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161 Cherry Hill Rd (2)Account #: 990002789 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)75]-87(0 IMPROVEMENT/OPERATION PERMIT Billed To: Ronnie Seamon 7 Reference Name: ��jyl�drp� �%%,e��J. ��w�'� Proposed Facility: Parsonage ���11��3 Tax PIN/EH #: 5756-43-8952 Subdivision Info: Location/Address: Cherry Hill Road-27028 Property Size: see map ATC Number: 3478 **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 #People "r #Bedrooms � #Baths �/.2 Dishwasher� Garbage Disposal: ❑ Washing Machine:�� Basement w/Plumbing: I� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � Design Wastewater Flow (GPD) V��,� Site: Ne�' Repair ❑ System Specifications: Tank Size /l'dt� GAL. Pump Tank Other: Required Site Modifications/Conditions: F 1� n � GAL. Trench Width �� Rock Depth �� Linear Ft. � �0 INIPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW FINISHED 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 1:30 p.m. on the day of installation. Telephone # is (336)751-87C0.**** � � � Environmental Health Specialist's Signature: ��/ Date: `'!�`'!/ � DCHD OS/99 (Revised) m DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Account #: 990002789 Bilied To: Ronnie Seamon Reference Name: Co n c..� 4!�'� t"�'►` . C�"'�' `� Proposed Facility: Parsonage ATC Number: 3478 Tax PIN/EH #: 5756-43-8952 Subdivision Info: Location/Address: Cherry Hill Road-27028 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � � **NOTE** This Authorization for Wastewater System Construction Mi1ST 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 WASTEWATER CONSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: � Date: ��ll '�� CERTIFICATE OF COMPLETION I**NOTE* * T'he issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit I 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. 1—L''�c7 Septic System Installed By: f � � Ss��� �� : ���,� ..- � l �7 y -�P� ��% �' ���' �� C�r��'flG��d P � � Environmental Health SpecialisYs Signature : -�`/ Date: � DCHD OS/99 (Revised) ll � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 I ���-_�L��� '.,.1� �' ! ( � j l: �� � JU,^� r �.,�3 �,, �� +� r7�'C F,�Fn i ru"" ***IMPORTANT*** THIS APPLICATION CANNOT BS PROCESSED UNLESS ALL TIiE—R�¢U'��tED` INFORMATION IS PROVIDED. Rafer to the INFORMATION BULLETIN r instructions. r �/ ' /I - �. Name to be Billed �ajg�/Q �yy� /Lj� �S�P(1e�- Contact Persor. '� Mailing Addresa �S7 /i1(,e U�1��L1%, �' Home Phone g"S � � City/State/ZIP �p�G�tV%1e.�/C 17oi� Business Phone � �J �2. Name on Permit/ATC if Different than Above l.rOttGp� �V1i'�1�Jo71fed/�/ LALt/Z�l Mailing Addresa 5 C�WI� City/St te/Zip �3. Application For: �Site Evaluation Improvement Permit/ATC ❑ Both ,�. 3yatem to ser�ice: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5 Type aystem requeated: L�! Conventional ❑ conventional modified ❑ innovative v6. If Residence: # People # Bedrooms � NJDiahwasher ❑Garbage Disposal �Washing Machine NJBasement/Plumbing .A'. If Susiness/Industry /Other: verify type # People _ # Commodes # Showers # Urinala IF FOODSERVICE: # Seats �. Type of water aupply: �County/City # Bathrooms �� ❑Basement/No Plumbing # Sinks # Water Coolera Estimated Water Usage (gallona per day) ❑ Well ❑ Community � no you anticipate additiona or expansions of the facility this system is intende�l to serve? ❑ Yes 6d'No If yes, what type? (�"r $�" � J ***IMPO��* CI�NTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED � i uFLnw, tphPr � Pi e�(r c�TE PLAN MU.ST BE SUB1N_ ITTED by the client with THIS AP.PLICATION. Pro erty Dimensions: �R. � �WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #��3�,q.s�. � d� �J Dj�'�'% �m ��.5c1� ��e. � P�- ' �- q Property Address: Road Name 1 i'� • Q�� ���1'PA4i/ Pmfn er o� �'h � �e5 c�tyiz,p ��h ri qh �- o� eti�errv I�r f(,,� ccsi- If in a Subdivision provide information, as follows: S�G�S {� �f r�1'� l.�i1LtiC�'1 pt�t /Pt�'� Name: Section: Block: Lot: �te home corners flagged: � b3 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 intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this app[ication. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suita ility. ` �ATE /� "' Cj �' � � vSIGNATURE v THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002789 Billed To: Ronnie Seamon Reference Name: Proposed Facility: Parsonage PROPERTY INFORMATION Tax PIN/EH #: 5756-43-8952 Subdivision Info: Location/Address: Cherry Hill Road-27028 Property Size: see map Date Evaluated: G-/1`�3 Water Supply: On-Site Well Community Evaluation By: Auger Boring ti� Pit Public t/ Cut HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: '�� LONG-TERM ACCEPTANCE RATE: l � REMARKS: EVALUATION BY: �c� � 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineralogv 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fll - 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) i ■ ■■�■�■ ■�■��■ ■����■ ■���■■ ■��■�■ ■����■ ■�■�■■ ■�■��■ ■����■ ■����■ ■����■ ■���■■ ■����■ ■■����■ ■�����■ ■�■�■■ ■ ■��■ ■■�■■�■ ■���■■■ ■■��■�■ ■�����■ ■�����■ ■����■■ ■■���■■ ■�����■ ■ ■■ ■�■��■ ■�■�■■ ■��■�■ ■■��■■ ■■��■■ ■��■�■ ■�■��■ ■����■ ■■��■■ ■��■�■ ■����■ ■�■��■ ■���■■ ■��■�■ ■����� i�iiiii ■���■■■ ■�����■ ■i����■ ■i���■■ ■�����■ ■■■��■ ■i��■■ ■��■�■ ■ ■ ■��■�■ ■�■■�■ �����■ ■����■ ■�■■�■ ■����■ ■��■�■ ■����■ ■����■ ■����■ ■��■�■ ■���■■ ■�■ ■a■ ■�■ ■ ■■■■�■ ■����■ ■■�■�■ ■■�■�■ ■�■��■ ■����■ ■����■ i�■■���■��■ i���������■ i���■��■��■ i���■■�■��■ i■�������� �■ ■����■ i�■���■���■ it�����■��■ t���■��■t�■ i�■�������■ i■■���■�■■■ i����■����■ i�■��■���■■ i■���■■��■■ i���������■ i■��■■���■■ �����■����■ i������■��■ i�■��■■■��■ ■����■ ■■���■ ■��■�■ ■��■�■ ■■■■�■ ■ ■■���■t■■����■���■■�■w�■■■�����■■��■�■■■������������■■ ■����������������■■�����■■�����■����������■■��■■■�����■ ■��������■■�t��■������■�■���■■������■������■����■�■���■ ■ ■ ■ ■