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188 Cambridge LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ���/�� � � �� IMPROVEMENT/OPERATION PERMIT Account #: 990001137 Tax PIN/EH #: 5810-16-2979 Billed To: Buck &Melissa Hill Subdivision info: Reference Name: Buck 8 Melissa Hilf Location/Address: Cambridge Lane-27028 Proposed Facility: Residence Property Size: 10 Acres �,TC �I�ip� b�r. 2412 i **N E* 'l his mprovement/Operation Permit DOES NOT authorize the construction of a septic tank syst�m 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 PERIV�IT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People � #Bedrooms � #Baths� Dishwasher: Ja Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size Type Water Supply �,�v !T/ Design Wastewater Flow (GPD) c31� � Site: New �Repair ❑ System Specifications: Tank Size%%7Qa GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width��� � Rock Depth �,Linear Ft�� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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.**** r/ /� J � / % /J V � {... � / � ' � O se/��«Ss ��� � Environmental Health Specialist's Signature: �C` — Date: � —� " � � DCHD OS/99 (Revised) �� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Account #: 990001137 Billed To: Buck 8�Melissa Hiil Reference Name: Buck 8� Melissa Hill Proposed Facility: Residence ATC Number: 2412 Tax PIN/EH #: 5810-16-2979 Subdivision Info: Location/Address: Cambridge Lane-27028 Property Size: 10 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: .- - Date: _,�' G�.� �� CERTIFICATE OF COMPLETION **NOTE** T'he 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. � �'" Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) Date: ������ �i 1. 2. APPUCATtON FOR SRE EYALUA710N/IMPROVEMEPIT PERMIT � Davie County Health Department Environmental Heaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 D ��c�a�� � APR 2 5 �t��a . ***Ii�ORTANT*** THIS APPLICATION CANNOT HE PROC,ESSED UNiI,ESS ALL THE REQUIRED INFORMATiON IS PROV�DED. Refer to the INFORMATION BULLETIN for instructions. 0 �) �/'� 1t l Name to be Billed �ll�Lp� � 1� ��/�AS��-�,�\ Contact Passon �c uU� �� , 1 FQ�1A�� �ll �'• Mailinq Addreas _ 1 � p l._ CLm� `� �O� �--c^ �-�- Home Phoae 1 �3� � � � � � 1 �� � City/State/ZIP �'� �t�.�7V� 5iL �� G b��� Z� Huainesa Phone �J�-P " iP�� - y-c�� (� Nama on Permit/ATC iP Diffareat thara Above ��-i�-�� lfailinq Addreea ��-rnQ� City/State/zip � ��� 3. Appiication For: G•Site Evaluation �Improvement Permi.t/ATC .�Hoth a. sYst� to se=,.ice: [d" House ❑ Mobile Home 0 Business O Industry ❑ Other s. If Residence: t People �_ � Bedrooms �� N Bathrooms �7 lyDist�Manher 11 Gasbaqe Disponal �ashinq !lachine hY�aaement/Plumbing II BasementJNo Plumbing 6. I! Huaineae/Induatry/Othor: Specify type � People � 3inke / Co�odee M Showers p Urinals � Water Coolera IE FOODSERVICE: # Sests Estimated WAter Usage (qnllone por dny) �. Type of water supply: Q County/City �ell ❑ Community e. Do you aoticipate additions or e=pansions of the facility this system is intended to serve? �i1'es D No If yes, w6at type? �O<S5 �� 1`-i rY�v� �d�O rv�5 �'�--� `1--1vi'�tu�'1ur'-C_: ***/AtPORTANT*** CLiE1�iTS MUST COMPLETETf1E REQUIRED PRQPi�RTY INFORMATI4!� s?��!��c�rFn n�.i.UW. �ither a�'LAT or Sli'E PLAN MUST BE SUBM/7TED by t6e clieat with THIS APPLICATION. Property Dimensions: � �CtCk'�2S Ta:Office PIN: # �� � � ` � l..P -' c� �� � � PropertyAddress: RoadName Ig� Ct�mbr�d�- w`n'�- c�Tyiz�p N�OC�SV� ��D , � C. If ia a Subdivision provide information, as lollows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville� to PROPERTY: I �- +-lu�� Cc � �}c� ��-�ta�ci — r�r�n�,�t � � r�; an-t� n�`� n,-na�roX', ma.t���� � m i l-P s mc�k(Q � � Y�,�+ on� c�r��d�. l�Cc. r�.e •�i r S-+ �f-ra �er Or `I-h� r i��,.`f-• � i c+C� ��s heh � � �tru� I�ec- . Date Property Flagged: �-{-125�taC� T6is is to certify that the information provided is correct to tLe best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, ii the site plans or intended use change, or if t6e information submitted in this application is lalsified or changed I, also, understand that I am responsible jor a!! charges incurred from this application. I, 6ereby, give consent to t6e Aut6orized Representative of the Davie Couqty H al Department to enter upon above described property located in Davie Cauaty and owned by ��.i C,� c 1��� S� ')-�.1:�.�- to conduct all testiag procedures as necessary to de rmine the site suit�bility. ' � DATE 7 I Z�J I(7� SIGNAT[JRE �D � I�'SG� �n/ '�I-�� THIS AREA MAY BE USED FOR DRA YOUR SITE PLAN (Include all oi the following: Ezisting and proposed property liaes and dimensions, structures, s�backs, and septic locatious). Revised DCHD (07/99) Site Revisit Charge � Date(s): � Clieot Notification Date: I EHS• Account No. � Invoice No. T �� _ _ _ . __. .- _ _ . if _. ._ _ -.._ _. _ VIRGINIA A• WHITE SS D8.14� PG. 574 3 � a � `S`4'- ' ' r9i � . . \ ��� � � O `I� \ ` O N �� o �� � °D N NEW 20 EASEMENT Ni g� N ��•/5 Z ALONG EXISTING � � � 2S°34' o FARM ROAD i' 23 �� E � � � 23 f �Q' ` � � � .44 ��\\� ��_1l � � � � � • � � � � � END OF `1� s o�� �� _ � � EASEMENT ` `���'�9„w _ � �� _ � � � � g v ti o � 00 h 2 NIP �� _ � ^ _�A . I�' V � � '// -� ;� J �. ,.� .`�;\ , ,, ��,-�� AREA = 10.244 ACRES � TRACT 7 � � � e2 � � �� �� S 15° 24' 43" W P�--ACET� �� �_ i R � N ` 1(:\1J. tl ' �� _� �� � � � � � � � � � � ' � 'E- S �� NIP O g "� � l� NIP � �� �'� � �� L. ~--'� S �g� 24 �: 1 1 � , . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • . , Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001137 Tax PIN/EH #: 5810-16-2979 Billed To: Buck 8�Melissa Hill Subdivision Info: Reference Name: Buck & Melissa Hill Location/Address: Cambridge Lane-27028 Proposed Facility: Residence Property Size: 10 Acres Date Evaluated: �-� '�--� Water Supply Evaluation By: SOIL WETNESS On-Site Well 6� Community Auger Boring Pit SITE CLASSIFICATION: �� LONG-TERM ACCEPTANCE RATE: REMARKS: Public Cut EVALUATION BY: OTHER(S) PRESENT: 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�oe■ ■���■■ ■���■■ ■■���■ ■�■�■■ ■���■■ ■�■■�■ ■■�■�■ ■��■�■■■�■����■■��■■�■��■■�■�����■��■�■■��■ ■������■����■■�����■���������■■��■■�������■ ■��■��■■■■■�������\��■��■■������■��■■�■■�■ ■�■�■■■■■■■���■ ■■��■■■■■�����������■�■��■ ■■s�■��■■■■■■�■�■�����■■�■■■�■�e�■■����■■■■ ■�■��■��■■���■��■■����■■��■��■■��■���■�■■�■ ■����■��■��■�■��■■����■■�■■■�■�����■■■■■�■■ ■■�■�■■�■■�■�■��■■��■�■■��■■�■■��■�■■■■���■ s■�a��s�■����■■�■■■�■�■■��■■�os��o�s■■■���■ ■■�■��������■�■��■��������■■�■■�■■��■■����■ ■■�■��■��■�■■�■�■��■�■���■■�����o�■■■■���■ ■■�■����■■����■ ■�����■��■■�■■�■■�■�■■���■ ■�����■�■■��e■■�e������■�■�■�■e��■�■■�■���■ ■��■�■■■■■���■■��■■�■■■■���■���■�■����■■��■ ■��■��■��■��■������■■■����■��■�����■■�■■��■ ■�■�■��■��■�■�■■�■■��■�■������■��■�����■■�■ ■���■��■���■■�����■�■■�����■��■■�■■����■■�■ ■�■■■■�■��■■■������■■���■��■�e�■�■���■�■■■■ ■�■�■■�■�■■■�����■�■■�■■�■■■■■��■■��■�■■�■ ■�■■■■■■�■■���■ ■�■■�■�■�■■■■■��■���■�■■■■ ■�■■���■�■■�■�■���■����■■�■■�■���■�����■�■■ ■�■��■�■■�■■■■�■��■■�■�■■�■��■■��■��������■ ■��■�■��■■�■���■■�■■■■��■����■��■s■��■����■ ■■�■�■■�■��■■■�■■■�■■■��■■���■■■�■■�■■�■��■ ■■�■�■■�■■�■�■■�■■�■�■■�■■a���■■����������■ ■■�■��■��■��■■��■■��■■■�■■■������■■■�■����■ ■■■�■�■��■�■■�■�■��■■■�■■�■■���■■■■������■ ■■■■■�■������■■ ■��■■■■�■��■�■■��■■��■���■ ■■■�■��■�■■�■�■�■■��■�■■■■��■�■■��■■��■���■ ■�����■��■■�■����■��■���■��■■�■����������■■ ■�■�■�■■�■■�■■■��■����■�■��■��■■■��■�■����■ ■�■�■�■■�■����■�■■���■■�■■����■■���■������■ ■�■�■��■�■■�■�■��■�������■��■��■■�■��■■��■■ ■�■■��a■�■■■■��■�■��������■����������■���■■ ■�■�■■�■■�■���■ ■■■���■�■■��■������■��■�■■ ■■■■■■�■■�■��■■�i■■■���■■■■■�■��■■��■■■�■■■ ■■�■■■�■■��■�■�■■�■■�■�■■�■■����■■��■■■■■�■ ■■�■�■■■■��■�■�■■�■■�■�■■�■■����■■���■■■r:�� ■■�■�■�■■���■�■.._===i�■����■■��s�'■■��■■■��.� ■��■�■■�■����■�■■�■■��■�■■�■■�■��■■�t��■■��■ ■■�■�■■���,■■����■��■u■��■��■■■■��■■����■■�■ ■■�■�■e�■�i�■■■�■■��■i�■■�■��■�■■■�■■����■■�■ �iiiiii�iiiiiiii '�iiiiiii�iiiiiii�iiiiiii�iii ■�■��■��■i�■■���■■�■�,■■�■■��■■■■��■���■�■■■■ ■■■��■�■■�■��■������■�■�■��■►i�■�■■��■�■■■■■�����■�■�■■��■■ ■■■�����■��■�■��■i��■�■��...�■■��■�■�■�����■���■�■■������a ■■■������■■■■■�■�i����:����■■■■■�■■��■�■■�■■■��������t■��■ ■■■�■�■e■�■■■■■�■����■��■■�■�■■■■■��■�■■■�■■��■�����■■■■■ ■�■�■�■�■■■��■■�■■�■�■■�■■�■■■���■�■���■■��■■■�������■■�■ ■�■�■�■�■■�■��■■■��■�■■�■■�■�■■�■■��■�■■��■■■■■������■■■ ■��■�■■��■����■■■■��■■■ ■����■■�■■�■��■■■■■■■■�����■■��■ ■��■�■�■�o■�■�■■�■■v�s■�■■■�■�■■�■■��������■■■■�■�����s�■ ■����■�■�ve■■�■■�■■���■■�■■�■�■■�■■��■��■■�■■■■��������■■ ■■�■■N���■■■�■■�■■����■�■■�■�■■��■■■■■�■■��■�■■■■■■■��■■ ■■■�■■�■�■■�■�■■�■■�■��■�■■��o■■■�■■�■■��■���■�■■■■■■■��■ ■��■�■�■�■�■■��■�■�t■�■■�■■�■��■��■■�■■��■�������■■■■■��■ ■■�■■��■����■�■■�■■t��■�����■�■■��■��■���■���■�■■■■■■���■ ■���■■�■�■■■■�■��■■�■���■■�■��■��■■�■■��■■����■■■■■■��■■ ■�■�■■�■�■��■�■■�■■�■�■ ■■�■�■■��■■�■■�■■������■�■■�■��■ ■���■■�■�■■■■�■��■■���■■�■■����■��■��■■��■��������������� ■■���■�■�■■■■■■■��■���■■■�■�■■■■■■■��■■��■■�■■�■■■������■ ■■�■■■�■■■■�■��■��■�■�■■��■■■■■■�■■■�■■��■■��■�■■■■����■■ ■■�■■■��■��������■■■■�■■�■■■■���■�■■�■■��■�����■■�■■�■■■■ ■■■��■■�■���■■�■■■■■■������■����������■���■����■■■■■■■��■ ■■■��■�■■�■����■�■■�o�■�■t■■����������■■�■�������■■■■�■�■ ■■■■��■■■�■��■�■■■■■�■����■�■�■����■����■■���■�■■�■■�■�■ ■■�����������■�■■■����■ ■����������■�■■�����■■�■■■■■■■�■ ■■■■■■■�■�■■■■■�■�����s����■■■��■���������■���■���t�■■��■ ■�■■■�■�■■�■�■��■���������������■���■��■������■��■■■■■■�■ ■�■���■�■����■�����■�������■�■■■����■��������■■■■■■■■■■�■ ■�■■■�■�■�■�■■��■��■■��■■��■�■��■����■■■�■■�■■������■���■ ■�■■■�■■■■�■�������■���■■��■����■���■■■■■■■�����■���■���■ ■�■�■���■��■�■��■■■■■■�■���■�■��■������■�■����������■�■�■ ■�■�■■■�■����■■■■■■■■■■ ■■■■■■�■■■�■��■�■■■■■�■■■��■■■�■ ■.■...■.■■■■■■.........�i.......■...■■■■.■..■.......■.■.■ ......................................................... ......................................................... ......................................................... .........................................................