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770 Chinquapin Rd (2)DAVIE COUNTY HEALTH DEPARTMENT . • Environmental Health Section � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Account #: 990003859 Tax PIN/EH #: 5813-59-6101 Biiled To: Prentice Steelman Reference Name: Shawn ATC Number: 4308 Subdivision Info: Location/Address: Chiquapin Road-27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I**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). 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 CONS RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. � Environmental Health Specialist's Signature: i yi / Date: � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Arti G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a g tee that the system will function satisfactorily for any given period of time. -�'� Ibo �ab �� Septic System Installed By: Environmental Health SpecialisYs Signature : DCHD OS/99 (Revised) , �J� l-�' Date: � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003859 Billed To: Prentice Steelman Reference Name: Shawn Steelman Proposed Facility: Residence Tax PIN/EH #: 5813-59-6101 Subdivision Info: Location/Address: Chiquapin Road-27028 Property Size: **NOTE�* 1fim Ier: 4308 �s mprovement/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 issuaace 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 _� #Bedrooms � #Baths �_ Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �'/ Type Water Supply ��� Design Wastewater Flow (GPD) � Site: New � Repair ❑ System Specifications: Tank Size ���GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width� Rock Depth � Linear Ft�'� 11�1PROVEI�1ENT/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 830 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)751-87G0.**** �" i . Environmental Health Specialist's Signature: Date: DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)75]-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 990003859 Billed To: Prentice Steelman Reference Name: Shawn Proposed Facility: Residence Tax PIN/EH #: 5813-59-6101 Subdivision Info: Location/Address: Chiquapin Road-27028 Property Size: **NOTE�* This Impro4emn t/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 #People _� #Bedrooms _� #Baths �_ Dishwasher:� Garbage Disposal: � Washing Machine�� Basement w/Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats /L/ Lot Size ``'� Type Water Supply � Design Wastewater Flow (GPD) �6� Basement/No Plumbing: ❑ Industrial Waste: ❑ Site: New�Repair ❑ System Specifications: Tank Sizef � GAL. Pump Tank GAL. Trench Width �� Rock Depth �� Linear Ft��� Other: As stated in 15A NCAC 18A.196�j5� Required Site Modifications/Conditions: accepted Systems may aiso be use I1�IPROVEMENT/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.rrj. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33C►)751-87G0.**** �'l/����. �o � ���ll �l°� �� �s r � . K� �1 �r�� �, � rp�c'� Gr 1s-�c �b� �� �! l !7� �i��lj _, / � 0 �.� V � ;s�v�� �- Environmental Health Specialist's Signature: Date: � DCHD OS/99 (Revised) «_-�t.. '1� 1 2. . . � APPUCATION FOR SITC EVALUATION/ih1PIi0VEh1ENT P� , Davie County Health Department '• Environment`a/Hea/il� Section P.O. Box 84f3/210 Hospital Stree Mocksvilla, NC 27028 (336) 751-8760 �c��o�� ATC JAPd Z 3 2000 �a Y ll'��� i��.�U 1 I f�� �i:..F.:i.Y D:;tiiE COU� 1TY ***It1y0RTANT*** THIS APPLICATION C1lNNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOit2S11TION IS PROVIDED. Refer to the INFORMATION BULLETIN for inatructions. Nama to be Dilled �/-f�ny�-�C(� .� f��l��irl, _��t=�'/rv�:'in Contact Peraon �N�-�"' Mailing Addtesn �y�� JGt�/�i'/1 l)C'1%�i/ �� Home Phone ��G' "%G�-3 - Z�I %Z. Cily/3tate/ZIP �'�;hu �"/��. JUG o� ��5 5 Businesa Phone .� 3C.� - Cv_�S �%%O�� _y_�=� Namcs <�n Pezmit/ATC if Different than Above "S�t�rt,.� Mailin� Addreas City/State/Zip 3. Appliccttion For: LJ' Site Evaluation L�" Improvement Permit/ATC ❑ IIoth 4. Syateiu to Servico: ❑ HouBa L�I Mobile Home ❑ IIuainess ❑ Industry ❑ Other 5. Typo uyc�Lem requoDtod: t_1 Conventional ❑ conventional modified ❑ innovativa p ac �epte d 6. If Residence: S People � # I3edrooms Z �� 13athrooms Z- Dialiwasher ❑Garbage Disposal �shing Machino ❑Hasement/Plumbing ❑Uaaement/No Plumbing 7. If Lu3inesn/Induatry /Other: verify typa # Peopla # Coaunodoa N Showera IF FOODSERVICE: �# Seatn $ Urinala 8 Sinks �i WaL-or Coolors Estimated Water Usage (gallona per day) 8. Type of water aupply: ❑ C4unty/City Q Well ❑ Community 9. Do you anticipate adciitions or Cxp:lIISl0I1S Oi illC faGllfj' t1115 S}'StCII� 1S 1111CI1�C(� f0 SCI'VC? ��'CS l'1 1V0 If �'cs, �ti�liat typc? '"**I�III'ORTilNT'°** CLILN7'S �1fUST COhtYLETE TII� REQUIXL•D PROPLRTY INFORNiATION 1tLQULST['sD [31;L01V. �ithcr a PL.AT ar SITG PLAN 1LfUST 6E SU6AfIT7'ED by tl�e clicnt �vitl� TIIIS APPI.ICA'tiON. Properly ])iuicusions: WI21TG DIRGCTIONS (L•om Nlocicsvilic) to PItOPCRTY:,� •rn. o rr,« ri�r: t� �F� 1�—�`� �� 1 O I �tv � N—�T• Lc �,� �.. C�i•� 4 p•�. �— Property Acidress: Road Namc C h►nt ' �� '��L �'►'LL� R.. �;�-. _ _� l City/Zip ��n�GC< � ;1 �2 �70Zg �.%w �k,G Z ?a - 1 S Z If i�i a Subdi�•ision providc infoi•tiiation, as follotivs: N:►mc: Section: Bloclt: Lot: llatc homc corncrs flaggcd: �" Z�''� L '1'l�is is to ccr(iS'y tl�at tltc iuformation providcd is corrcct to thc bcst of nry l.nowledga I undcrstand tliat any permit(s) issucd Itere:ifter are subject to suspensiot► oi• revocation, if tlie site plans or intended usc cl�aiige, or if ll�e iiiformatio�i subuiitted iii tt�is application is falsificd or clianged. I, a1so, rurderstan�l tlrat I a�rr responsible jor al/ cicrrrges i�tau•rerl jra�r t/tis applicaliorr. I, l�creby, give consciit to tlic Autl�oriud Represcntativc of tl�c Davic Cou�ity I-Ie:iltli lleparhncnt to entcr upo►� abovc dcscribcd property Iocatcd in Davic Cow�ty and owncd by to conduct :i11 icsling procedures as iiccessary to determine tlie site suitability,, DATE /' z S' � 4 SIGNAT'U � `�`�n��n�,i.c�_ lt�-� -� . � TFIIS ARI;A ;�IAY B� US�D TOR DRAWING YOUIt SI'f� PLAN (Includc all of thc follotiving: Lsisting and proposcd property lil�es and dimensioi�s, structures, setbaclss, and septic locations). � s�s« ����t� Rcviscd DClill (05/03 Sitc Itcvisit Cliargc I Datc(s): Clicnt Notifcatio�i Datc: I �IIS: '. Accounl No. ��SJr� . �2 I�ivoicc No. �,.,v _ 0 0 � I � �I � (1.11 A) M; 7660 I 1010 572 (20.01 A) 6101 B200000034 A 7.240A 5604 B20000003404 �I 211 -- - -- -- --- �25_ - - ---- ----- -- ------ - i II --- � 125 'i � j I"' � � (1. 95A) 6�9 � �� 9742 , -_ \ � `\�ZQ \� _ � 1209 1527 / I •� ' , � ., � ; . a APPLICANT INFORMATION Account #: 990003859 Billed To: Prentice Steelmar Reference Name: Shawn Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5813-59-6101 Subdivision Info: Location/Address: Chiquapin Road-27028 Property Size: Date Evaluated: Water Supply: On-Site Well � Community Evaluation By: Auger Boring � Pit FACTORS 1 2 3 Slope % � � , HORIZON I DEPTH �� Texture grou �jCG Consistence /=r Structure �� Mineralo i, '% HORIZON II DEPTH � � Texture rou � Consistence Structure � Mineralo , ' / HORIZON III DEPTH � Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , � SITE CLASSIFICATION: 1�-� LONG-TERM ACCEPTANCE RATE: �� REMARKS: �� EVALUATION BY: Public Cut 5 6 OTHER(S) PRESENT: 7 LEGEND i,andsca�e Position R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope CC - Concave slope CV - Convex slope T- Tenace FP - Flood plain H- Head slope Ts�tiug 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 CON IST .N . NIQiSL VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm � 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 - Granulaz ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralo�v 1:1, 2:1, Mixed LY4�S 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 - gaUday/ft2 DCHD OS/OS (Revised)