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696 Cedar Creek Rd (2)Account #: 990001470 Billed To: Don�ld Smith Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5842-45-2462 Subdivision Info: Location/Address: Cedar Creek Road-27006 Property Size: 11.54 acres **NOTE�* Ttiibgrripro em�er►t/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 /, j7%7� #People _� #Bedrooms ,s� #Baths .� Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size f�G' Type Water Supply J�C//� Design Wastewater Flow (GPD) �� Site: New� Repair ❑ System Specifications: Tank Size/,� GAL. Pump Tank GAL. Trench Width�6�� Rock Depth � Linear Ft.�l Other: �y� ��s �i,�.,�/ .�-�, �%`��-c Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Coun ealth D ent for final inspection ofthis system between 8:30 a.m. to 930 a.m. or : 0 p. . m. ' s allat� . elephone # is (336)751-87G0.**** . �� � , Lr ❑ Environmental Health S ecialist's Si ature: � � Date: ��✓O � P � DCHD OS/99 (Revised) Account #: 990001470 Billed To: Donald Smith Reference Name: Proposed Facility: Residence ATC Number: 2634 DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section r. o. Bog sasmo x�p�tai s��t Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5842-45-2462 Subdivision Info: Location/Address: Cedar Creek Road-27006 Property Size: 11.54 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction M[JST 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 WASTEWATER NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �V "� Date: l� ��� CERTIFICATE OF COMPLETION **NOTE** The 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. Septic System Installed By: Environmentai Health Specialist's Signature : DCHD OS/99 (Revised) Date: APPLICATION FOR SITE EVALUATION/IMPROVEI44ENf P�ti�9oi & ATC Davie County Health Department Envinvnmenta/ Hea/tfi Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 � ��� r���� --=_i�, u � ��r 2 6 zn���� _.""'---.� � ***IMPORTAIVT*** THZS APFLICATION G;:.�v'OT IIE P12ih�S�D Li7'�SS ALZ TFic. n�QUIRED INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions. 1. Nama to be Billed � .C`� �(''� � � � �� Y \ � Contset Peraon � 6(.1 ��1) Mailinq Addres����aa� Fiome Phone ��� ��"� (�— ���� t ,�1 + � ��� �y'7 /� City/State/ZIP 1 (��j����Q�i \V��� { 2� Businesa Phone ��,p / / �� V30 � 2. Name on Permit/ATC if Different than Above Mailing Address City/3tate/Zip 3. Application For: '�Site Evaluation �Improvement Permit/ATC ❑ Both � �\ �iA�� 2 W i C� ¢, a. sy8t� to se�i�e: � House � Mobile Home '❑ Business ❑ Industry 'Fa Other �� � �� � � � s. xf Residence: N People �_ p Bedrooms � # Bathrooms �� bt� , 1� Diahwasher 11 Garbage Disposal � Washing Machine ❑ Basement/Plumbing U Basament/No Plumbingr3� 6. Sf Businesa/Industry/Other: Specify type i Commodes # Shoxera � Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay) �. Type of water supply: 0 County/City � Well ❑ Community e. Do you anticipate additions ar eapansions of tl�e facility this system is intended to serve? ❑ lles �No If yes, what type? ***IMPORTANT*** CLIEN'j'S MUST CObtPLETETHE REQUIRED PIiOPERTY INFORMATION R�QUI;ST�D BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the clicat with THIS APPLICATION. Property Dimensions: 1� � �� Q�,. Tax Office PIN: #��� a��a y(� a Property Address: Road Name � b � c�tyiz;� �vc�,n,es�, Nc a7o01� If in a Subdivision provide information, as follows: Namc: Section: Block: Lot: WRITE DIRECI'IONS (from Mocksvillc) to PROP1;Fi7'Y: � ��, �� • � �� � � . , � �i1 � • � —� 1� ,��. �_J � ; � ...�:;,� �:; � � •� `•� ' - Date Property Flagged: _ ��� �cj � OD This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued 6ereafter are subject to suspension or revceation, if the site plans or intended use change, or if the information submitted in this application is Talsified or changed I, also, undersland that I am responsible jor all charges incurred jront this application. I, hereby, give consent to the Authorized Representative of the I2avie County Health Department to enter upon above described property located in Davie County and owned Uy ��nn�c� l� .S r"r;;�_ to conduct ail testing procedures as necessary to determine the site suitability. DATE � O, 2� 1 O�O SIGNATUIiE __ • �. ��� THIS AREA MAY BE USED FOR DRAWING YOUIi SITE PLAN (Include all of tLe following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit CLargc Date(s): Clieat Notification Datc: EHS: Revised DCHD (07/99) Account No. � / � � Invoice No. � c� � � � O�w .588 ]590 A m m F I I � D500000013 i JE%E� ON 5812.1� I INDE%FD ON 5812.1♦ m INDEXED ON SBe210 � <]]J IIQ��� ON SM2.11 IRIDIXED CN 5&215 �Davie County .7�ealtFr Depar�ment and .�fome .�ealtFr .�yency 21O HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-5985 5epten�:r : �. 1':�`=� = i.�or",nld lv. 5�ith �_�. o. r� � Y��.}a i='ir,-�acle. ��:�_ �i�v,�:3 �:E: sir�= EV%�1Cl�tlGfc G_da�� Cr,_�ek Road L�a;~ �1r. S.:,i�h: R� ;�:�a�sas'r.=d, a t,�c:r•��ser��a;:ve �r�on t��i� af; ice vi�ited t�e c�fGt'2�1ei1�1Grie� Sit� o;i Se�';��7Ler' ic•, ��yc. Tt.: 51:e �a�•: f.:;+_ii�G pY'��visicrraiiy Si_ti��`.�ble �07' �i':e 7.;1•;,t��il�tt3.uit Df � O;�G_.��d dbSG�';��:�T =e:rct�2 Sy5�eL1. Ir yClt r��t'Ji %K?'�Y ���.te•3'GiO�i�, j�ie%�5� 1`eei �Y'=e 'Gu Ccfct3C� 'i.i�is of'FiCe. Sir,4�r = y, ���,-�,,T �%'�i�- j!�c� � �- i.•�i.+3'r`� _. riyil. Y , �.5. �r:vi;�on^�;�tal H�alin 8nctia;, ?; ,.' ,. � c.��Ciu��-tt'8 DAVIE COUNTY HEALTH DEPARTMENT , . .. ,� Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001470 Billed To: Donald Smith Reference Name: Proposed Facility: Residence Tax PINIEH #: 5842-45-2'�OPERTY INFORMA'T�O�.... -ysram�.��.. Subdivision Info: LocationlAddress: Cedar Creek R�d?3 �JC� Property Size: 11.54 aCGes Date Evaluated: ��_—�------ Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit Cut_ tcx�uic �i�uY Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Swcture Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE REMARKS: �//'X � ✓C��� z � � , �¢�;� : � � / / OTHER(S) PRESENT: � �!� 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely �rm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - Very plastic tructure 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 we[ness - 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 DCi-ID OS/99 (Revised) ■�■�■■�����■■�■�■■■ ■�■■�■��■■��■�■�■■■ ■5���■���■��■����■ ■■�■�■■�����■■�■ ■ ■��■■■��\■■�■��■��■ ■��■��■��■�■■■■���■ ■■��■�s■����■����■■ ■�■■■■����■���■■��■ ■�■■■��■����■v��o�s ■�■�■����■■���■��■■ ■�■�■�■■��■��■���■ ■■��■�������■�■■ ■ ■■■�■�����■���■��s� e�■��:�■����■�■����i ■�-��■�■■��■���■■■� ���■�■�����■��-_■_�■ ■����■����■■���■��■ ■�■�■■��■��■���■■�■ ■�■■��■�■■ ■�■���■�■■ ■�■��■�■�■ ■�■��■■■�■ ■■■o■■■s■■ ■■��■����■ ■��■s■■s�■ ■■�■����■■ ■■�■���■�■ ■��■s■■■■■ ■■�■����■■ ■�■■��■■�■ ■�■■���■■■�■��■�■■■�■■�■�■�■�■■�■■■�■■��■�■�■■��■�■■s■�■■■ ■�■■■�■■���■�■�■�■■�■■■■���■ ■��■■■�■■�■�■■��■������■�■■�■ ■�■■■�■■�■�■■■■�����■■�■�■�■■�■���■��■■��■■■��■��■��■■■■�■■ ■�■■■■�■�■■■��■���■�■■�■■■�■■�■��■■■�■■���■■�■■�■■���■■■�■■ ■�■■■■�■■■�■��■�■■■�■■�■�■�■■�■■�■■■�■■�■�■■�■��■■■■■�■■■■■ ■���■■���■■�■���■�■■■■��■■�■■�■■���■�■■�■�■■��■�■■■■■■■■��■ ■��■��■■■■■���■�■�■■�■��■���■��■���■�■■��■■■��■��■������■�■ ■■������■■■■�■��■����■������■�■■���■■■■��■■■������■■�■��■�■ ■■���■��■■■■�■■������■�■■■�■�■������■■�■�■■�■■��■■�������■ ■■���■■��■����■���■■�■�■■■�■ ■■�■■��■■■■�■��■■�■�■■�����■■ ■����■■���■�■�■■■��■����■■■■■�■■�■�■��■�■�■��■■�■■■■■�■���■ ■■■��■■�■■������■■■■�■������■�■■��■■���■■�■■�■■�■■■■���■��■ ■■���■■�■■��■�■�■■■■�■��■���■�■����■����■���■����■�������■■ ■■����■�■�■��■■���■■�■■�■■��■�����■■�■■■■�■��■���■■■�����■■ ■■■■��■■■�■����■■■■■■�■�■���■�■��■�■�■���■�■��■��■■■■�■�■�■ ■■����■■��■�■��■�■�e��■�■■■�■��■■■�■■�■��■�■■�■■����■■■■��■ ■�����■■�������■■��■��■�■■■���■������■■������■■��■�■■■■■■■ ■��■■����■�■�■��■■■�■■■�■o■■ ■■■■�■��■��■�■■�■■■��■■■����■ ■��■■��■■■■■���■■■�■■■■�■■■�■■�■■■�■■�■��■■■■��■■����■■■�■■ ■■�■■��■��■■���■�■�■��■�■■■�■��■■��■■�■����■���■��■�■■■■�■■ ■���■�■■���e�■�■�■��■■■�■■■�■■�■■���■�■■�■�■■��■�����■■■■�■ ■■�■■■■■���■■■������■■■�����■■�■■■��■�■■�■�■■�■■■��■■■■■■�■ ■�■�■�■■��■�■■��■��■■■■�■■■�■■�■■���■�■■���■■�■■����■■■■��■ ■�■■��■���■����■■■�■■�■�■�■��■�■■������■����■��■■�■�■■■■■�■ ■■■■ ■���■■ ■�■■�■ ��==��; 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