-ID OS/99(Revised) _� ■�■��■��■■�����■��■■■��■■�■��■��■���■�������■�■■��■��■■�������■■�■ ■■��■������■�■■■��■��■���������■■�■■�■�■■■�■��■�■�■■��■�■�����■�■■ ■��■■������■��■��■�������■��■■■��■��■�■■��■■��■��■�■■■��■���■■��■ ■��■■���■�■■����■�■■����■■■�■��■ ■■����■���■��■�■■���■�■■����■�■■ ■����■■��■�■�■■�■�����■�■■■�■������■���■■���■�■■�■����������■����■ ■��■���■■■��■■■■■��■��■��■■■��■���■��■�■■��■■�■■��■��■�■�■����■�■■ ■■�■����■■����■������■■�■■■■■��■�■■����■■��■��■�A■�S■■��������■■■■ ■�������■�����■�■��■■�■■■■����■��■■��■�■■���■�■■�■■�■����������■�■ ■����■����o��■■��■��■��■������■���■��■�■■��■��■o��■�■a■s��■����■�■ ■������■■��■■�■��■���■���■��■■��■�■��■■■■�■■��■��■���s■■�■���■��■■ ■����■■���■�����■���■■■��■�o■�■��■��■�■■�■■�����■��■�■��■��■■■��■ ■�������■■■�■�■�■����■■���■����■ ■��■�■��■��■■���■■��������■��■�■ 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