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1336 County Line RdDAVIE COUNTY HEALTH DEPARTMENT • - - • Environmental Health Section ' P. O. Boz 848/210 Hospital Street ` Mocksville, NC 27028 (336)751-8760 Account #: 990002365 Billed To: Jason Powell Reference Name: Proposed Facility: Residence. IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 4890-93-3223 Subdivision Info: Location/Address: County Line Road-28634 Property Size: see map � ATC Number: 3212 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATTON IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification:. Building Type i�l� #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 Sizg��GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �� Rock Depth � Linear Ft��� IMPROVE111ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a re resentative ofthe Davie CountyHealth Department for final inspection ofthis ', system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p. . e day of installation. Telephone # is (33G)751-87G0.**** , — � Environmental Health Specialist's Signature: . Date: ���J"' '��' L� DCHD OS/99 (Revised) + . w � Account #: 990002365 Biiled To: Jason Powell Reference Name: Proposed Facility: Residence ATC Number: 3212 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 4890-93-3223 Subdivision Info: Location/Address: County Line Road-28634 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLJED 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 WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: J✓ fi'�- ^' ' Date: ��G� `"� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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 Syst�l�s " s a m. AY be taken as a guarantee that the system will function satisfactorily for any given period of ti Septic System Installed By: � -- - -- - --- - _ - - - -- - Environmental Health Specialist's Signature :_������ Date: !� v DCHD OS/99 (Revised) APPLICATION FOli SITE EVALUATION/lM11PROVEh9ENT PERAfIT & IiTC Davie County Health Department Envi�onmenta/Hea/th Seciion . P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 p � �-�. � D �j J�C ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Address City/State/ZIP 0 Contact � � Lr Fiome Phone�� �,~ � �y � � iness Phone �� �Q � O� lJ1 6� 2. Namo on Permi.t/ATC if Different than AboiYo � Y�_ Mailing Address SC,� �vt/ City/State/Zip S`C�� 3. Application ror: ❑ S:ite �vaivatian ❑ 2mprovement Perma.t/ATC �yr! Bo�h 4. System to service: ❑ House � Mobile Home ❑ Business ❑ Industry �J Other �. If Residenco: �k People �J q Bedrooms J �► Bathrooms �_ � Disliwa�her I.I Garbage Disposal � Washing Machine I:I Hasement/Plumbing i.I IIasement/tto Plumbinq G. If IIusiness/Industry/Other: Specify type # People Ik Sinks A Commodes #i Showers # Urinals # Water Coolers II' I'OODSERVIC�: 4� Seats Estimated Water Usage �gaiions por day) 7. Typo of watcr supply: l�1 County/City L� Well ❑ Co�unity a. Do you anticipatc additions or cxpnnsions of thc facility this systcm is intendcd to scrvc? !1'ycs, �v6at typc? ❑ Ycs �I No ***IAIPOK%AN7'*** CLIGN7'S I�lUS7'COh1PL!%TBTHE REQUIXED PRQPGRTY INFORMAT[ON RGQUI:S'I'GD 131�.L0\V. Githcr a PLAT or SlTI: PLAN dIUST BESUBMl77'F.D by thc clicnt with TII1S AI'PLICATION. Properly Dimension���� �-���� i'VRiTC DiREC'I'iONS (irari� �LZac:csvillc) to PROPi;R'CY: � o � q3- a �� � s��e, �i� �� ���:�Xo�,��� ��«�: �� �i b9 3 �3 �ownl 6 Properly Address: Road Namc � l�^ Th�'� ✓v �O�''N � CQVi^�t%� L�Ne- City/Zip I �1 � �{ �(j vt � �f � � �L°,-S Ci /✓ o 1..03 � , If in a S�ibdivision providc information, �s follo�v . � � Namc: �;cclion: l3lc�cl:: Lot: Datc Property �laggcd: l� (/T Z` "fliis is t�� ccrtify tl�at tBc information providcd is corrcct to thc best of my Icno»�Icdgc. 1 undcrstand tl�at any permil(s) issucd I�crcaftcr are subject to suspension or rcvocation, if tl�c sitc plans or intcndcd usc cl�angc, or if tl�e information submitted in lhis application is f:�lsified or changed. I, also, «�rderstaud tkall nur resp�nlsib/efur n/1 c/rruges inarrrer/fron� 1/ris npplicatio�r. I, hcrcby, givc consent to tl�c Authorized Representativc of thc Davic County Ilcalth Dcparhncnt lo cnter upon above dcscribed property located in Davie County and owned by lo conduct all testing procedures as necessary to determine the site suitabilily. 1)A7'1? �r� `O� SIGNA'i'URG TIIIS ARGA MAY 13C USCD rOR DRAWING YOUR SITC PLAN (Includc all of t6c following: I;xisting and proposcd property lincs and dimcnsions, structures, sctbacks, and scptic locations). Reviscd DCIiD (07/99) Sitc Rcvisit Chargc Da tc(s): Clicnt Noti(ication Datc: CHS: Account No. � � v � Invoicc No. � � � `�' `� j � . � � ''; , � _, � , � I � ; _ � : � �� :. � (979} ... ; � � � s;,,,,,, r , � ;,< � 3 (11.45A} 371� I ,, � � �� � :;• � , � � �' I, �. �y ;,:,, ,; : I � � & ; ;; � (1026 ) ' ,�; � �_ �� 0 � � �' � �; ' ,, �. � i '' �, (1,4. 51 A) � � � »�--_ � �� � � '�� �3223 �� ____ , .. . � y: -� �_-.c i� F r � I r.. �� t � � �� � .. . . � Q �... f' N �� �'�� � - .. . � .. ... ... . f :, ,. C' II j� i I$�J�.2� � � ',,' I �/.'���., �,. � i d� �-: /,%;, ,; II _ i�=firs,i� . � �� . .. , / �% .; � .. � �roJ. �. - ":.i..r ,.- .. � � j/�, „'� ��r�" � � � � � � I I � /' //.t�'� - i �//r,, el� -. �/�/ }t � �� i I ( �� � � i ("I7.80 A) ' � ' (9. � � ' ... � �i c� , $'. � . %���� � �304 ��� �: � !�� ' ���_ . ,,,,o,,,, ,=; �� � ; „�,M �. . .... ., �, � �� . d '��� . , :. � � . ' , • �'� , • � L DAVIE COUNTY HEALTH DEPARTMENT ' Environmentoi Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002365 Billed To: Jason Powell Reference Name: Proposed Facility: Residence Property Size PROPERTY INFORMATION Tax PIN/EH #: 4890-93-3223 Subdivision Info: Location/Address: County Line Road-28634 see map Date Evaluate� ,�� �7��� Water Supply: On-Site Well Community Evaluation By: Auger Boring �� Pit icnwic �,ivu� Consistence Structure Mineralogy HORIZON I� 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:� REMARKS: Public t� Cut EVALUATION BY: 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 MineraloQv 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 - gaUday/ft2 DCHD OS/99 (Revised) ■■ ■■■�■ ■���■ ■���■ ■■��■ ■■��■ C■�■■ .... ..... ..... ..... . ..... ..... ............................... ............................... . ■■■ ■�■ ■■■ ■■��■��■ ■�■��■�■ ■�a����■ ■���■��■ ■■����■■ ■�■����■ ■������■ ■■�����■ ■■����■■ ■������■ ■������■ ■■��■■�■ ■������■ ........ ........ ........ ........ ........ ........ ........ ........ ...... ...... ........ .■..■.■. ........ ........ ........ ........ ........ ........ ........ ............ ............