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630 Childrens Home RdDAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �'� �-�.�-�% .. , _ � y_1��� �� ���( IMI'ROVEMENT/OPERATION PERMIT Account #: 989900186 , Tax PIN/EH #: 5813-72-3673 Billed To: Boger Real Estat%S�� �'�`��/�� ��y� Subdivision Info: Reference Name: -Gil� �'KSa� r`�avid �%ry�. Location/Address: Children's Home Road 27028 Proposed Facility: Residence Property Size: 3.5 Acres ATC Number: 2244 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 ��o/si #People #Bedrooms _� #Baths �� Dishwasher: �1 Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size J-� ��' Type Water Supply ��!/ Design Wastewater Flow (GPD) � Site: New �" Repair ❑ System Specifications: Tank Size ��6� GAL. Pump Tank Other: Required Site Modifications/Conditions: � GAL. Trench Width �� `� Rock Depth �� Linear Ft,��Zi IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6`� 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. t p. .�he day of install tion. Telephone # is (336)751-87G0.**** Qn `S �' � �� u �' �� � � �``� -s �� �-3 ,� _ a2� ��� � � ��� � ��p�' S r , � ,...T—i771 Environmental Health Specialist's Signature: DC�-ID OS/99 (Revised) i� ���� �� �,� . , .. , . ��� p � DAVIE COUNTY HEALTH DEPARTME �G � Environmental Heaith Section �� P. O. Boz 848/210 Hospital Street � M�-� C� Mocksville, NC 27028 (f�� ��,,�( � (336)751-8760 � U' Account #: 989900186 . � ,� e_Tax PIN/EH #: Billed To: Boger Real Estate��u'��� €�v � Subdivision Info: Reference Name: �u�� � �uv�o� b�y � Location/Address: Proposed Facility: Residence Property Size: ATC Number. 2244 5813-72-3673 .���z� ,,s �s'� -�S � Children's Home Road 27028 3.5 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). 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 Specialist's Signature: „� l- � Date: l/'//�'�� CERTIFICATE OF **NOTE** The issuance of this Certificate of Completion shall ind has been installed in compliance with Article 11 of .S. Disposal Systems," but shall in NO WAY be taken s a given period of time. ,s; i�� s:f� s`S/en D� �_� c $,� ►°�, y�ti ��9 �n � �,�� �/ce � �-,,, � s� : !� �� �tB'Y�r ����s j f„ j���� f a;�,� d�(� f �';r'�r,�� �v' ��e_ �(r�"e�° /�b�� — � � ��� �d�� �� � ���� �en��� �'��. l+ ���r )� N p�► � � J�`� b��a ��- %�s �6 � p� � , � � �;1� � �W� � e ;,� � �� E ����< <� �� II �� ,,�0 �e�� r� � �i � ., /.� �� � �a 1 � � �,�`� �� � •�l x � L CP � ,��ss�� �,�. �' y �R - � ��,r�� �s�°`� �� �, '�'� ��,v 1<.� ��� � �, , 6 ' '' -,�2 �� �,� m � 1 � ��� C �P�'S �� � `` Septic System Installed By: :� � ETION system described on ImprovemendOperation Permit 130A, Section .1900 "Sewage Treatment and � that the system will function atisfactoril`for any � �e �)�1 ,�,` �� ,D� � � D �� � �s)„i' C pv� � b � ���ti�G� }/ , Y � �� �� � l r�� �� ��� �q �.�� , 1 1 �� L/ /l�l /7A�f d v - / Environmental Health Specialist's Signature : ����Yc�i E' � Date: �—�' -- D� DCHD OS/99 (Revised) � ���� q��� ��� C(�►V" ,�,,;c�' � APPLICATION FOR SITE EVALUATION/IMPROVEMENfT PERMIT & y'`� Davie County Health Department �� 5�,.� � Environmenta/Hea/tfi Se�ction Q"` / P.O. Hox 848/210 Hospital 3treet Mockaville, NC 27028 � D'ECE � �/ �J�i��336) 751-8760 �' d � . ***iI�ORTANT*** THI3 APPLICATION CANNOT BE PROCE3SED UNLE33 ALL THE REQUIRED INFORI�ATION IS PROVIDF.D. Refes to the INFORMATION BtJT.LETIN for instructions. Nam� to bo Hi12�d T p� �� l L�J 1 r4' I`� Contaat P�rsoa '� � �_ Mailinq )1ddr�ss ,� 2� iJ S f-� �1�1 � S�� som� �ona ,�9'�� 7% 3 8 City/Stato/ZIP /��d �.�iCl C' E� �jf • e • a,L, %��� Buainess Phono / / a � ��� � Nama on 8armit/ATC if Diffarant than Abow �i4 A.{� O Ci'� /v�f:�� /✓ �1�� Mailinq 71dcLr�es City/Stato/Zip � Application For: ,� 3ite Evaluatioa 0 Impronement Permit/ATC /�,tt,�q E'�Both � syet.� to so�i�o: �House ❑ Mobile Home ❑ Business � Industry ❑ Other s. If Residenca: i People � Bedrooms � � Bathrooms � _ ❑ Dishwasiur ❑ Garbaqo Disposal ❑ lvaahinq Machiao O Has�t/pivmbinq ❑ Hasam�nt/No Hlvmbiaq 6. If Susinass/Industry/Othor: Spocify typa # pooplo # Siaks � Commodas A Shox�rs i Uriaals ��Pat�r Coolore IF FOOD$ERVICE: # Seats Estimnted �ater Osnge (qalions par day) �. Zjtpe of �ater supply: ❑ County/City �' Well e. Do you anticipate addiHons or eapans��ns of tLe facillty this system is intended to serve? If yes, what type? /1� t� ❑ Community ❑ Yes 0 No ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. �ither a PLAT or SITE PLAN MUST BE SUBMITTED by the client w[th THIS APPLICATION. Proper4y Dimensions: 3.� %�-C Y E'S' Taa Office PIN: # _��/3 ""' 7-z _- C Propert,y Address: Road Name _ City/Zip ���- �.2� � Sf ia a Snbdi-�ision provide information, as follows: Name: Section: Block: Lot: WR1TE DIRE�CTIQ Y�f%m (.�i���lcGw..PEfi � i4P Goi�✓ - L. C!� %�', �-�v� o� G , a/ ��.1 vl ' e o C� r7'L� �' �S % � A/ LI��kJ !�v YY� ea.'t a�- Date Property Flagged: S : -� lfiis is to certify that the information provided is correct to the best of my knowledge. I nnderstand that any permit(s) Issued hereafter are subject to saspension or revocation, if the $ite plans or intended ase change, or if the informaHon submitted in this application is falsified or changed I, a/so, understand that I am responsIble jor all charges incurred from thJs application. I, hereby, give consent to the Aathorized Representative of the Davie Connty Health Department to enter upoa above described property located in Davie Connty and owned to conduet aA testing procedares as necessary to determine the site snitab DATE -- �Z � —' n/ 7 SIGNATURE TffiS AREA MAY BE USED FOR DRAWING YOUR S1TE PLAN (Include all of the following: Eristing and proposed �roperty lines and dimensions, stractares, setbacks, and septic loeat3c���,+. Revised � =."1D (07/99) Site Revisit Char�e Date(s): _� Client Notiiicstion Date: EHS• A cconnt Na �� Invoice No. �Z_ , . . llAVIE CUUN'I'Y HEAL'fH DEPAIt"I'MEN'1' ' , , _ .' � ' ' � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900186 Tax PIN/EH #: 5813-72-3673 Billed To: Boger Real Estate Subdivision Info: , Reference Name: Gilbert Boger Location/Address: Children's Home Road-27028 Proposed Facility: Residence �roperty Size: 3.5 Acres Date Evaluated: �0 �7 Water Supply: Evaluation By: FACTORS Landscape gosition s�o� % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON lII DEP'I'H Texture group Consistence Stnicture Mineralogy HORIZON IV DEPTH Texture group Consistence Swcture Mineralogy SOIL WETNESS RESTRICTIVE HORI; SAPROLITE CLASSIFICATION LONG-TERM ACCEF SITE CLASSIFICATII On-Site Well L� Community Auger Boring Pit Public ' Cut �00000� �� L������ �s���■����� �r�������� � ��i������ 0 0 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �`� OTHER(S) PRESENT: REMARKS: S�VI� II� �.✓ �A—�i�� 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 ois VFR - Very friable � NS - Non sticky NP - Non plastic FR - Friable Fl - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - l�e:�a plastic tru re SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR -�rismat:c Mineralo¢v 1: l, 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 ��ater or incnes from land sarface to soil colors with chroma 2 or less Ciassification - S(suitable), PS(provisionally :,uitable), U(unsuitable) LTAR - Long-term acceptance rate - gaVday/ft2 vCHb (Revised OS/99) ■�■ iii ■■■ ■■■�■ ..... ..... ..... ■��■■ ■��■■ ■ ■■ ■■�■ ■��� ■���■���■■��■■����■■■■�����■■■ ■��■���■■■���■���■�■■■�����■■■ ■■��■��■■■��■■���■■��■ ■����■ ■���■��■�����■■�■�■■■■�i���■�■ ■��■���������■■��������■��■■■■ ■■��■��■■�����■�■■■�����■�■��■ ■����■�■■■���■����■■■■■������■ ■��■����■���������■■■�■����■■■ ■��■���■■�����������■■�■■�■��■ ■��■■��■■��■�������■■■■��■���■ ■���■��■■������■■�■■■�������■ ■■■■�����������■■■���■ ■�i��� ■��■■■��������■■■����r.��■��i�■ ■■���■���������■����►���■�■■��■ ■■����■��■���■■��■����:�■���■�■ ■�■�����■■���■■��■�������■���■ ■�■■������■���■■��������■����■ ■��������■���■■■��■■�■■■�■���■ ■■����■�■������■■�■��■ ■���■■ ■�■��■■■■■■���■��������ii■����■ ■��t����■■�■■�■��■■��■�����■■■ ■�■��■������■�����■■�■■����■�■ ■����■����■�������■■��t■��■��■ ■��■��■��■�■��■�■'�������..=:. ■���■��■�■��■���e�:������■��■ ■■�����■��t�■��i����■■■�■��■■�■ ::::C:�::::::i�:::::C�C::::: .............................. iiiiiiiiiiiiiii:::::�����■■�■ --�.�::�■■ ■�■■��■����■��■iii��■■■■�����■ ■■����■������■�������������■�■■ ■�■■■■��►!����■■■■��c������■■��■ ■��■■■■r�■���■�■■■������■���■ ■■�����■■■■■�■����■r�■■ ■����■ ■������■��■��■�■��■����■�■���■ ■��■■�����■��■�����■��■■�■���■ ■���N■■■■���■�■■■■�������■■■■ ■■���������������■���■��■����■ ■■■■�■�����■■�■������■��■����■ ■■�����■■���■��■��■��■■�����■■ ■���■�������■��■��■��■ ■■���■ ■■��■���■�������■��■■��i���■■■ ■��■�■���■�����■■■����■■■����■ ■ ■��■■ ■��■■ ■�■�■ ■■����■���������������I ■��■����■■���■■�������I ■��■■����■■���■■■�����I ■���■�■��������■������I ■■��■■�■■��������■■■��I ■�O■����0����������■��I ■■�■�■��■��■����■■■■�■I ■■������■■����5�■■���■I ■�������e■��■■■■������i ■�■■■��■���■������■��■i ■�■���■�■��■�������■■�i ■�■■■■����■■�■■■������i ■�����■���■�■��■■�����i ■■■��■���■■��■■■■�����i ■■����■���■�����■����■i ■■■■�■����■■����■■����i ■■�e��■��■■■��■■■■■���i ■�■��■���■■■���■�■■��■i ■■■■■���■�����■■����■�i ■��������■���■■■■■��■�i ■�■■�������■■�■■�■■■■�! 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VESTAL i 1 ' ppla D.�, � Pa .3s new ���4f y er��t�� 5 8t' i9' J6" �--.— tron � .. N el• 19' 36" W ��n 215.00 � 3�2.f2 ���� � � R��I �� �� exl�tln9 �SQ �9 �'vn �+� = N �� � O1' S9'• �, � � nsir � Npn � , • i � . lIAARVIN P. ENQLE p,s. 1S8 P� 84S exltilnQ tran ,,,�.-•- 11" broks olt) ,,,...-�'" '�,� ' $ � 1 � 1 1 � �. �_ � AREA � 2.937' A�C��� I a�� I 3• s1 ? . . CLAYTON NL �3ROCE p.Br 141 Pt�. �C8 ..�� �75.92 N T o• ��. 59` W S0'd +660Z8666T6 31tl1S3->'7Fi321-+213�08 6S: T T Q3M 66-SZ-Nfl!' ,�, � t ' .� , ° , . Dik�fl� �d�UtJT� �I�LT�i U�i���t.TA��IT ENVIRONMENTAI HFALTH SECTION P. O. Box 84S/210 Hospital Street Courier #09-40-OG Mocksville, NC 27028 Phone #: (336)751-8760 November 2, 1999 Gilbert Boger 5248 US Hwy. 158 Advance, NC 27006 Re: Site Evaluation/Children's Home Road Tax Office PIN: #5813-72-3673 Dear Mr. Boger: As requested, a representative from this office visited the aforementioned site on July 19, 1999. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system for a four bedroom house. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, /�a�� ��,/��,. Robert B. Hall, Jr., RS. Environmental Health Specialist RH/mp Enclosure(s) ,� ' . , ', . ', . � , , � � ... .... _._ _ ........ ..... .. ...... ._ _ _ _.... _ .. . .. ,. . D��li� C4U�1TY �LT�i DE�'��T1�I�I' . . _ ENVIRONMENTAL HEAITN SECTION P. 0. Box 848/210 Hospital Street " Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 July 20, 1999 Boger Real Estate Attn: Gilbert Boger 5248 U.S. Hwy. 158 Advance, NC 27006 Re: Site Evaluation/Children's Home Road, 3.5 Acres Tax Office PIN: #5813-72-3673 Dear Mr. Gilbert: As requested, a representative from this office visited the aforementioned site on July 19, 1999. Based upon the information provided on the Application for Site Evaluation and after an evalua.tion was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house✓mobile home location staked off. If you have any questions, please feel free to coirtact this offce. Sincerely, ,I�i2!�t�B, ����,. Robert B. Hall, Jr., RS. Environmental Health Specialist ��i1 • Enclosure(s) '9