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569 Cedar Creek Rdv DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002747 Billed To: Augdene Thomas Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5842-13-8730 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: see map ATC Number: 3466 **NOTE** T'his 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). 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 ��JS� #People Z #Bedrooms 3 #Baths Z Dishwasher: d Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �- ���S Type Water Supply �i�=-rLJ�. Design Wastewater Flow (GPD) 3� Site: New � Repair ❑ System Specifications: Tank Size ��`�GAL. Pump Tank Other: � I.71 S Required Site Modifications/Conditions: IM1IPROVEMENT/OPERATION PERMIT FINISHED GRADE. ****NOTICE: Conta system between 8:30 a.m. to 9:30 a.m. or 1:00 . � � a � i' `) � �� � � � �Z ( Env' onmental Health � AD�i.,� � �r. 'r%A�� �rf � �e.. raax�� ���ST ialisYs Signature: � �a� ��l�2 DCHD OS/99 (Revised) � � ,A O JT - A PR t a ep es ati e c �.m to 1:3 p. . o , � � � �— � � _,•� ��<.,� GAL. Trench Width 3� Rock Depth � Z�� Linear Ft�` �-�11aT1.�� +Sr� � 1��L1ie e C.�'����� . %� S � � �t� f��l��t. �-JLZL VED EFFLUENT FILTER. RISER(S) IF G" BELOW "the Davie County Health Departrnent for final inspection of this � the day of installation. Telephone # is (33G)751-8760.**** � .�-v1� �►^�S r'� �Q��- %�`1�N� (5 ��I�� �-��;,,�. ► ; �pv,�S��S �Pi� - ISS� Date: I� I Z� O�I `��I�� '; s �� DAVIE COUNTY HEALTH DEPARTMENT , , � ' Environmental Health Section " P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 �� pi(�i � -�� �.� 6 �-� � � IMPROVEMENT/OPERATION PERMIT Account #: 990002747 Tax PIN/EH #: 5842-13-8730 Billed To: Augdene Thomas Subdivision Info: Reference Name: , Location/Address: Cedar Creek Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3466 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa 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 ��ljs�= #People � #Bedrooms 3 #Baths �- Dishwasher: � Garbage Disposal: ❑ Washing Machine: �� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size L-. � 1�;'�,� Type Water Supply V`'t=U-- Design Wastewater Flow (GPD) �� Site: New � Repair ❑ System Specifications: Tank Size��� GAL. Pump Tank GAL. Trench Width�� � Rock Depth L Z� � Linear Ftl.p��� Other: `T �SI�,�JI����i "F�X�� r�LT�.Q/JtaTIr.1G� �LC�i Jp�-� T RequiredSiteModifications/Conditions: �����.1...- e9�i C.�hj`tO�Q, �-�� ��� E-�� ��Q C�`X�+ ��' l.J �%l-l._ IN[PROVEI�1ENT/OPERATION PER1�11T LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6`� BELOW FINISI�ED 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 (33()751-8760.**** �,...___-___ ___ ;; Environmental Health Specialist's Signature: DCHD OS/99 (Revised) � \� � �� I� ��D . ., , 2 ��o�� '� � � , 5 s' � c�i 7 J'n��� ��� u��;s �� �� �, . 1 . DAVIE COUNTY HEALTH DEPARTMENT �%�� Environmental Health Section � P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Account #: 990002747 Tax PIN/EH #: 5842-13-8730 Billed To: Augdene Thomas Subdivision Info: Reference Name: Location/Address: Cedar Creek Road-27028 Proposed Facility: Residence ATC Number: 3466 Property Size: see map 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 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER RUCT O LID F R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: D �`� � CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the ystem described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130 , Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarant tha the $yst j will function satisfactorily for any given period of time. � �ja�11�D�� (j•2R Septic System Installed By: Environmental Health Specialist's Signahue : DCHD OS/99 (Revised) Date: �. I - , : � . , �NS�� , p�ih�� �� ` ' , 1l1"�NT�Ll� N , • Af' '(� IQN �OR S9Ti� EVr1LUA7-if�4/IMPiiO�'[@'lEEVT �`yE(i11E�' y1c tiT�'i; ,� 2 2(�,p3 ;^1 Davie C�unty Health Dep��rtrrj�nt . Mp`( � �-: �, �nvironinent`,�/he:�a/i`Jr 5'�c��`i�vn '-1 .0. Box 848/210 Hospital SLreet �1 � `� � ^ Mocksv�lle, NC 2702 ^u �(\ � 5 (336) 751-876� �\1 I�RT�iNT*** THIS APPLICATION CANNOT BE PROCF.SS.F.Zi U27L�;SS ALI� THE REQIISREU ZNFORMATION IS PROVIDED. Refer to the INFOR�SATIOPd BULL�T]'N for insi:rv.ctions. rr.une tr� l�e Billod y�����-s�-��_� /h n i��_S Contact E�er.son •-- .,.J��� ------- / 1 -_' �• c/ �/ Mailing I�ddress _L% � ���R Fio:ne Phoiio � ��_��__�o � � �City/State/ZIP� ��_ ��Fi'usiness shane ___ _ __ �2!Name on Permit/ATC if Different than �'lbove� ���_� �,�.������5 `��m'p'S /� � �� � /-7 r343iling Addreas �///� G.: ��(�^ ��.__� City/State/Zi O� I ��_� ���r � � �— 3. Application For: a.te Eval�}a.�ion Uvement Permit/AT . � oth l � ���. sy3tem to service: House Mobile iioma IIusiness Tradustry Other __ v' 5. If Residence: k People � # Bedroom� �_ � Bathzooms�_� �. Diahwaeher Garbage DittF�sa]. ashizg Machine BasemanL•/Plumbing Basement/No Plu:nbing 6. If Husinesa/Industry/Other: Specify type ___ 4'r Peu�.le _____ _ '# Sinks _ _ # Commodes � # Showers # Urir..al.: ____ # Water Co�lers _____ IF FOODSERVICE: # Sea�B �stimatecl Natc,x' Us��ye (gallons per dv.;�) __ �;/7. Type of water supp].y: County/Cit�* Well. Community �/a. Do you anticipate additions or expansions of the facility this system is intend�d ta servc? �'es No If yes, wl�at type? ***IMPt7RTAN7`"** CLIENTS D1US7'COh1PLCTETHE REQUII{Elf y'ROi'i:,K1'Y IiV1�Ul2MA'1'IOiti I�EQt1L'STGU BELO�;'. Eitlier a PLA'P or SIT'E 1'I.,AN MUSTBE SU13;Y11TIED by Yhr. clicut ��;th TIIIS APPLICA'E'ION. Pro tv lliu:�nsions: Tax Ofitce PIN: # ������ D Property Address: Road Name I.Y�Go4 Cr tGI�C, l�l c►cyiz;� If in a Sub�iivision provide inforr�iatimn, as foIlo�vs: Namc: Section: 131ock: Lot: �1'[21TG DI�;LC�'I']O[�'S (#':'4t11 b'ioCksvllll') t0 i4'ROPLRTY: �i�E L1 D Er� S t -�_.��in : n�� �� ��_�����_ a��i�_�d� � P� � �..��__ �'��,� � � ? r��-� �d /���eQ L�� �uRvc o��LL -� � � ,.�-li55,_� p�C��� u�� a r1 � e �/1i�' �t c/ Date home ccrucrs f7:ig�;ec1: �� This is to certify that the informatioyi pro��i�led is cUrrect ta thc best of my knP.►vvle�i�;e. I undcrsland tinat auy permit(s) issued t�ereafter are subject to suspensi�n or revocation, if tlie site plans or intended use change, or if tl�e inforcnation submitted in this application is falsified ur cl�anged. I, also, iuic.'erstand t1�ut d au� respunsible for all cliar�es incrirrrerl fr•un: t/iis applicatiar. I, hereby, give consent to thc Authorized Represe�itativc of tlre B�?%` 1�C CO Iltiy 1lealtl� artment to enter upon abuve described property located iu Davie County and orcned byG!� -- —__1��_���� — to couduct all testing procedures as necessary to determine the site suitabilitJ•. � DATE � ' �' � ' � 3 GNATUItE __,� THIS Al2EA MAY BE USED FOR DRAWING YOUR SI7['i, PL�' nctude all uf tiir following: �aisting and pruposed property lines and dimensions, structGres, setbacks, aud septic Eocations). Sign given Revised DCF (07/99) ������;�. C '� � �� � �-J� 3� �3 � L S � � �'� Site I2evisit C'hargc 1}.att(s): CIic.Tit Notiiicatiou i�atc: EHS: A�.couait rTo. ���_ Invo�ce No. _.�-+.�� 3_ c/ � � �"� � �� '� .... }, . ., ,, . f �rR-._ '� ..�,.� `�� _ � �r , � �� ' � � � •.� _•,' J. . ' } � .. � ' , � ... F j� i R 'J .'� '°+F , . `, - . '. . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002747 Billed To: Augdene Thomas Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5842-13-8730 Subdivision Info: Location/Address: Cedar Creek Road-27028 Property Size: see map Date Evaluated: -� ?o� Water Supply: On-Site Well Community, Evaluation By: Auger Boring Pit FACTORS Slope % HORIZON I DEPTH Texture group � Consistence Structure II DEPTH Texture group Consistence � � • Structure ' Mineralogy ` HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Texture erouv Structure SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ����� i ��i'��� �iA�'�r�,TJ ; Z; LONG-TERM ACCEPTANCE RATE: � � REMARKS: Y�1'�i "-�L�C Y�' j�TL�r•i[� 3���'h 9 4 � F� EVALUATION BY: OTHER(S) PRESENT: _ �5r J� �.xA�c h- �v b - ,+ 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 - Subangulaz 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 - gal/day/ft2 DCHD OS/99 (Revised) ■�■■ ■��■ ■■\■ ■��■ ■��■ ■��■ ■��■ ■��■ ■■�■ ■■�■ ■��■ ■��■ ■■�■ ■■�■ ■��■ ■��■�■ ■����■ ■���■■ ■����■ ■����■ ■ ■ ■ ■■ ■■ ■■ ■■ - ■��■■ ■■��■ ■���■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ �� ■■ ■ ■ ■ ■■■��■� �.������u ■���� i�i ■����a■ ■■���■■ ■��■■�■ ■��■�■■ ■■���■■ ■ ■��■�i ■��■■■ ■���■■ ■����■ ■����■ ■���■■ ■�e��■ ■���■■ ■�■■�■ ■����■ ■��■■■ ■����■ ■�■�■■ 1���■■ J�l��1�7 ■��%►1� ■����i ■■���■ ■■���■ ■����■ ■ ■ ■■�■ � `"�� � � � �� � 812 � , , �4�0 ,.. ,' �� �� ,s -� ,,� � '� 8�� --_ � _, ■ l� y :� r � r . r�� ...:. . � . . : e... . . .. l f� ' SR �43� � i CF� � r�`! � �RCRFFK � 1�1 , r rrp� R�aG .._ . l.. � S, J � q J � N a �r i � '.. .ww ._,,,.,, : . ,. . i i r � � �� �`�� �� _ ; �, ��A� 7�2 , '%����'��� , ��s� , , ,s � /' R r43q i !� � � CECJAk� CktkE�. 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