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340 Cedar Creek Rd (2)''� � '� r Account #: 990004026 Billed To: Jerry Oxendine Reference Name: ATC Number: 4456 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mceksville, NC 27028 (336)751-87G0 Tax PIN/EH #: 5842-02-6004 Subdivision Info: Location/Address: Cedar Creek Road-27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST 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 WASTEW TR ALI F PERIOD O FI YEARS. Environmental Health Specialist's Signature: Date: � CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion 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 guarantee that the system will function satisfactorily for any given period of time. r Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) , Date: �! (/3 .. s ��� . ' DAVIE COUNTY HEALTH DEPARTMENT ��- :. ' Environmental Health Section : P. O. Boa 848/210 Hospital Street ' Mceksville, NC 27028 (33G)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004026 Tax PIN/EH #: 5842-02-6004 Billed To: Jerry Oxendine Subdivision Info: Reference Name: Location/Address: Cedar Creek Road-27028 Proposed Facility: Residence Property Size: 8.34 acres A�C �-j�J(o **NO�.�*�'Fu�' �jgrpro�a#g�nt/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 TIIIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �M� #People � #Bedrooms � #Baths Z Dishwasher: ❑ Garbage Disposal: 0 Washing Machine: ❑ Basement w/Plumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ 1 Lot Size Type Water Supply � Design Wastewater Flow (GPD) '-.� Site: New � Repair 0 �l ii � System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width W Rock Depth IJ Linear Ft.�� Other: k��s-�-Ct' I LJJ � �'��T"r�-, .Z �S`�,Q1�fi�a�J .��� '/�'� � Required Site Modifications/Conditions: ��ST�I.L (`� �nl"rDl%�, �U� � (�-� a(��; I1�9PROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FiLTER RISER(S) 1F C, `° 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 1:30 p.m. on the day of installation. Telephone # is (33C)751-87G0.**** 45 ��� �� M��{. � � �„_, ��,►` �1 ��►�� � �P �-��'� �z�. ���,� Environmental Healt�pecialist's Signatu��e DCHD OS/99 (Revised) � �X � f�� , 1 �„ � ��7 U,S � � � C�D:.� Date: Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (33�751-8760/ Fax (336)751-8786 Improvement Permit Jerry Oxendine 340 Cedar Creek Road Mocksville, NC 27028 Re: 8.34 Acre Tract / Cedar Creek Road Tax PIN# 5842026004 Dear Client(s): T'his Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. System To Serve: � � Wastewater Design Flow(GPD): � Valid: Years ❑No Expiration System Type: ❑Conventional 0'Accepted ❑Innovative ❑Alternative ❑Other Site Modifications/Permit Conditions: Site Plan o �aQ U? - - - �-� i.p.letter 7/06 ,�-�r P�Q i.-� �� �..�� �5' � crc �P � I ► � ►i��L s��-uv�, Date �-A2 � � � �i �+v � Ce "H i' : d"�NI%ilillb iI `i,.. i'�' Po��!�' i � il^�rrt1 �S�*,�� s �n.�e �mll`�h9�'' � �=, .'� 'v;�'.kr 1 a r , °;� �:� I �6� 5 s 3 d4 g .:.� i � IW � 3" �� yr� � 1�,� � . �� � �� +ei�lu"�„ � s � ,�s�yw��.����'���k'���"�I u � �r'k ���w i � � � � h� � �_ti��� ���.� � � � �� �� � ��.� wv 7 � � ��kli'?�'�' i�������r��ir��,������iN� � �'�"������ . 6��+�'� �s�'�.+1ic�'r :�. �. ,y`�G�.iP " e�U �:: 1 ��'-� .� ��w '�`{,� "^�N",�"xw � '�(rt .'U }ti. �` ",� _d ,��:���ftro��,�ia�-rcm;�Hiim�,„���j��'�r��&*.4���._.,i:, '�w",��,� �..�p�, x' ���� : `�:� y �a i°I �" �: '' �� a��ie � N� ti:r.ag�" �a"i�"�ia*a'� �t- n ..'�%� a ti`hr�^��. �r"�,�i� �'" r ��' ���� ud� : �'� ^� ��,,��°i ' �`�`.'�� a^�, s th`�s �1 �1�r,�fiR 6 � '� .'k+��P����u��� ������'' t I �h'��i� . �ue, i, rt��t �., d �� ,.: 'k���i , ��� �l �" ,� ��4�s� ��g�i`��a'�aa``���.v� "'�.;,�..ti �uw�, ; � '��'�r a�" �la� "� �� a�`9� :-�', s� r W •�� ^� ���y�.r"- ,.�. ��'xY2'����"'�,� 44r a"+��''�`���:'�ti`�� � ::: a �. � a;�.�� I� �y`�a'�rP� i d ;i k li�a ��'�� iw � �. �.;,w. 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Box 848/210 Hospital Street ` Er�ViftOf�rl�EiJ1AtNEA�TN , MOCkSVllle, NC 27028 1' DA�nECOUi.n (336)751-8760/ Fax 6)751-878 ��" ���a� ./ �� Application For: 1� Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed ��� � r� y OX e�! a�� �t/c% Contact Person �E y y y �X eNdi�/�. Billing Address ,�/�o C� day. C,,• �?e ric � d Home Phone -r'j 9' ��l (� / City/State/ZIP /�oG i�C,�G�j/�ij( G oZ �0,� g Business Phone �-�' Name on PermibATC if Different than Mailing Address PROPERTY INFORMATION Ci NOTE: A survey'plat or site plan must accompany this application. 3�'ijjZ� �Z� /_ �'�,/ (Permit is valid for 60 months with site plan, no expiration with complete plat.) 7 ���7 Street Address__3 L/ D C eD��.�- Ca-e eiF /�City_ %Y/0 C. c SG ///e Tax PIN# ���� Subdivision Name Section/Lot# Lot Size i. 3�} ^ Directions To Site: �a.,. �:,,�� r� .v %' To Av�'�/in�a R ri,��i � /� � Ti� ,i��aG.t Date House/Facility Corners �Flagged '7/3 �p lo If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes �10 Does the site contain jurisdictional wetlands? ❑Yes �'No Are there any easements or right-of-ways on the site? ❑Yes �No Is the site subject to approval by another public agency? ❑Yes S'No � Will wastewater other than domestic sewage be generated? �Yes �To IF RESIDENCE FILL OUT THE BOX BELOW # People �_ # Bedrooms _� # Bathrooms �1. Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes f�'1Qo Basement Plumbing: ❑Yes �10 IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBnsiness Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type systemrequested: �Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: � County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes f�No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pernut(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incarrred fi-om this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to conduct necessary inspectxons to determine compliance with applic�ble laws and rules on the above described property located in Davie County and owned by .r��-- e�r,� � �} )( �,�/olin/P_ or owner's � �� Date Sign given gYes ❑No Revised 2/06 - signature Site Revisit Charge Date(s): Client Notification Date: _ EHS: Account # -��� Invoice # � N � • APPI.ICANT 1NFORMATION Account #; 990004026 . ��. Billed To: Jerry Oxendine Reference Name: . Pr�posed Facility: Residence DAVIL COUNTY H�ALTH D�I'ARTIVILNT Environmental Health Section Soil/Site Evaluation . YROPER7'Y INFORMATION ' Tax PIN/EH #: 584 - - Subdivision Infa � Location/Address: Cedar Creek Road-27028 Property Size: 8.34 acres Date Evaluated: 7 j i d Water Supply: On-Site Well Community Evaluation By: Auger Boring _ Pit FACTORS I Landsca e osition Slope % ' HORIZON I DEPTH D �' Texture rou Consistence Swcturc Mineralo �( HORIZON II DEPTH - Texture rou Consistence - Swcture Mineralo HORIZON �II DEPTH , • Texture rou �< < Consistence Swcture Mineraloev S7.1r IV DEPTH I �S2— Consistence \J ' Stcucturc Mineralo t„_ S01L WETNESS RESTRICTIVE HOKIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ,� SITE CLASSIFICATION: �S " f V�►'�1- LONG-TERVI ACCEPTANCE RATE: �� Z� REMA -I'ii{S: �� ��� ���� ���� �i - S ��h,l C�o" � �•�� � � � EVALUATION BY: OTHER(S) PRESENT: �-�'"� ��� LEGEND � Landscapc 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 T ur 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 - �ONSISTENCE oi VFR - Very friable FR - Friable FI - Firm VFI - Vcry �rm EFI - Extremely firm � " NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky � NP - Non plastic SP - Slightly plastic P- Plastic VY - Vcry plastic r cturc 'SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic �Vlineralogy 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 - gal/day/ft2 nCHn �`��� (Rcviscdl C ::CC 'CC::::C::C::::::::�_::::::::C:::::::C::C::�:::■:'. ���������������������� ■■ ��/ ��\1���������i���■ ■����������������%��������������� ■ ■ C ��•.-������������C������������������������������e��i •��■ ■�■■■���■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■ � ,■ ■ ■ �■■ ■►■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ � ■��.��������t������������������������������������������iii ::�.. nC...►���..�................................................. � C ����:����:::::C:...................�................... �� 8�����������������■ ■������� . ■������������������a�����■ ■■ .. .0 �....R�.�►..;....C:::CC:::C::CCC:C::C:C:::C:C::........::::: �� ■ ����e:�- ����i��������������������o�������������iiiiiiii■����� �■ ■ ■li�■ � ■����������������������������������������������iiii . ....0. ................................. ................. ....:.............�,.......■.............�■................ �E6:::CC:::C::::..�,....................... ............... ..�.......�...............�.......... .... .... ..........:�:C:C::..:C:C:::C::CC:CCCC:':C:::C:::::: _ ��•�..��..................�........ ......... ......... ■��C�ii� Caiiiiiiiiiiiiiiiii�"""""C""'����C����� ■���i'i' E ..�..=C............. .....::::::::�::::::::CC:. ::C . ..C.� :o�::.. �. .....�........C....�.....................5 .: :EC:C:' .. ....... ......�....... ........... .......... . ....� �':::�::::::C'::::...��........■..�..........0 ..C■... �//��/�����������/���/�%��«iy�����������������������/��/��� .BC : C:::C:�::C:::.............�.....:CC:C:C::C:::C:::.......... . . 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